HMO Blue/DME benefit reached

[Vampira]

Hi.
I apologize ahead if this topic has been addressed a lot already, but I have searched with keywords, table of contents, Googled like crazy, but I cannot seem to find enough answers.
I have HMO Blue New England, with a DME benefit of $1500 per calendar year. In January 2013, I asked my sleep doctor if I could try a BiPAP since CPAP wasn't really working as well as I'd hoped after 10 years on it. She ordered a sleep study, which I probably skewed by staying OFF my back because it was hell without my CPAP.
Luckily it was approved, I got a BiPAP from my DME company starting in April. They told me insurance would pay the rental of $197.60 for 10 months and then I would own the unit. I also get supplies like a new mask, hoses, etc via an automated system from the DME every 3 months.
I understand the benefit can be exceeded on occasion, and one year I owed $160.00 and paid it. What I did not expect was to get a notice from Blue Cross informing me my benefit limit has been reached as of 8-3-2013, and the balance of $425.00 is my responsibility.
I was able to login to the Blue Cross member site and view my claims. I can't make heads or tails of how the limit was reached when I look at the amounts charged and benefits paid.....the numbers just don't make sense to me at all. I called Blue Cross twice, and they pretty much told me "Yup, the balance is your responsibility."
I emailed my DME asking for some help to understand how it works and how much I will have to pay. I am really clueless when it comes to insurance matters.
Right now it looks like at least $375.00 rental each month for the next 4-5 months! I just don't get how to read the claims and how they were paid, and I see a big expense coming for me!
I'm assuming I still need to rent the machine until I own it, but I know they sell for much less if I had an R/X and could get one elsewhere.
Forgive my ignorance! This machine is a keeper. I don't know exactly WHO to contact about this. I'm hoping the DME will get back to me....I'd really like to know how much I have to fork over.
Thanks for any links or suggestions....or just for listening!

[oak]

I would just say to be careful with your DME. I called and had the insurance person go through each claim from my DME with me while I was looking at the amounts charged and paid for each one online. Well I never have trusted the DME and low and behold, they billed once for my CPAP and humidifier, and then billed for ANOTHER humidifier, plus they billed for both masks (I tried them both out within 30 days). If you havent read this, I recommend it: http://maskarrayed.wordpress.com/what-y ... me-part-i/

Your out of pocket situation sounds complicated: hope you can sort it out and not be out too much money.

[pbriggs]

Hello Vampira,
The insurance is very confusing for sure. While I don't have the same insurance as you, I have BCBS, there is a statement that you should receive called an "EOB" or Explanation of Benefits from the insurance company. In this it should detail who billed the insurance and for how much. Then it should list what is "covered" which is also known in the insurance industry as reasonable and customary. So, let me explain this a bit. Lets say the dr charges 200 for an office visit. The insurance has a contract with dr's that says the reasonable and customary charge for an office visit is 100. Then the only amount that anyone can be billed is 100 for the office visit if they have insurance. Then lets say the insurance pays 80. The dr will then bill you 100 - 80 or 20. You are not required to pay the other 100 that was not considered customary. On the EOB it should say something like "amount not covered" with a reference number after it - lower on the EOB it should have this reference number explained. Typically I see something like this "THIS AMOUNT REPRESENTS THE DIFFERENCE BETWEEN THE ACTUAL CHARGE AND THE
PRE-NEGOTIATED REIMBURSEMENT AMOUNT. YOU ARE NOT RESPONSIBLE FOR THE
NON-COVERED CHARGES AND THEREFORE WILL NOT BE BILLED BY THE PROVIDER."

I hope that helps to understand that part of the EOB. Another important part of the EOB is the summary information. Here is should keep track of items such as deductibles, out of pocket maximums, max benefit and the like. These totals should add up for each claim.

If you don't get the EOB - call the insurance company and ask for them. Let me know if I can help further
Paul

[Vampira]

Thanks for the links and info! I was aware of the "EOB", but of course panicked over my potential cost seeing that the latest claim was denied, and I have no idea what is coming.
I will see what they send me next, but I sure hope I don't pay anything close to what these claims have on them.
The Blue Cross member website really doesn't have a lot of info. Every time I try to get into my co-pays and limits reached part of my account, it comes up "This information is not available at this time."
I have to say, the most informative people are on these boards. I waste valuable lunch time at work trying to get answers over the phone, and get nowhere. I really appreciate the answers here. The insurance companies have everything hidden with codes and confusion. All I want is a good night's sleep and not have to pay 5 X's as much for something the insurance I pay for out of my paycheck should help me with.

