Outrageous DME/Insurance Billing Practices?

[AMC4x4]

EDIT: It appears I'm late to the party on this "try/buy" stuff. Reading some more in the forums here, seems it's standard. Man, what a friggin racket they've got going here. Preaching to the choir it seems.
-----------------------------

After seven years of full compliance with my old CPAP machine, I started the cumbersome process of getting a new one. My DME is Apria, who I pretty much despise. But they work with my doctor & insurance, so I decided to start the process with them.

Finally, after a month of getting all parties aligned (visit to doc, get script, get sleep study, etc.), I get a call from Apria. They are beginning the process with insurance (Aetna) and will call me back once they have coordinated everything.

I get a call back this morning. They started talking about how I'm responsible for my share of rental costs on my new Airsense 10, which begs the obvious question - is this a rental? Turns out it's a "trial." They will "rent" me the machine for 10 months and charge me a $30 co-pay each month, and my insurance pays a $60 co-pay each month. After that ($900), they will put through with my insurance to purchase the device, and I will be responsible for half that cost (~$500-600 my cost).

I call Aetna to see if there's a better way to do this. I mention my seven years of full compliance. After an hour on the phone and being put on hold many times, I discover Aetna's contract with all DME's is the same. Try, then buy. If I buy myself and then want to submit through insurance to get the 50% back, I can't because my purchase has to be from an in-network provider, and not with an online supply company.

So it looks like it's actually going to be cheaper for me to use my FSA dollars to shop around & buy it online (~$700 outright vs. ~$900 just in co-pays)?

Anyone have any other suggestions? This all seems kind of outrageous. So much for trying to save myself and my insurance company some money. By the time Apria is done, they'd have us pay for the machine three times. Utterly ridiculous and outrageous.

[Pugsy]

So it looks like it's actually going to be cheaper for me to use my FSA dollars to shop around & buy it online?

Yep. Sometimes it's cheaper to just buy it and not only have it be cheaper but avoid some headaches that seem to come whenever Apria is involved.
It all starts with your own particular insurance plan and goes from there. They have their own way of doing things and make no provision for someone who has been on cpap for years.

It's why we tell people to "do the math" and figure out which way costs them the least amount of money out of pocket and start from there. You've done the math already. It's fortunate that you have the FSA option you can use. Some people don't have FSA accounts and they still have crappy insurance plans.

Check out the prices at cpap.com for a new machine. Even if it was swapping dollars and not saving you some money you would be avoiding potential headaches that seem to come when Apria is involved.

[Julie]

Cpap.com (forum's sponsor) has loads of machines, masks, etc. with pix, reviews, and best prices. Lots of people here call your DME Crapria !

[SewTired]

Hey, it's no different with other medical equipment, so don't beat yourself up. YOUR insurance company is the one who made this deal because they don't want to pay for your equipment. That's the bottom line. If they make it hard, maybe you'll just go away. It was cheaper for my brother to go out and buy a power chair for my late sister-in-law than getting it through insurance not only because of the ridiculous rent-to-own and copays, but also the enormous time involved between doctor visits, DME visits, etc. etc. He had to take time off work every time, so it just wasn't worth it.

[poppi2]

...So it looks like it's actually going to be cheaper for me to use my FSA dollars to shop around & buy it online?

Before I retired, I used my FSA money to buy an auto from our host to replace my six-month old insurance "brick".

[Physician]

EDIT: It appears I'm late to the party on this "try/buy" stuff. Reading some more in the forums here, seems it's standard. Man, what a friggin racket they've got going here. Preaching to the choir it seems.
-----------------------------

After seven years of full compliance with my old CPAP machine, I started the cumbersome process of getting a new one. My DME is Apria, who I pretty much despise. But they work with my doctor & insurance, so I decided to start the process with them.

Finally, after a month of getting all parties aligned (visit to doc, get script, get sleep study, etc.), I get a call from Apria. They are beginning the process with insurance (Aetna) and will call me back once they have coordinated everything.

I get a call back this morning. They started talking about how I'm responsible for my share of rental costs on my new Airsense 10, which begs the obvious question - is this a rental? Turns out it's a "trial." They will "rent" me the machine for 10 months and charge me a $30 co-pay each month, and my insurance pays a $60 co-pay each month. After that ($900), they will put through with my insurance to purchase the device, and I will be responsible for half that cost (~$500-600 my cost).

I call Aetna to see if there's a better way to do this. I mention my seven years of full compliance. After an hour on the phone and being put on hold many times, I discover Aetna's contract with all DME's is the same. Try, then buy. If I buy myself and then want to submit through insurance to get the 50% back, I can't because my purchase has to be from an in-network provider, and not with an online supply company.

So it looks like it's actually going to be cheaper for me to use my FSA dollars to shop around & buy it online (~$700 outright vs. ~$900 just in co-pays)?

Anyone have any other suggestions? This all seems kind of outrageous. So much for trying to save myself and my insurance company some money. By the time Apria is done, they'd have us pay for the machine three times. Utterly ridiculous and outrageous.

