DME overcharge for mask replacement

[bombadil]

My DME (Apria) allows me a replacement mask every 3 months. I recently called and requested a Mirage Quattro. They told me the copay would be $80.82, which is 20% of the mask "price" of $401.40. Now the same mask is sold at cpap.com for $176. I asked Apria why the base price was so high, and they told me to ask my insurance. Called my insurance. They told me they can't discuss with me their contract with Apria because of HIPAA regulations, and that I should ask Apria. Typical run-around.

Has anyone else had a similar experience? Any advice on how to deal with this?

Thanks.

[Perrybucsdad]

Well, CPAP.com is much less expensive because it is cash and carry. They don't deal with any insurance, so they can keep their prices lower.

As far as HIPAA regulations go, that sounds like a BS answer as this has nothing to do with HIPAA.

As far as the price of the full mask, that sounds about right if you ask me. I know when I bought my Quattro FX full mask (not just the replacement pads) it was over $350, but I don't recall the exact amount.

First question though, do you need a full mask replacement? You can get just the cushions/pads for a heck of a lot less and these are generally what will wear out.

John

[bombadil]

Well, CPAP.com is much less expensive because it is cash and carry. They don't deal with any insurance, so they can keep their prices lower.

As far as HIPAA regulations go, that sounds like a BS answer as this has nothing to do with HIPAA.

As far as the price of the full mask, that sounds about right if you ask me. I know when I bought my Quattro FX full mask (not just the replacement pads) it was over $350, but I don't recall the exact amount.

First question though, do you need a full mask replacement? You can get just the cushions/pads for a heck of a lot less and these are generally what will wear out.

John

Thanks for the feedback, John. Actually, I'm using this as an opportunity to try a different mask. I currently use the Quattro FX. Also, I'd like to have a spare mask on hand, just in case.

David

[LSAT]

My DME (Apria) allows me a replacement mask every 3 months. I recently called and requested a Mirage Quattro. They told me the copay would be $80.82, which is 20% of the mask "price" of $401.40. Now the same mask is sold at cpap.com for $176. I asked Apria why the base price was so high, and they told me to ask my insurance. Called my insurance. They told me they can't discuss with me their contract with Apria because of HIPAA regulations, and that I should ask Apria. Typical run-around.

Has anyone else had a similar experience? Any advice on how to deal with this?

Thanks.

It's NOT Apria that allows the mask replacement every 3 months...it is your insurance company. Your 20% co pay should be 20% of the amount your insurance company pays...NOT 20% of the Apria full retail price. I would GUESS that the amount your insurance company pays is closer to the cpap.com price.

[2flamingos]

You want a good laugh at an "over charge"? My DME bills a replacement hose at $70.00. Insurance pays them (agreed upon price) of $12.00. I got this from DME main office when I noticed they had billed insurance $70.00 for something and I could not tell what it was. Called DME and went thorugh all the charges and it was for the hose. No that is an over charge - almost 600% mark-up.

The reason I called DME is that insurance rejected the charge because I had met max for that benefit for the year. DME realized that local provider made a mistake by not telling me, and so they are going to eat it. When I told the lady I was talking to that I could return it, she said not to - they would only be eating the $12.00, not the $70.00. I feel sorry for folks without insurance if they do not use CPAP.com or other on-line retailers.

[xyz]

> They told me they can't discuss with me their contract with Apria because of HIPAA regulations

That's not just wrong, it's total bs. Each and every time I order something from my dme, my insurance company sends me a statement showing what the dme billed and how much the insurance company paid them, i.e., "the contract price".

When you think about it, that's smart. Otherwise a dme could bill an insurance company for items that a patient never ordered and which were never delivered. Pure profit.

Are you sitting down? Recent order:
ff mask: billed $980, contract price $117 (12%)

Your problem is that it's as hard to get a knowledgeable, helpful person to talk to at the insurance company as it is at a dme. Maybe harder, since CS reps at the insurance company don't seem to know much about dme issues, probably because it's a small percentage of the calls they get.

There is one way to deal with this. Write a grievance letter to your insurance company. 1) Don't rant. 2) Do your homework before you write the letter.

Some insurance companies give you three choices: a letter, a phone conversation with a CS rep, an online webform. Be sure to write a letter. (And make a copy.)

Keep it as brief as possible. Confirm with the _insurance company_ (not the dme) that your co-pay is 20%. Have them send the page of your insurance policy that says that, or show you how to find that page on their website. Print it out and attach it to your letter. Say that the price that the dme quoted for the mask is an "imaginary" (i.e., made up) nonsense number. That you have no intention of paying 20% of such an inflated number. Include hardcopy of a couple of webpages (e.g., cpap.com) that show the common retail price of that exact mask. And close by saying that you will pay 20% of the insurance company's contract price to the dme. And ask what that amount is.

[Janknitz]

DME bills are works of pure fiction. NOBODY pays the prices they charge, unless you're some poor, hapless sucker who either doesn't have insurance or they can't wait until three months go by to get another mask or part, and who doesn't bother to check around to see if he can get a better price.

Insurers set the allowable fees for DME equipment and supplies. Then, depending on your contract with your insurer, you will pay a copay which is a percentage of that allowable fee (not a percentage of the amount the DME wants to charge) plus any applicable deductibles. Some DME's refuse to "accept assignment" and MAY be able to charge the difference between the allowed amount and their fantasy charge, but in MOST cases, state law and your insurer prohibit that practice. If a DME tries to charge you the difference, DO NOT agree to pay without checking with your insurance company and other DME's to see if you really have to pay that. And certainly shop to see if your out of pocket costs will be cheaper online.

[bombadil]

Thanks, everyone.

David