Insurance Price Unavailable

[Wulfman]

I think they can bill different insurance companies differently depending on their contractual-relationships. At least that's the way it is with regular medical care. Say a network doc's rate to Joe Consumer is $200. His network negotiated rate might be $150. However, another "out of network" doc is "retail" $200. But the Reasonable and Customary is $160. Well, then he's going to bill you $200. You can mail the claim to your provider who will only reimburse you for your portion of the $160. The $40 remaining is yours to suck up.

Right. But, if that $200 (or $160 or $150) item is available somewhere else (like an Internet seller), you could probably buy the thing "out-of-pocket" for.......$40.


Den

[Roman Hokie]

True, Wulfman. I think for my first unit and getting set up with it - until I consider myself an SME (Subject Matter Expert), I'll work with the local bunch. I will always keep Johnny and his crew in mind in the future, that's for sure.

[CyberPro]

Hi Mattman,
I forgot to answer your question if they flat out refused to provide a price.
Both stated that billing was handled by the corporate office and pricing was not available locally.
One did state the she thought it would be in the neighborhood of $3000.00!
I did not ask for the amount that was my responsibility but the amount that was going to be billed to Cigna.

At that point I decided to go "out of network" and buy from CTalk.com.

Thanks again for your feedback.

Frank

[mattman]

Hi Mattman,
I forgot to answer your question if they flat out refused to provide a price.
Both stated that billing was handled by the corporate office and pricing was not available locally.
One did state the she thought it would be in the neighborhood of $3000.00!
I did not ask for the amount that was my responsibility but the amount that was going to be billed to Cigna.

At that point I decided to go "out of network" and buy from CTalk.com.

Thanks again for your feedback.

Frank

Ugh. That sucks. I hate hearing crap like that. That's just lame in my opinion. Certainly crappy customer service.

Sorry to hear you got that got of runaround from someone but glad to hear you got what you needed from somewhere at least.

mattman

[mattman]

Can you answer this question: "how much do you intend to bill the insurance company for this particular machine?" It should be a constant, correct?

Not always, unfortunately. With most insurance contracts, the Insurance Company will specify both the billed amount (The "submitted amount") and the amount they actually pay (The "allowable amount"). Not all, but most are setup that way.

Sorry, but as I understood the question was what is the BILLED price, not what is my insurance's price or my copay price, etc. What is the BILLED price is easy enough to understand. Or do DME's bill BILL different insurances different prices??? Now THAT would be interesting from a legal standpoint.

Yes, they do. Again, it all depends on the specific insurance contract.

According to some information previously posted by the DMEs who frequent this forum.......

The DMEs base the co-pay (amount paid by the user) on the "billed amount" and not on what the insurance provider actually pays.

So, in the long run, the insurance pays for the cost of the machine to the DME and the end-user pays about the same amount......which is PROFIT for the DME.

Den

Not entirely correct. The contract with the patient's insurance company will typically specify both the submitted and the allowable price. Further, the Patient's insurance policy will also usually specify what, if any copay is required and what it is based upon. There are additional laws in many states and also stipulations with most insurance companies that a DME provider is legally required to collect whatever co-pay outlined by the patient's insurance policy. In many cases it is actually illegal (and considered insurance fraud) to waive a patient's copay. So in cases where even when a provider may very much want to reduce or waive a copay, they absolutely have to decide if it's worth risking getting in legal trouble for.


Trust me, understanding this stuff is very much a full time job. It's every bit as convoluted and annoying from the providers side as it is from a patient side - and I'm speaking from experience on both sides!

mattman

[Dennisla]

<x- cut> I also have Cigna and have been told by them to use Apria as my DME provider for my CPAP equipment. <cut X->
Update
I also have Cigna and have now been told they changed to carecentrix from Apria as my DME provider for CPAP equipment.
We are tied to a $1500 limit each year for DME equipment. I've already got a replacement mask 1 in jan.
And have ordered replacement mask two already. (don't have it yet)
My doctor just wrote me a new script, it reads as follows.

---------------------
Resmed S9 autoset with H5i humidifier and climate-line
Setting: 7 - 10 cm H2o
No replacements. This machine is required for
patient erratic and shallow breathing.
His existing macine is old and not functioning as necessary.
---------------------

After reading this thread I imagine I may also be in for a ride.
Also I don't see anything good written about carecentrix on cpaptalk anywhere.. YIKERS

Dennis

[WilsonVilleUSA]

Here is my experience....

My employer is also "Self-insured", they use Aetna to manage the process. What I learned in my initial trip down the OSA path, and has continued is this:

As far as insurance is concerned, a CPAP, is an APAP, is a CPAP. Make, model don't matter. They ALL get billed using the HCPCS code E0601. This is insurance code for "CPAP Machine". Same code is used for APAP machines, but BiPAP and other do have different codes. These are standardized insurance codes, and for every code there is a "Usual and Customary" charge. This amount varies depending on the location of the provider. If you get it from your local DME provider it may be one rate, if you get it from CPAP.com it will be based on their location (Missouri City, Texas). This "Allowable charge" is the same whether you get a basic cheapo CPAP or the Cadillac of APAP's, the ResMed S9 AutoSet ( ).

