Insurance company's stupidity!

[bevangel]

My insurance company (Blue Cross) approved me to get a replacement machine when my six year old Respironics RemStar C-Flex with heated humidifier quit working. The in-network DME where I got my original machine has gone out of business so I went looking for another provider and happened upon CPAP.com - which, of course, is NOT an in-network provider.

My policy pays 80% for in-network services but only 60% if I go out of network... unless they approve an exception which would allow me to be reimbursed for 80% of out of network services instead of just 60%.
Well, I just fought a losing battle with Blue Cross trying to get them to approve an exception.

The replacement I want is $599 at CPAP.com. The Blue Cross "approved amount" for the same machine at the in-network provider is $980. (I have no idea what that DME charges people who don't have insurance for the machine but I'm sure it is probably more than $980. The $980 is the amount my insurance company "approves" and then bases their 80% payment on.)

Thus:

In-network:
"Approved price" = $980.00
Cost to me = $196.00
Cost to Blue Cross = $784.00

Blue Cross's cost if I go in-network is $185 MORE than the total cost of the machine through CPAP.com so Blue Cross would actually save money if they just bought the machine outright for me from CPAP.com and didn't require me to pay any co-pay at all. But I didn't even ask them to do that.

I just asked them to approve my going out of network and reimburse me 80% of the out-of-network price instead of just 60%.

If purcased at CPAP.com WITH approval to go out-of-network (80% reimbursement):

Price = $599.00
Cost to me = $119.80
Cost to Blue Cross = $479.20

As you can see, this would save Blue Cross $304.80 and it would save me $76.20 as well. Blue Cross wins. I win. You would think Blue Cross would have jumped at the deal.

Nope. They denied the out-of-network approval. Thus if I go out-of-network, I must pay 40% and they will only reimburse 60%. So...

If purchased at CPAP.com WITHOUT approval to go out of network (60% reimbursement)

Price = $599.00
Cost to me = $239.60
Cost to Blue Cross = $359.00

Obviously this would be a great deal for Blue Cross but I would have to be stupid to pay an extra $43.60. I pointed out that I was NOT going to do that and that, if they insisted on sticking with the reduced reimbursement if I went out of network, then I would go in-network and they would not get any savings at all. No good. Blue Cross refused to budge.

Go figure. I guess the insurance companies have got money to waste. Seems like out and out stupidity to me tho.

[drj130]

Sounds like the military to me with the prices they pay for some items.

[dalemeyer]

Good Afternoon,

After reading your post Cigna, my insurance is just as stupid,

Mirage Liberty mask at Cpap.com $205.00, and with a little shopping can be found on sale elsewhere around $160.00.
Apria Healthcare charges Cigna $440.30 for the same Liberty mask. When I questioned them about the same idea of going out of network I also got the same response. But it is also Cigna and my employer that give me the same "be cost conscious" mailers and e-mails. You would think they would be good (or smart) enough to follow their own advice.

[DuaneCox2003]

I just went through the same process you did. I also have BCBS and wanted to buy from CPAP.com. No can do. The main reason I wanted to avoid the DME was because I would get bottom of the line equipment and still have to pay the coinsurance as if I was getting a Cadillac. So since the insurance denied the CPAP.com idea off to the DME I went. I was issued a S8 Escape with humidifier and mask. The insurance paid about $1500 for the equipment I could have bought for $700. Even though the Resmed S8 Escape was a good machine it gave me nothing extra. After getting home and educating myself with cpaptalk I knew I wanted a machine that would give me data feedback. So I wanted to upgrade to the S8 Elite. Called the DME and asked about the upgrade and to my surprise they upgraded me to the Resmed Autoset II for no extra cost. Apparently Blue Cross pays enough for the standard machine that it covers most machines out there. So I went from the Ford to Cadillac for no additional cost. I asked why I was not given the option for the upgrade when they issued the machine; the only reply was this is standard operating procedure.

Good Luck
Duane

[cinco777]

Bevangel wrote

As you can see, this would save Blue Cross $304.80 and it would save me $76.20 as well. Blue Cross wins. I win. You would think Blue Cross would have jumped at the deal. Nope. They denied the out-of-network approval.

The in-network DME(s) very likely have an iron-clad contract with Blue Cross that doesn't permit Blue Cross to allow/approve exceptions to their in-network vs out-of-network charges especially when the other provider is an Online establishment like CPAP.com. Additionally, we don't know about any "fine print" in the contract between Blue Cross and their DME(s). Blue Cross may be telling you one price as the price they pay, and getting a much lower price from the DME - similar to what the new car dealers have re their contract/agreement with the car manufacturers. The dealers often divulge "their cost" to us, but "their cost" is much lower when all the manufacturer hidden-from-us "give backs" are factored in. Many folks would consider these hidden "give backs" to be "kick backs".

[timbalionguy]

And this kind of entrenched thinking is what needs to be broken to really fix the healthcare cost problem in this country. With these kinds of attitudes on both sides of the money trough, it is going to be extremely difficult. This is the kind of thing that results from anti-competitive legislation like the Prescription Drug Act passed in the '30's.

The whole system needs to be torn down and rebuilt from scratch, with competition allowed where appropriate, and price controls where appropriate. Not only would costs be less, but service would be better.

[fuzzy96]

welcome to the world of medical insurance. the same greed that flushed the mortgage industry down the toilet lives and thrives here.

in all truth these companies commit extortion,price fixing,various anti trust law violations ,conspiracy, and a host of other crimes that any individual would rot in jail for.
but then again who usually sets prices? the us congress. they pass the medicare rates that everyone follows. only a moron would bill less than these rates even if they can do the same thing for 1/2 the price. and by setting in network providers the profits are assured. every wheel gets greased.
you are lucky most hmo and ppo contracts have no out of network benefit.

take what you can get and hopefully you can find a dme that will get you what you want. since it is a replacement and one time billing someone may just give ya ba break to make the quick buck.

good luck

[apnez]

This is exactly what Americans consider as being the best health system in the world! All based on private industry, profits and heavily relying on insurance companies. And according to what we hear in Canada those days, Americans want more of it!

There is something that I don't catch very well ...

[Muse-Inc]

This is exactly what Americans consider as being the best health system in the world! All based on private industry, profits and heavily relying on insurance companies. And according to what we hear in Canada those days, Americans want more of it!

There is something that I don't catch very well ...

I despise the current system! Far as I can tell, the only ones it's working for...profiting...are insurance companies, HMOs, and big pharma, the rest of us gotta beg for reimbursement and the right of our docs to practice medicine as they determine is appropriate. The whole system is corrupted by the profit-motive.

[OldLincoln]

Has anybody bought from CPAP.com and submitted it to Medicare? What happened?
Will cpap.com do a "courtesy billing" to Medicare (you pay in full they bill on your behalf)?

[jdm2857]

No way.

Medicare requires several compliance follow-ups and other record keeping that cpap.com doesn't provide.

[Pugsy]

Has anybody bought from CPAP.com and submitted it to Medicare? What happened?
Will cpap.com do a "courtesy billing" to Medicare (you pay in full they bill on your behalf)?

What are you wanting to purchase? They should treat masks the same as any other supplies (ie diabetic stuff).
People get reimbursed for those.

Machine?? Medicare does require compliance records but it might be possible to give them what they need.

I would check with Medicare directly. Ask them exactly what might be needed. If you don't ask, the answer is always no.