Just got insurance EBO from BC/BS

[msradar65]

I just got the EOB for my CPAP equipment. The DME billed for $800 for my S9 autoset. My insurance discounted that price by $525 and paid them $220 and my co-pay was $55. The DME now owes me money. They told my my co-pay $303.60 and at my appointment to pick up my equipment I paid them $150. They owe me $95!!

I will be calling for my refund next week.

Its really sad though that BCBS pays sooo little. I can see why some DMEs do all kinds of stuff to get the maximum about of money they can from the patient.

[Slinky]

What were the charges, reimbursement and copays for the humdifier and mask??

[jules]

As Slinky asked, you need to get all the information. I suspect that EOB is probably just for the humidifier and not the machine or mask.

A DME may send through lots of charges for a new customer such as machine, mask, filters, hose, humidifier. The mask might be broken down into several parts too.

I would wait and find out what other EOB's are out there before you ask for a refund.

[LSAT]

I agree the price indicated cannot be for the CPAP...In most instances the humidifier and mask are purchased up front and the machine itself is rented for a period of time.

[Laurie1041]

I just got the EOB for my CPAP equipment. The DME billed for $800 for my S9 autoset. My insurance discounted that price by $525 and paid them $220 and my co-pay was $55. The DME now owes me money. They told my my co-pay $303.60 and at my appointment to pick up my equipment I paid them $150. They owe me $95!!

I will be calling for my refund next week.

Its really sad though that BCBS pays sooo little. I can see why some DMEs do all kinds of stuff to get the maximum about of money they can from the patient.

Your DME is under contract with BC/BS and knows up front before the contract is signed as to what the insurance company will reimburse under any applicable billing code. If a provider finds they do not like the terms of the pre-established reimbursement schedule, the in-network provider will simply refuse to sign another contract with the insurer. This happens all the time - providers opt out of the network due to low reimbursement rates.

An in-network provider that engages in practices to "do all kinds of stuff to get the maximum about (sic) of money they can from the patient", is either committing fraud upon the insurance company or hoodwinking the patient by participating in a scheme known as "balance billing" - charging the patient x amount of dollars over the charges they are responsible for (deductibles, co-pay). The practice of balance billing is illegal under Medicare and many insurance companies
specifically state in their contracts with in-network providers that "balance billing" is specifically prohibited. Using an in-network provider provides an incentive for the patient because the cost-share of the service is less than using an out of network provider. Out of network providers are not under contract and therefore may be able to bill at the "reasonable and customary" charge for a given region and a patient's cost-share can be as high as 60%. It stands to reason, that many would rather use an in-network provider and only be responsible for their deductible and a co-pay of 20% (depending on your insurance plan).

In-network DME providers who defraud patients by obtaining additional monies over and above applicable deductibles and co-pays should be promptly reported to the insurance company. I reported my DME to my insurance company for trying to extract an additional $300.00 over and above my co-pay of the "allowed amount" for my S9. In less than 24 hours, I received a call from my DME stating they had "made an error" and to come in and pick up my machine. Laurie

[Janknitz]

I don't feel sorry at all for a DME if they are contracted to receive a certain price for DME. They have a choice whether or not to enter into the contract with the insurer or not. If there was not a benefit to the DME's bottom line, there would be no reason to agree to the contract. If DME's refused to contract with insurers because of poor reimbursement rates, insurers would have to negotiate better reimbursement in order to fulfill their contracts with their insured members. Then they would raise your premium rates--sigh--it surely won't hurt anyone's profit but YOURS. BC/BS profits are in the BILLIONS, BTW.

Many times, there are hidden sources of profit. For example, Crapria has an exclusive contract with Northern California Kaiser (perhaps all Kaiser regions?). This means that Kaiser members, because it's an HMO can go ONLY to Crapria if they want Kaiser to pay anything. Crapria gives Kaiser a good price on the machines, and in exchange gets repeat business for the life of the Kiaser member. What they lose in individual profit they more than make up for in volume. So it's a win-win for Crapria and Kaiser (sometimes it's a win for the patient, too).