Insurance payments and my payments do not match

[Kahfree]

I know we have gone over this in the past, but I am confused.

In January when I received my entire CPAP machine and supplies, I was told to leave a payment of $300.00 and I did. The amount on the charges stated $1,250.00. This would leave me a balance owed of $950.00, of which the DME sent me a bill for that amount. However, today I checked my insurance plan online and the statement of what they applied to my deductible for my equipment seems more than I was asked to pay. Can someone tell me if it is likely that I will be billed more than I signed the paper for, or since I signed that paper, is that all they can charge me?

Bill received by Aetna on 03/31/2011 $1798.20
Claim ID
Status:Completed
Payment: Made to Provider
Health Care Professional: Advanced Homecare

Your Aetna member rate $1,060.20

SERVICES IN THIS CLAIM:
CONTINUOUS AIRWAY Billed to Aetna $250.00 Agreed amount $225.00 Applied to my deductible $225.00 My responsibility $225.00
HUMIDIFIER HEATED USED W PAP Billed to Aetna $475.00 Agreed amount $427.50 Applied to my deductible $427.50 My responsibility $427.50
POS AIRWAY PRESSURE FILTER Billed to Aetna $ 48.00 Agreed amount $ 43.20 Applied to my deductible $ 43.20 My responsibility $ 43.20
POS AIRWAY PRESS HEADGEAR Billed to Aetna $ 90.00 Agreed amount $ 81.00 Applied to my deductible $ 81.00 My responsibility $ 81.00
REPLACEMENT FACEMASK INTERFA Billed to Aetna $120.00 Agreed amount $108.00 Applied to my deductible $108.00 My responsibility $108.00
CPAP FULL FACE MASK Billed to Aetna $195.00 Agreed amount $175.50. Applied to my deductible $175.50 My responsibility $175.50
TOTAL of CHARGES $1,060.20

Amount paid toward meeting your deductible
$1060.20
Amount paid toward your remaining coinsurance
$0.00
Your copay amount
$1,060.20
Your total Responsibility
$1,060.20
Bill Part Two__________________________________________________________________________________________________________

Claim ID
Status:Completed
Payment: Made to Provider
Health Care Professional: Advanced Homecare

Bill received by Aetna on 03/31/2011 $1798.20
Your Aetna member rate $558.00

SERVICES IN THIS CLAIM:
TUBING WITH HEATING ELEMENT Billed to Aetna $120.00. Agreed amount $108.00 Applied to my deductible $108.00 My responsibility $108.00
CONTINUOUS AIRWAY Billed to Aetna $250.00 Agreed amount $225.00 Applied to my deductible $225.00 My responsibility $225.00
CONTINUOUS AIRWAY Billed to Aetna $250.00 Agreed amount $225.00 Applied to my deductible $225.00 My responsibility $225.00
Total Amount $558.00

Amount paid toward meeting your deductible
$558.00
Amount paid toward your remaining coinsurance
$0.00
Your copay amount
$558.00
Your total responsibility: $558.00

So...does this mean they will keep charging me all those same amounts each month? If I add the two together, it amounts to $1618.00 that I am responsible for but the DME gave me an original bill of my responsibility of $1250.00, of which I paid down $300 and got a bill for $950.00. Help me understand, please.

[mebeingme]

What is your deductible amount on your insurance? What percentage is your insurance covering ex: insurance pays 80% your resposible fro 20%?

[idamtnboy]

Someone who has Aetna can probably clarify further. I see a $250 charge three times for a continuous airway. Have you had the machine for three months and so this reflects a monthly rental? As I understand, and have seen on my EOBs (explanation of benefits), only the PAP machine itself is rented. All the other parts and pieces, including humidifier, are purchased for a one time charge.

So, it looks to me like you are seeing a rental charge for three months of an agreed amount of $225/mo, plus all the other agreed amounts for purchased items. You also must have a deductible of $2000, or greater, for the year for your medical insurance. Is this right? Aetna won't pay anything, unless your insurance plan specifies otherwise, until you have met your annual deductible. After you meet the deductible then you have a 10% to 20% copay, right? Apparently you have not had any other medical charges which, when added to these charges, bring you up over your deductible for the year, correct?