They still have the wireless modem on my BiPAP sending data every day to my DME people, Doctor, Blue Cross, who knows? since April. At least someone knows I use the heck out of it.

[chunkyfrog]

Blue Cross/Blue Shield was once a respected company, and earned the reputation.
In recent years, company management had traded on the recognition and licensed other companies to use the name.
Not all of these companies have been as carefully screened or audited as was once the case . . .

[wm_hess]

Hi Vampira

I've never been on a rental before so I could very well be blowing a lot of smoke your way. If so, forgive me.

I straight out purchased my S9, humidifier, and heated hose for around $800 from Apria a year and a half ago. I had been using a brick for the previous year, and wanted to fully data capable machine. Going in, I was aware my insurance would not cover any of the cost, as I'd only been on CPAP for about a year. This was the contracted price between Apria and my insurance (Kaiser) that they had agreed to for their purchases.

My point is, can you turn in the machine since it is a rental. If so, can your insurance company work with your DME to sell you a complete unit at their cost (not rental). I don't know what the pricing is for your particular machine. I also am not sure exactly what you are saying you owe. I first thought it was $425 dollars in which case this scenario probably wouldn't work. But if if is 5 months of $375 dollars, purchasing it outright at their contracted price might be cheaper than the $1900 that the five months will cost you.

Hope this helps.

-Bill

[Janknitz]

If the negotiated rental amount is $197.60 per month, I don't see how your DME could charge you $375 per month when you topped out your $1500 cap.

What I would expect to happen is they issue the bill for $375, your insurer knocks it down to the contracted rate of $197.60, but you pay that since your benefit is maxed out. If that's not what happens, you may be able to get everyone's attention by making a report to your insurer's fraud unti since the DME is charging you more than the contracted price.

[herefishy]

Have you added up all the charges to see if it equals $1500? Seems like since April at $197.60, that should be about $1000, and maybe you have gotten $500 in supplies? So you might be exceeding your benefit, but you should be able to see from your EOB what your responsibility is.

[chunkyfrog]

I hate HMO's.
Such a slimy business!

[Vampira]

The postings have been very helpful and clear some things up.
Looking into the claims details on the Blue Cross site - if I add only the columns that say "amount allowed", it seems closer than anything else to the $1500 DME limit. ( Not exact, but within a few hundred.)
The scary thing is the "my balance" column that says $375.00 for the latest DME rental claim. I received a claims summary letter in the mail from Blue Cross that has my balance as $424.60. That seems to be for the latest $375.00 rental claim for August, plus a partial payment of $49.60 owed from the previous one that must have just pushed it over the $1500.00 threshold in July.
There is also a DME claim from April when I first got my new BiPAP for $400.00 ($256.82 allowed on that. Maybe that was the humidifier? I really didn't expect to exhaust my benefit so fast by getting a new machine after 5 years and not ordering much more in replacement masks, tubing etc. than usual. Obviously, I won't order anymore scheduled supplies until 2014......I can get mask cushions at least online.
It's frustrating to think (naively) that all my equipment needs would be covered by insurance, then to find out that I didn't budget the equipment very well. I love my new machine! I've always had bad brain fog for ten years on CPAP, and this machine really has helped me since i've gotten it. I have said to myself many times that I would pay thousands to get restful sleep if I had to. Let's hope it's well under that.
I still haven't gotten an official bill, but I really am nervous about what I may have to fork over. I am still fearful of and confused as hell by insurance claims, but the advice and info here is greatly appreciated!

[oak]

There is also a DME claim from April when I first got my new BiPAP for $400.00 ($256.82 allowed on that). Maybe that was the humidifier?

Boy if I had to pay out of pocket for much of this like it sounds you will, I would double check on that April DME claim with the insurance company. Who knows what they may have billed for and if it went towards your $1500 max?
As you can tell, I really don't trust my DME because they are trying to double bill for a bunch of my stuff. I am going on Medicare soon and will have to switch anyway, otherwise I would dump my
DME provider like NOW!