Wow. Sorry to hear of your plight. My experience with Apria has been excellent for several years. No problems with equipment, no problem with supplies, and fast service.

When Apria bills Medicare, they do it monthly as a rental for 13 months. But there's an option for one time billing of the entire amount for non-0Medical non-Medi-cal patients.

Did you try to get through to a billing supervisor?

[chunkyfrog]

Sometimes it pays to push back, even with crapria.
It all depends on your endurance, and phone batteries.

[ChicagoGranny]

new Airsense 10

Do you know which model you are getting? There are at least four models.

AirSense 10 AutoSet
AirSense 10 AutoSet for Her
AirSense 10 CPAP
AirSense 10 Elite

I would not accept anything but one of the two AutoSet models. Be careful.

[lwieland11]

I have BC/BS. Went through hell with them to get my AIrSense10 paid for. They had me on the rent to own plan. I started paying 101 a month. BC/BS checked compliance for a month in the beginning. I complied. Five months in, they decided to check me for a 3-month period(hoping I'd fail). I didn't comply then. I was struggling with my mask and some other issues that that the DME could not figure out. BC/BS refused to pay. DME demanded that I pay the balance($463) in full immediately or they would come and get the machine the following day. Yeah, this really happened. All I could do was cry. Felt so helpless. The insurance companies are in charge and no one can stop them from demanding downloads and creating compliance rules that are hard to attain, setting the patients up to fail so they don't have to pay. Never seen anything like it. I spoke to one of the BCBS advocacy nurses to explain the difficulty I was having. Decided that those folks are just there to keep the insurance companies from looking like badasses. She was of no help whatsoever.

So now, I have my paid for AirSense 10 and they are switching me to BIPAP. $2,500 sleep study to pay for out of pocket and now a BIPAP machine. Will this ever end?

[Sheriff Buford]

I've been using Crapria since 2010. My cpap machine crapped out a few months back. Though I don't have the out-of pocket issues or copays, I had to choose to deal with them to get a machine or NOT deal with them and pay for the machine myself. I chose to deal with Crapria, but I had to prepare myself, especially the mental part (frustration). I was like a boxer in the corner and the Mrs. Buford was splashin' water on me, encouraging me... holding the spit bucket for me, and dabin' the blood spots on my face. I say if you are a doctor, lawyer or such... pay outta' your pocket and be done with it. Us po' folks have to deal with Crapria.

Sheriff

[LSAT]

I have BC/BS. Went through hell with them to get my AIrSense10 paid for. They had me on the rent to own plan. I started paying 101 a month. BC/BS checked compliance for a month in the beginning. I complied. Five months in, they decided to check me for a 3-month period(hoping I'd fail). I didn't comply then. I was struggling with my mask and some other issues that that the DME could not figure out. BC/BS refused to pay. DME demanded that I pay the balance($463) in full immediately or they would come and get the machine the following day. Yeah, this really happened. All I could do was cry. Felt so helpless. The insurance companies are in charge and no one can stop them from demanding downloads and creating compliance rules that are hard to attain, setting the patients up to fail so they don't have to pay. Never seen anything like it. I spoke to one of the BCBS advocacy nurses to explain the difficulty I was having. Decided that those folks are just there to keep the insurance companies from looking like badasses. She was of no help whatsoever.

So now, I have my paid for AirSense 10 and they are switching me to BIPAP. $2,500 sleep study to pay for out of pocket and now a BIPAP machine. Will this ever end?

Each Insurance company has their own compliance standards, but most use the Medicare rules. If you don't comply, they won't pay.

Objective evidence of adherence to use
(defined as use of PAP devices for 4 or more
hours per night on 70% of nights during a
consecutive 30-day period anytime during
the first 3 months of initial use) of the PAP
device, reviewed by the treating physician.

[ChicagoGranny]

Each Insurance company has their own compliance standards, but most use the Medicare rules. If you don't comply, they won't pay.

Objective evidence of adherence to use
(defined as use of PAP devices for 4 or more
hours per night on 70% of nights during a
consecutive 30-day period anytime during
the first 3 months of initial use) of the PAP
device, reviewed by the treating physician.

The insurance companies are in charge

Is it the insurance companies or your big government? Federal regulations have a lot of hands tied. As evidenced in LSAT's note, insurance companies must protect themselves from federal regulators. One way to do this is to adopt the Medicare rules.

What's the reason for switching to BiPAP? You do know BiPAPs can be very expensive?

[Pugsy]

What's the reason for switching to BiPAP? You do know BiPAPs can be very expensive?

From her past software reports...I suspect the centrals that were seen and the fact the OA stuff wasn't really dealt with all that well either along with problems dealing with pressures needed to fix the OA stuff.
She was supposed to get another sleep study to determine if the centrals were real or not and to decide if regular bilevel would deal with the centrals (if they needed dealing with) or see if ASV bilevel was needed.

She has some complicating factors going on...need for more pressure to deal with the OA stuff and the presence of a large number of centrals that may or may not be related to the pressures.

[lwieland11]

CPAP no longer works for me. I have both OSAs and centrals.

[ChicagoGranny]

Got it!