Newbie with DME ?'s

[ksilb]

Howdy-me again! Reading here led me to ask another question.
This one is about the DME provider and cost. I realize that everyone's insurance is a little different and the bottom line here will be to check with mine but before I do that I would love a little guidance on if it sounds like I should bother.

Background-very severe apnea. That is probably all the background needed and I don't want to repeat from previous posts where I gave the numbers.

I was prescribed the coveted Resmed S9 Auto CPAP without any need to ask for an upgrade. After reading here a bit before receiving it I felt pretty lucky not to have to fight anyone to get it. Just figured that was due to the severity of my apnea. I was also called by a DME who the doc contacted rather than them sending me the prescription and a list of providers covered by my insurance which is BC/BS. I was prepared to do some price shopping but everything moved along quickly and conveniently so I didn't. I just wanted to sleep!

The DME came to my house, fitted the mask, gave me good instruction on the machine and since then I have gotten follow up calls both from him and their home office in less than two weeks.

I was told that my policy was the standard 80/20 and my portion of that was $645. This included the humidifier and all necessary replacement supplies for life(hopefully they won't go out of business but are statewide and have been around for awhile). Though this was more than I anticipated I just presumed when getting the Jag of machines you pay the Jag copay.

When I got a copy of the statement it was billed as $320 for the equipment and $325 for an "upgrade". Does this sound right to you?

Thanks to you all and all those who replied to my earlier mask question earlier today. Kathy

[jules]

all necessary replacement supplies for life

Den has some ocean front land in WY to sell you.

[KatieW]

ksilb, that doesn't sound right to me. Or too good to be true. Better re-read the fine-print on your contract, and check with your insurance company as well.

And get a copy of your prescription and sleep/titration study, in case you ever want to buy elsewhere.

[CT58]

I'm a Newbie as of April 6th. Also received the S9. My Ins. is 70/30 but only paid $394 for the whole works. There was no mention of "upgrade" cost. However I was not allowed by BCBS to get "life time" supplies (if I understood you correctly). Those are pay as I go.

Good luck with your DME. I hope they come clean with you. I don't know if your Ins. people could help you by looking into this as well? Am sure others here with years of experience will know more.
Best wishes!

[echo]

all necessary replacement supplies for life

Den has some ocean front land in WY to sell you.

Better check what exactly those "life time supplies" are .... the little connector hoses and power supplies? I can't think of a single thing on my machine that is replaceable except for the filters, and maybe the humidifer tank. They're for sure not talking about hoses and masks!

I think they're hoping that in our sleep deprived states we'll either be too stupid to notice or too tired to fight back.

[jules]

When I got a copy of the statement it was billed as $320 for the equipment and $325 for an "upgrade". Does this sound right to you?

If you were not informed there would be an upgrade charge, that is also wrong imo.

You were told supplies for life -------- that has to be a joke - DME's demands frequent new Rx for billing supplies to insurance.

You got taken for a ride imo.

I would be in touch with insurance company and Better Business Bureau and state consumer fraud hotlines.

[ksilb]

Thanks for your replies but I did ask both the DME provider and the person in the office who told me that she was the one that would be sending supplies. She said I was on a three month reminder for a new mask every three months, a new hose every month and three filters and something else that has to do with the mask though I didn't quite understand that one every month. She said that if I had more than one mask they would alternate which replacements they sent. She was very clear that there would be no additional charges on these items. I thought it was a little odd too so I asked twice. And while I would love to have some ocean front property, not in WY thank you but if anyone has anything in CA or Ore, I'm on...LOL.

I plan to talk to the DME guy again next week about another mask so I'll ask again but I asked clearly and reiterated that were they sure there were no further copays and they said yes. I just thought that was because I had to pay more for the machine in the first place. I did not receive a contract, only a receipt for my payment.

I do need to get a copy of the prescription which I don't have yet, but thanks for reminding me. Kathy

Kathy

[ksilb]

Ok I did look and I do have a contract which doesn't state anything about supplies. It seems to be a pretty standard contract but I have taken all your words to heart and will be looking into this next week. I want to get something in writing about these supplies if I did understand it correctly and if not then find out exactly what they were saying though I'm sure I heard them clearly. Also after the response about the cost on a 70/30 being so much lower than what I paid, I will contact BC/BS. Let me say however, that I am a state employee and it is possible that my coverage is different than another BC/BS in another state or independently purchased. However, one thing I don't understand (well probably more than one in this new world) from reading the posts on here is about the coding being the same for the machines. It would seem that some machines would cost more than others. The newer models or the ones that have more features would seem to cost more. If they are billed 80/20 then it would stand to reason there would be variable out of pocket costs on the copays depending on which machine you got and from which providers. Is the coding the same discounted rate for all the machines to the insurance company? They did tell me that the cost of the machine to the general public is much higher than what they are allowed by insurance and they get a lower rate from the insurance company though it certainly covers their profit margins I understand. But is that what you meant about the coding being the same for the various machines?