Insurance payments fall into three general categories. Medical expenses applied to your annual deductible, expenses not subject to the deductible but are subject to copay, and expenses not subject to deductible or copay. It looks like Aetna uses coinsurance to refer to what I'm used to calling copay. You and Aetna together will pay the agreed amounts, but nothing more. As you already see, the agreed amounts are less than the billed amounts. Your policy probably has an individual deductible and a family deductible. The family deductible may be less than 2x or 3x the individual deductible. This means if you have several family members with medical expenses you may reach the family deductible before you reach any one individual deductible. At that point you pay no more deductible. You undoubtedly also have a maximum annual out of pocket limit of something like $10,000 individual, $15,000 family. That means when you reach those limits you pay no more out of pocket. Now, these numbers are all over the place depending on your specific insurance policy. They also vary for high deductible and low deductible plans.

Does this help? Do have access to more than one insurance plan? If so, next time you can make a change you will want to explore the premium costs vs. the out-of-pocket costs to see which plan is likely to be best for you.

[Janknitz]

I'm not sure I understand where they came up with the $1250 either, but do be aware that DME BILL more than the amount allowed by Aetna (they BILL more than they ever get from insurance companies--I guess it's supposed to make the insurance company feel good by slashing the reimbursement ). You and Aetna only have to pay the allowed amount, in this case that's called the "Agreed Amount". If you had met your deductible, Aetna would have paid a percentage of the "Agreed Amount" (usually 80%, but not always) and you would be responsible only for the remaining percentage to bring the "Agreed Amount" to 100%.

Since you are paying into your deductible, the DME cannot charge you more in total than Aetna's agreed amount. If you had no insurance, the DME would cheerfully charge you the full $1798.20

It looks like to me that there is a $250 per month charge for RENTAL of the CPAP machine. Aetna won't start picking that up until your deductible is met. The first bill included your first month's rental and the second bill included 2 months rental plus additional supplies. If this is the case, the $1200 they quoted you on the first month was incorrect, but there will be additional monthly charges until the rental is paid (if Aetna does capped rentals) or forever if Aetna does not cap rentals. You need to call Aetna to understand if they cap rentals (meaning you are renting to own and after a certain number of months the machine is yours).

Note that if your machine is still in a rental period at the beginning of next year, your deductible will be reset to 0 and you may be paying out of pocket again!

Notice also that they parted out your mask. Instead of charging you for a mask you can buy with all parts included for about $180, they charged you separately for the headgear ($81), cushion ($108) and mask ($175.50)--wasn't that nice of them to double the cost???? And I'll bet it all came in the same sealed package! This is common practice, but it stinks!

When you have a large deductible and pay out of pocket, it's always worth it to calcualte the costs of deductibles, co-pays and billing headaches and determine if it's a better deal to buy online. Sometimes (not all the time) those online purchases can at least go toward your deductible.

[aka fuzzy96]

as usual it looks like youd've been better off buying online.
most insurances are ripoffs unless something drastic is going on.

[Kahfree]

To answer everyone's questions, I have a $2,000 deductible and after I meet it they pay 80%. I am the only person on my insurance, so meeting this will take time.

Also, I just noticed on my Aetna Claims online that they applied the deductible to my OUT OF NETWORK charges. TO me, this is unacceptable. I was never offered a choice with who I had as a DME...(I have since learned I could have refused them and purchased my machine myself though online or through an approved DME) I wrote to Aetna to ask why this was done and if the DME that sold the equipment was an out of network provider. If so, I also complained that they work with the doctors office and that no one informed me they were not the preferred provider for Aetna, which to me seems unfair to someone who is not familiar with the system. All I knew that day was they are in the office working with the doctor and I was told they will bill Aetna. No mention was ever made to me that they are not the preferred provider. I will have to wait till tomorrow for a response from Aetna.