My experience in buying three machines through insurance over the years is that your insurance is ALWAYS billed well over the "allowable" amount. If you are using an an in-network DME, they will write off the overage (that is part of their agreement when they become a network provider) and you pay your percentage of the allowed charge. Since this allowed charge is the SAME regardless of machine, you can expect to pay the same amount no matter what your machine.

Another part of the network agreement is the insurance will cut side deals with the DME to limit your choices/maximize the DME's profit and only "allow" certain equipment. This why if you are going in-network it is important to get your Doc to write your script for a SPECIFIC machine and to DISPENSE AS WRITTEN, NO SUBSTITUTES. My network provider has one CPAP option and one APAP option, along with three mask choices (one FF, one nasal, one Pillows). If your RX doesn't specify something different, these are the "only" choices. None of the options my in network DME had were popular or current items. There was some variation in the different in-network DME I checked with, but all were offering what I would consider second (or third) tier equipment.

With my initial purchase, I found I was going to be billed my percentage of my insurances max allowable and get a basic machine (no data capabilities) and was only presented with two masks to try on to see what felt comfortable. Instead of getting my machine from the in-network DME place, I bought the then top end Respironics Auto with C-flex (aka "Tank") from cpap.com, got the data card reader and Encore software bundle with the machine. With cpap.com's fair market/legitimate pricing, I got the top-end machine, card reader, and software and paid LESS then I would have going through the local DME and getting a basic machine. I had to deal with reimbursement process, but I saved money and got a better machine.

When billing insurance they also tend to "Part out" the item purchased and bill every available billing code. This is the dirty little secret about insurance and part of why costs are so high. Your insurance never sees what make/model of equipment you get, all they see is a billing code and the billing code description (ie "A0733 Nasal Pillow, Qty 1).

At cpap.com you buy a Swift FX for $129. It comes with S-M-L pillows, and headgear. In fact almost every mask comes packaged as a complete unit. If you get the same mask from an in-network provider they are parting it out and billing insurance under every allowable code, that looks something like this:

Nasal mask A0732(the part with the tube) Charge- $150 Allowable- $100
Headgear A0735 Charge- $100 Allowable- $75
Nasal Pillow A0733 Charge- $50 Allowable-$50
Total Charged $300, Total allowable- $225

On an 80/20 split, insurance pays $180 ($51 MORE than cpap.com total price) and you pay $45
If your insurance spits 65/35 for out of network, insurance pays $146.25 and you pay $78.75.


EVERY CPAP/APAP comes from the manufacturer with a hose and a carry case. Some even have integrated humidifiers. If you buy an APAP, for example a Sandman Auto HC with an integrated humidifier (cpap.com sells for $579), this is what you could expect for insurance billing:

CPAP Code E0601 Charge- $1200 Allowable- $900
Heated Humidifier E0562 Charge-$400 Allowable-$350
CPAP Hose E7037 Charge-$50 Allowable-$30
CPAP Filter A7038 Charge $15 Allowable- $11
Carry case E1399 Charge-$100 Allowable- $50
Total Charged $1765, Total Allowable-$1341

On a 80/20 Split, you pay $268.20 to in-network provider (assuming you could get this machine) with insurance paying $1072.80. Buy it at cpap.com and with a 65/35 out of network split, you pay $202.65 after reimbursement. If you could buyit at cpap.com with a 80/20 split, insurance would only pay $463.20, less than half. Your 20% would be $115.80. So where is the "benefit" of insurance trying to push you to an in-network provider? Hmmm, don't want to sound like a conspiracy theorist but maybe by reducing the benefit and limiting choices, they would really rather see you go out of network so they can pay less. Even if they occasinoally pay more for those who go in network. Regardless, they get to complain about all the skyrocketing costs and keep raising premiums, deductibles, copays, etc. while reducing coverage even more.

These are just a few examples, dollar amounts will vary based on location, etc but these amounts are a representative example and not exaggerated. You would be shocked to see what insurance allows for this stuff (assuming you know what cpap.com's prices are...) The system is all about keeping the system going. DME's don't charge "Suggested Retail Price", they charge what they can get and that varies with insurance providers.

Any talk about skyrocketing costs is just to justify the increases they charge. If insurance was really interested in controlling costs they would look at the actual equipment involved and real world prices instead of generic billing codes. They would also and quit penalizing the patient with lower coverage splits when they go out of network and buy things at fair market value. The fact that cpap.com and other online suppliers DON"T deal with the hassle of insurance is why they can charge the prices they do. The more paperwork being shuffled and the more bean counters employed, the more cost involved.