Obviously you have my attention on this and I can assure you that I don't get taken often as I try to be a really informed consumer though in this one I moved more quickly than normal. I do ask questions and I do get answers. The only thing I didn't feel that I did well on this, before reading your replies, was that I didn't "shop" the providers. I hate interacting with doctors so when I didn't get a choice in providers and because the customer service was so good, which is so unusual, I just didn't ask. I did ask the DME rep why I hadn't been given choices and he told me that I certainly could shop for price comparisons but the reason that my particular PCP had sent the prescription to them was because they have a good working relationship. And no, don't offer me that ocean front view again, I did wonder if they had a "reciprocal agreement". That said, I have found this physician's office to be pretty much on the up and up. They don't nickel and dime me to death with visits and copays which I have experienced in other practices so I just didn't question it. I will now of course. Thanks again. Kathy

[jules]

your insurance pays for whatever will treat your condition not all the bells and whistles - so as far as they know you could have gotten a bottom of the line basic machine with no frills

they are all billed same code - your insurance contracts a rate to pay the DME for that code not different amounts based on what machine you got

it sounds like the DME wants to fill their coffers with all these other supplies - you don't need all of those things that often (the monthly thing was mask cushion or nasal pillows) - you sure don't need a new hose each month unless you have cats that play with the hose - I have lost 2 to cats in over 4 years - some things are nice to replace often like filters - one thing you don't want is AUTOSHIP

your doctor ordered the new fancy machine - they filled it - they should have told you there would be an upgrade charge if they wanted to charge it - they should not have lied (that remains to be seen I know) about no more copays for supplies - they have to bill you your part unless your coverage is 100 % for DME supplies

[ksilb]

Ok, Jules, thanks. I will call on Monday to get all this clarified and in writing. I do believe they were talking about an autoship so I will make sure that is out. I agree it didn't seem that I needed that much and you are correct, it was the cushion on the mask that was monthly and then the mask every three months. I will also contact the insurance company if I don't get a reasonable answer from the DME. I don't have cats, just a little dog who hopefully would never eat my hose but it is out of harm's way in a drawer she can't get into. Thanks again. Kathy

[Wulfman]

Howdy-me again! Reading here led me to ask another question.
This one is about the DME provider and cost. I realize that everyone's insurance is a little different and the bottom line here will be to check with mine but before I do that I would love a little guidance on if it sounds like I should bother.

Background-very severe apnea. That is probably all the background needed and I don't want to repeat from previous posts where I gave the numbers.

I was prescribed the coveted Resmed S9 Auto CPAP without any need to ask for an upgrade. After reading here a bit before receiving it I felt pretty lucky not to have to fight anyone to get it. Just figured that was due to the severity of my apnea. I was also called by a DME who the doc contacted rather than them sending me the prescription and a list of providers covered by my insurance which is BC/BS. I was prepared to do some price shopping but everything moved along quickly and conveniently so I didn't. I just wanted to sleep!

The DME came to my house, fitted the mask, gave me good instruction on the machine and since then I have gotten follow up calls both from him and their home office in less than two weeks.

I was told that my policy was the standard 80/20 and my portion of that was $645. This included the humidifier and all necessary replacement supplies for life(hopefully they won't go out of business but are statewide and have been around for awhile). Though this was more than I anticipated I just presumed when getting the Jag of machines you pay the Jag copay.

When I got a copy of the statement it was billed as $320 for the equipment and $325 for an "upgrade". Does this sound right to you?

Thanks to you all and all those who replied to my earlier mask question earlier today. Kathy

With $645 as your 20% share, that would make the total come out to $3225.

You say ".....without any need to ask for an upgrade"......but then you say "....and $325 for an 'upgrade'."

No, it doesn't sound "right" to me.
Depending on what your insurance provider actually PAYS for the billed amount, that could make a difference......but the 20% is usually calculated on the "BILLED" amount and not what the insurance "PAID" amount will be.

When a person uses a "brick & mortar" DME, they need to do the math and read their contracts carefully (before they sign on the dotted line).

Good luck.

The Wyoming ocean-front property is not for sale to Texans......they already have plenty of everything.....


Den