I will have had the machine since January 17. Am I allowed to return the machine to the DME and then pay for one myself online? Can I give it back? The DME told me the machine is mine when I am done paying for it. I assumed that meant the $1,250.00, but who knows. Would that mean they keep billing as a rental after I submit the $950.00 to boost the the Deductible what it needs to be to meet it? He said it takes about 9 months so that by the end of this year I can get all new supplies paid for by the Insurance provider, but...my OUT of pocket Deductible is a lot higher, so I am sure it will take longer.

So aggravated, yet I wish I had known more before I agreed to the machine. I really had no time to research as they gave me the machine on the spot.

[Janknitz]

This is a problem when your sleep clinic is in cahoots with the DME (and probably gets some form of kickback from them). You are given a diagnosis and told you need a machine to save your life, and by the way, here's a supplier who will "give" you the machine and bill your insurance.

At that point in time you are reeling from the new diagnosis and the treatment you are facing and have NO idea what's going on. They think they are helping you, but by failing to give you time to process everything so that you can make an informed decision about the DME and equipment.

You can whine all you want to your insurance company that you weren't given information or a chance to shop elsewhere, but your insurance company is not going to care. The only leverage you have is with the DME because you relied upon their representations that were unintentionally misleading at best and possibly deliberately false.

If it's a rental, you probably CAN return your machine--but now you'll be out of pocket for 3 - 4 months rental and all those accessories and may be left with NO machine when you recognize you really need it. So don't be too hasty. Calculate how much it's still going to cost you and then see if you can find an equal or better deal online, or through cpap auction, secondwind, craig'slist, or a DME that DOES work with your insurance.

[idamtnboy]

You're pretty close to meeting your deductible already. The only issue is how patient the DME will be in you getting them paid. I'm sure you can make the DME take the PAP back and you will no longer have the monthly charge. How much of the other stuff they will buy back is a good question. If you scream and holler at Aetna you may get them to cut you some slack because no one told you the DME was not in the network, but I kind of doubt it. It's the patient's responsibility to know if any particular provider is in or out of the network. Not necessarily fair, but then much isn't in the insurance world.

I think at this point your best route is to take the flow generator back to the DME, and keep everything else. Regardless of how you slice it, you will eventually be out $2000 for the deductible, so whether that covers 10 pieces of equipment, or 20 pieces, doesn't make a tremendous difference in the end. Then get a flow generator the same as you have now from an in-network DME, or a lower cost online supplier. That way you will save as much of your investment so far as practical, and save on future cost as much as practical.

If you take the $1250 your DME originally quoted, and add to that two more months of rental at $450, that adds up to $1700 which is close to the what the Aetna bill lists as your member rate of $1060.20 + $558.00 = $1618.20. I believe the $1250 the DME quoted (charged?) you at the beginning was all the purchased stuff plus the first months rent of the flow generator. It sure looks like they did not make clear to you what the system was going to cost on an ongoing basis, that you would be renting, not buying, the flow generator. But, as many on this forum have said, many DMEs do a super job of misleading or misinforming the patient about costs, etc.

At this point you owe the DME $1618.20 minus the $300.00 you already paid. See if you can find what the in-network cost would have been for the entire list of stuff you've gotten so far, and offer that to the DME. Maybe sweeten it a hundred or two, and see if the DME will accept it. After all, that is all they would have gotten from any contracted insurer so they have nothing to lose. I would suggest you do this after you have gotten a flow generator from somewhere else and taken this one back. That way you put them in the position of accepting what you offer, or pursuing you via collection means, which will cost them 50%.

Get another script from your doc, and express your great unhappiness that they didn't make sure they were sending you to an in-network DME. Good luck. Hope this helps. Let us know.

EDIT: I just read what Janknitz wrote. She makes a good point about the rental you have already paid. Find how much more that the $675 you've already paid they will require before you own the machine. If it's less than what a machine from somewhere else will cost, then you may need to stick with the current DME, for the machine rental only, until you can finally stick it to them!

