Questions about mask purchase as Out of Network Ins.

[Rogue Uvula]

I am happy to say, though, that in the past two days, I have encountered some of the most professional help and great customer service at cpap.com and from DeVilbiss! This has taken my stress level down several notches from the utter frustration of dealing with my pathetic HMO!

Let us know how you like the DeVilbiss! Glad to know they have great customer service.
I used to deal with DeVilbiss on the paint side, and the were excellent to deal with and had some of the best gear out there.
I expect to eventually buy one of their units as a backup (after my CC cools down a bit from buying the S9 system).
However they do it, they seem to pass value pricing on to the end user. Nonetheless, my doctor is familiar with ResMed, so I figured that is what I would get through insurance.

Cheers,
Kurt

[Gia]

At the risk of putting a bulls-eye on my back - I will admit that I actually work for one of the evil empires (Insurance companies) and have a couple of thoughts:

Sometimes instead of EOC you will hear the phrase SPD. This stands for Summary Plan Description. Both are basically your benefit booklets - but usually the EOC/SPD are not as specific as people think they are. They do not give you frequency limitations on DME, the medical necessity criteria etc. They will generally define what DME is, and have some generic phrase about medical policies. Medical Policies are a fluid process where they are all constanty reviewed - so placing detail such as that in a specific contract doesn't make much sense, and can actually limit peoples benefits. Also if it is some type of group contract, then the EOC/SPD is not the actual contract - the employer group has the actual master contract and may or may not be willing to share it with their employees.

Interesting point - most health plans do have medical policies related to XPap and they do distinguish between CPAP and APAP even though they share the same HCPC code (other types of xPAP have their own codes so I'm addressing those). BUT, and this is the key - most plans will not waste limited employee resources on suspending every claim for E0601 to determine if it is a CPAP or APAP (cannot guarantee that this is true for all plans). This could also true for supplies as well - although the DME providers will state that your plan permits you to replace this supply every X months - take it with a grain of salt. I have never seen a specific medical policy (aside from Medicare) from any insurance carrier (and I've search websites of a lot of major carriers for various purposes) that specific lists any limits. Not to say some do not have any coded in their system, but frequency limitations on things like this are actually few and far between - even though health care providers like to spout off these limitations left and right.

As far as the OON question goes - it all depends on what your plan's OON pricing is - if they base it on Medicare's rate - then you will have a much higher member liablity than if they base it on their own network pricing (Medicare usually has the lower fee scehdule). There is also the issue of whether or not our OON copay maximums and your IN copay maximums are co-mingled. If they are it is usually a one way street (IN counting towards the OON, but not the reverse). Also be aware that not all HIA/HSA/HRA/FSA plans will reimburse you for charges over the allowed amount by the insurance carrier (and will require a EOB from the carrier even if it is a denial). They will usually only cover deductibles, coinsurance, copays, benefit maximums, and specific non covered services.

So basically there are too many variables based on your specific contract to say one way or the other whether or not it will make more sense to go in network or out of network.


Not much helap is it ?

[Rogue Uvula]

Actually, it does help.

I was asking for replacement intervals and the BCBS rep said that they did not have a schedule and it was up to the doctor. That fits with what you are saying, but I haven't seen anything here that has mentioned the doctor prescribing a new mask interface every 3 months, etc. I suspect that the reality is I'll replace the consumables at whatever frequency the manufacturer recommends and I'll stay under the radar.

Insurance companies are big and it sounds like the confusion is core to the entire institute, not only at the consumer level.
You have my sympathy!

[Emilia]

Hi Kurt,
I am very excited about trying this new DeVilbiss AutoAdjust machine with the Smartflex. They also just released a new software package for the Smartlink (v. 2.0), and cpap.com just started to stock it as of last evening on their website. I believe with these upgrades to the machine/software, they are going to give the 'big boys' a run for their money. I would imagine a new product challenge will be held soon!

[Rogue Uvula]

Hi Kurt,
I am very excited about trying this new DeVilbiss AutoAdjust machine with the Smartflex. They also just released a new software package for the Smartlink (v. 2.0), and cpap.com just started to stock it as of last evening on their website. I believe with these upgrades to the machine/software, they are going to give the 'big boys' a run for their money. I would imagine a new product challenge will be held soon!

Seriously, between the price increase, price controls, and (as I just discovered) unavailability of software, it seems like ResMed has made a decision to empower the local DME's at the expense of end users who want control over their own treatment. I mean, why would they quit selling software to the consumer???

The overall quality of treatment comes first - and as a complete noob, I felt compelled to buy what the local doctors seem to be familiar with. I'll find out next Wednesday if the doctor even cares about data, much less which brand the data is coming off of. If not, I just did my part to needlessly increase the cost of health care!

[Emilia]

I think you will learn that the software was never for sale to the consumer.... the software was for DME or doctor use only. However, if you PM Uncle Bob here on the forum, he will provide you the secret handshake and decoder ring to get a copy of the software!! At least that is what I've learned from reading the many requests for it. DeVilbiss seems to offer their software for sale even though there is a disclaimer it is for DME/Doc use And Respironics has software readily available for purchase, too.... so why does ResMed hide theirs? Good question!!

[Rogue Uvula]

Thanks!
I got on "the list" for the software this morning.
I figure he probably batches them out once every couple of days. Otherwise, I think it'd be a full time job!!!

[chunkyfrog]

Replacement-allowable interval, instead of being a set schedule, seems to be a 'play it by ear' process.
Kind of indicating they can make up the rules as they go along.
It reminds me of a card game they played at the State Fair--
It was called 'Razzle-dazzle' and there were no set rules, as long as the dealer always won.
It was banned by the State Patrol, because it was basically, CHEATING.
Oh, yeah--insurance companies can do that. . .
Anybody know one that doesn't?