Conversation with Insurer About Equipment Purchase

[joeslide]

Ok, I found some good stuff about purchasing equipment from DME's. So I decided to ask the insurer a question:

Do you allow reimbursements for cash CPAP purchases? Do you pay by HCPC code or do you cover only certain machines/models? If so, do you pay more for some machines/models than others? Do you buy the CPAP machine outright or is a rental arrangement required?


Here's the response:

When you pay for equipment by cash and file a claim for reimbursement, the provider must be registered with us and we have verified their credentials, if they are preferred, they must file the claim and reimbursement goes to them. The provider's tax identification number, national provider identification number (NPI), address, and phone number is required for processing. You may purchase the CPAP instead of renting it and the provider files a claim for your benefits. It is not mandatory that you rent to own the CPAP. When you purchase and the preferred provider files the claim for reimbursement, they may request any applicable deductible and coinsurance that your plan applies up front, then file the claim to us. As of today you have applied $XXXX towards your $XXXX annual deductible. You have applied a total of $XXXX towards your total in network out-of-pocket for 2021 of $XXXX. Payment is based on the allowance for the HCPC/procedure code for covered devises/supplies and medical necessity. A devise is considered to be purchased after ten rental payments. Differences in payments depends on the type of the equipment like, Bi-pap or CPAP. The Bi-pap is more expensive because it is for more severe cases of sleep apnea.

Here's my follow up question:

The reply is assuming that I purchase from a preferred provider. What if I don't? Online retailers (cpap.com) sale the equipment at a significantly reduced price. DME's charge a higher price since they submit claims to the insurer. Can I purchase from a non preferred provider and still submit a claim for some level of reimbursement?

Am I asking the right questions? Still awaiting the answer to my follow up...

Here's the answer to my follow up:

Online the provider would not be able to fit you to the correct equipment to meet your needs. If you use a none preferred provider, including online, you will still need the provider's tax ID, NPI, address, and phone number. They will need to be registered with the local Blue Cross and Blue Shield plan in the state where they are located. You will have to file a claim with this information to the local Blue Cross and Blue Shield FEP plan in the state where the provider is located. Example: the provider is in Texas, the provider will need to be registered with Blue Cross and Blue Shield of Texas. You would file your claim for reimbursement to Blue Cross and Blue Shield of Texas FEP area claims department for processing. Your benefits are still subject to your deductible and reimbursement is reduced to 65% of what Texas allows. Example: you paid $300.00 and Texas allows $150.00, they would only consider the allowance of the $150.00. They would subtract your remaining deductible of $17.04 and 35% of the remaining balance, which is $132.96 (132.96 x 35% = 46.54) $132.96 - 46.54 = $86.42. In this example of using an out of network provider from online that is registered with the local Blue Cross and Blue Shield plan, out of $300.00 spent you are looking to receive $86.42 in reimbursement. This is only if the provider is registered, meaning that their credentials have been verified that they are licensed to supply the equipment that they are selling. You would only get credit for the $17.04 toward your deductible and $46.54 towards your total out-of-pocket. The $150.00 over allowed amount and $86.42 reimbursement does not apply towards your out-of-pocket. You are at a greater risk for not getting much/any reimbursement out of network.

[Janknitz]

That's great that you got that in writing!

I think IF they will reimburse for online providers you will still come out with the same out of pocket expenses. But if they do not reimburse for providers that are not registered with your insurer, it will be 100% out of pocket. So either way, I don't see that you save any money by buying online and you may spend more money.

Since CPAP.com is also a regular DME, they MAY be registered with your insurer (possibly) but CPAP.com will probably NOT submit billing for you if you order through their online store. It does look like (again, if they ARE registered with your insurer) you can buy from them and submit the bill yourself. I would double check with CPAP.com to make sure that the provider number for their brick and mortar DME can be used for online purchases, if they do turn out to be registered with your insurer.

[ChicagoGranny]

Online retailers (cpap.com) sale the equipment at a significantly reduced price.

This sounds like you are confusing the price a brick-and-mortar DME charges the insurance company (so-called list price) with the price the insurance company actually pays. Insurance companies have contracts with their network DMEs that specify prices that are always much lower than the "list prices". I found that the insurance company's contract prices are very close to internet supplier's prices. The last CPAP machine I bought was cheaper and less hassle to buy from a network brick-and-mortar DME.

The right question to ask your insurance company is, "What is my cost of a machine from one of your network providers?"

Insurance companies only know HCPS codes. They don't know beans about manufacturers or model numbers.

Good luck with the purchase!