[codinqueen]

It is common practice for the Dr's office personnel that are arranging the CPAP machine and accesories to call the insurance co for approval of the machine and see which DME cos are in-network for the patient, and THEN to call the DME to order it. I don't believe your Drs' office did all the research they should have, before sticking you with an out-of-network provider. Most insurance companies these days have "in-network" and "out-of-network" charge and payment schedules. The Dr could very easily lose you as a patient because they are spending your money and your insurance money, unwisely. If you love the Dr whose office ordered it for you, you can try to appeal to Aetna your situation, but I doubt they will do much UNLESS the DME is the ONLY one within 50 miles of your home. If you aren't totally "feeling the love" for the Dr who ordered the CPAP, I think I would request my records from that sleep Doc and find a new sleep Doc whose office workers will pay attention to little details like in-network suppliers for their patients.

I am not sure what you should do about your situation, but start by calling your insurance member service line to find out if there is a DME in-network in your area, and then explain your situation and maybe they can help you navigate an exchange of CPAP machine or possibly they will cut you a break and reconsider the out-of-network charges as if they were in-network, depending how far their in-network DME is from you. But you need to have your machine until another is received. You cannot sleep without it, please don't risk it.

In the future, don't let any of your Drs refer you to any other Drs, DME's, hospitals, radiology centers, or labs unless they are in-network providers, You should check with your insurance to see if anyone/anyplace you are referred to are "in-network" before you receive the service, to get the best advantage from your insurance premiums. Good luck, I hope they resolve it within reason for you. CPAP can be expensive when first starting out, but is a life-saver, and a healthy alternative to breathing disorders during sleep!

[howkim]

they applied the deductible to my OUT OF NETWORK charges. TO me, this is unacceptable.

I have Aetna, too. They did this to me for my new mask from Apria. I contested it, saying that Apria was listed on the website as an in-network provider and they fixed it. Funny thing is that they left the amount credited to my out of network deductable for the year.

[leejgbt]

As a DME provider I will give you the "other" side of the story. First, DME companies are REQUIRED to bill for each component of the mask, that is why there are separate HCPCS codes for each (blame Medicare). That being said, wow, this DME charged an OBSCENE amount for the mask and components. Also, the DME should have informed you UPFRONT if they were out of network with your insurance provider. While it is not against the law or anything, it is piss poor customer service not to inform the customer of this very vital piece of information. There is a loophole of sorts that may allow this to be paid in network; if your physician was in network and referred you to this DME the network designation is supposed to flow to the referral as well. You usually have to fill out some paperwork from your insurance to accomplish this.

As far as the deductible situation, this sounds like a high deductible plan. Usually these plans have no copay amount after the deductible is paid. In other words the total out of pocket and the deductible amount are the same amount. It is worth asking how much out of pocket expenses you have after your deductible is met. As a comparison, my insuance has a deductible of $1000 and total out of pocket of $1500. So, after my deductible I have $500 of copays before insurance pays 100% of claims. Also, if this is considered out of network the deductible is a SEPARATE deductible from your in network deductible (ouch).

I highly encourage anyone who has this kind of experience with a DME company to complain to their insurance carrier and their state association (there is one in every state except Wyoming). I also recommend you find a different supplier. The people here seem to like CPAP.COM. Just find a company that will give you the same CPAP that goes with your heater and you should come out okay, especially given how much this DME charges.

[idamtnboy]

There is a loophole of sorts that may allow this to be paid in network; if your physician was in network and referred you to this DME the network designation is supposed to flow to the referral as well.

It's good you said "may allow." I just checked my brochure for BCBS Federal. It has a paragraph specifically warning that if you are hospitalized in a preferred provider hospital, say for surgery, and they bring in a non-PPO anesthesiologist, you will be liable for the anesthesiologist's billed amount above the plan allowance.

[poppi2]

Kahfree,

Thank you for making your original post. I've learned more about insurance in this thread then I ever knew.

I need to make some phone calls to my DME and insurance tomorrow.

Earl