Insurance loophole for overseas online purchases - BCBS

[ziggytosh]

Ok, so I'm not actually sure if this is a bug or a feature, but this surprised me:

According to a letter I received from Blue Cross Blue Shield - Texas, you can buy a CPAP from an overseas, non-preferred DME provider and be reimbursed at preferred rates REGARDLESS of whether you yourself are overseas or not. Benefits are determined based on the location of the DME, not on your location. I'll quote the letter directly towards the bottom of this post.

I found this out because I work overseas and am a member of a US-based Blue Cross Blue Shield Basic option plan. This plan stipulates you can use in-network providers only while in the US, but can use any providers abroad and be reimbursed at in-network rates. Since my work involves being overseas more or less for my entire career, it seemed like a no-brainer to select the Basic option, which is $100 less per month but provides exactly the same benefits as long as I'm not physically in the US.

ANYWAY, I ordered a PR System One when they first came out and paid out of pocket. My reimbursement claim was initially rejected with an EOB stating that since CPAP.COM is in the US, I was not eligible for out-of-network benefits.

I wrote an appeals letter that cited the sections of the plan that stipulate full "in-network" benefits for services received overseas and demonstrated that I was overseas regardless of where CPAP.COM's warehouse was. While not accepting the arguments in my appeal, BCBS went ahead and gave me the benefit based on courtesy and in recognition of confusion that may have been caused by the wording of their benefits plan. So in the end, they paid full benefits (which still left me about a $200 copay) for a PR System One bought from CPAP.COM.

But what was interesting, and what my be valuable to some other people who live in the US, were some of the explicit responses that they made to arguments in my appeals letter. I had said that the wording in their benefits plan document seemed to base the location for benefit-assignment purposes of the service provided on the location of the recipient/patient. Meaning, it seemed like their brochure was saying that as long as I was overseas, I could buy from a US provider and the service would be deemed to have been provided overseas. I said I couldn't imagine the intention of the wording to be otherwise, since this would create a perverse incentive -- one that would work to BCBS' detriment -- for patients in the US to simply order from the provider of their choice based in Canada, Europe or Australia and claim full benefits for a service provided overseas.

To my surprise, while agreeing to pay me on a one-time basis, they said yes, that's exactly right: a patient living in the US who chooses to buy from a provider overseas can claim full benefits, regardless of whether the provider is in-network or not. Here's a direct quote from BCBS-TX:

"You also ask if the Plan would still deny the claim if the situation were reversed and you lived in Texas and ordered online from an overseas provider. If you would have ordered from a provider in a third country or ordered online from an overseas provider while living in Texas, the benefits would apply."

Again, this is very surprising to me, but there it is in black and white. I assume that if every patient in American ordered DME supplies from overseas, BCBS would change this policy in a hurry. But for now, if, like me, it annoys the living crap out of you that BCBS insists on paying Apria $2200 for a machine inferior to one you could get online for $850, there is a solution. If your plan uses the same boilerplate BCBS language that mine does, you can buy from the provider of your choice, as long as they are not based in the US, and get reimbursed at the maximum level your plan allows. If that is, say, 25%, well ... it doesn't take a math wiz to figure out that a 25% copay on a $850 item is much cheaper than 25% for a lesser item at a DME that charges $2200.

[LoQ]

Very interesting. I will have to check with my insurance company. I have a 30% copay in-network and a 40% copay out of net-work. I'll have to see if I can use the overseas DMEs as in-network.

What about shipping costs? Some places ship for free for large cost items, but typically not overseas.

And does anyone know how to find DMEs not in America? Can we just find some online DME and order online?

[bearded_two]

There are online CPAP providers in Australia, one of them sells the Aussie Heated Hose. It is ironic that Americans would be looking for an overseas provider because it seems that many people overseas want to buy from American online CPAP providers.

[echo]

There are online CPAP providers in Australia, one of them sells the Aussie Heated Hose. It is ironic that Americans would be looking for an overseas provider because it seems that many people overseas want to buy from American online CPAP providers.

That's because cpap supplies are about half the price in the US (at least compared to where I am in Europe). At least that's the case for masks, I don't know about the machines but those are probably much more expensive too. The selection is better too, as the DME-like entities don't carry all brands or all flavors of masks & machines (again based only on my experience).