am i getting ripped off?

[heckler]

Hello all

Here is a frustrated newbie with a question. I did a search on the board and kinda got some info but want to confirm I got it right.

Here is the situation.

My mother got a prescription for a bipap machine. I found a local DME and after a bunch of phonecalls i found out a few things:

A) They wanna sell her a Respironics M series auto bipap for $4000 and a Respironica M Series heated humidifier for $300, mask-tubing-headgear and filter for about $220 (and i guess change the accessories every 3 to 6 months)
B) The insurance (United Healthcare) has a limit of $2500 a year


Then through dumb luck I stumble upon cpap.com and almost blow a fuse when I see they are selling the very same Respironics M Series bipap and humidifier together for 1329.

What the hell?

I call the insurance and tell them I saw this thing online for quarter of the price and ask them if they'll cover any of it. They said that websites would be out of network and that means a 1000 dollar deductible and then 80% of the rest could be covered IF cpap.com can give them some codes and I tell them about this before i order it and can get them to help me file a claim by providing some documentation and whatnot.


What should my next move be here? Call the DME and have them tell me EXACTLY what my out of pocket cost will be and compare that to the worst case scenario if I buy from cpap.com and get no reimbursment from United Healthcare?

Any advice would be greatly appreciated.

Thank you

[onecoknower]

My insurance would cover 0, nuttin', nada, if I order it anywhere but at the DME. So, I only use the DME when I know it's well within my interest to do so. Having said that, to me, the extra effort to save the cost listed would be worth it. I'm not scared to fight with the insurance company, nor am I intimidated by the DME. A rip off is a rip off.
Oneco

[tomjax]

Relas.
They are trying to screw you.

Call cpap.com or billmynsurance.com- the address is on this site.

They will handle it all for you.

Relax

[Bearded_One]

I would compare DME to worst case cost from online and go with with the online store if it is significantly cheaper.

What you are experiencing is not uncommon, it can be cheaper to buy xPAP equipment online than to use insurance at a DME. You have a particular problem because BiPAPs are much more expensive than CPAPs

One caveat, if this is her first xPAP, there may be advantages to using a local DME. They can do more hand holding and if there is an equipment problem it can probably be resolved faster.

[heckler]

It is her first bipap or any other kind of pap machine. How important is local support to someone new to this?

[Slinky]

Unfortunately, the depends completely on how good - or bad - the service from the local DME supplier is - or at times the sleep lab will provide assistance if the local DME is one of the sheisters. We can't necessarily say that MOST local DME suppliers are less than good 'cause the majority of us on this forum are here BECAUSE we encountered lousy DME suppliers and HAD to get online to educate and help ourselves. But the percentage of less than desirable local DMEs is pretty high. If she has a good local DME supplier or at least a good sleep lab that will assist and/or followup there are DISTINCT ADVANTAGES to having assistance close at hand.

If you can handle the choice of which DME she gets her supplies from and can find one that you feel will be of true assistance and provide the follow up and assistance and mask exchanges then definitely there is a distinct advantage to going w/them. You'll just have to feel out the local DME options to decide if there are any good ones to go with.

[Wulfman]

This would actually be a better machine than the M Series you're looking at.....less expensive, quieter and easier to fill the humidifier.
It functions exactly the same as far as therapy goes.

https://www.cpap.com/productpage-bundle ... undle.html

If there's a $1000 deductible no matter where you go, then buying online would make the most sense.......especially financially.

Some of us approached our insurance providers and asked them if they would reimburse US for purchasing out-of-pocket.....which they did.

Many of us didn't need a local DME.

Den

[dllfo]

Should be an eye opener about the quality of your insurance. At that markup I would wonder if the Insurance Company isn't getting a kick back.

Put another way. IF it is cheaper for you NOT to use the DME your company insists on, it sounds like collusion between the two. I would ask my insurance company why this relationship is required?

Is that even legal? I wonder what your insurance commissioner in your state would say? For example, your insurance company owns a "shadow company" who pretends to be an independent DME, then they charge you so much, you wind up paying for the entire item yourself, PLUS the kickback to your insurance company. I would not put that past some companies. Most are reputable, but some are not.

What does it cost to ask the state?

[heckler]

the 1000 dollar deductible applies for "out of network".

But in network through DME seems to be so expensive that it goes over the insurance limit and we'd end up paying more anyhow.

I mean if it was a couple hundred dollar difference I woulnd even think about it. But i'd hate to pay almost a 1000 dollars more throug DME and perhaps even more.

[Wulfman]

the 1000 dollar deductible applies for "out of network".

But in network through DME seems to be so expensive that it goes over the insurance limit and we'd end up paying more anyhow.

I mean if it was a couple hundred dollar difference I woulnd even think about it. But i'd hate to pay almost a 1000 dollars more throug DME and perhaps even more.

You need to find out if your insurance provider considers YOU as being "in-network".
Many insurance providers will reimburse their members for out-of-pocket purchases at the in-network rate. If they will do that, what you would do is to submit a bill to them for the items you purchased. CPAP.COM includes all of the insurance codes on their invoices and also sends you a form to present to them for your reimbursement. This is what I did three years ago. I was reimbursed at the 80% in-network rate for DME supplies. If you go up and do a search on the word "reimburse" and my user name "Wulfman", you'll see many posts that I've made about how it worked for me. Many others have also used this method to save themselves and their insurance providers quite a bit of money.

Den

[heckler]

I called the insurance company today and told them about the difference between the price from the DME and online. She said that almost certainly online retailers will be viewed as "out of network" and be subject to the $1000 deductible and 80% coverage afterward.




Another question I have is about the setup. How straightforward is it to set these things up. Does that require some sort of expertise or can I follow instructions and do a good job with no prior experience with this sort of thing.




btw thanks for the replies so far, I really appreciate it

[heckler]

[quote="dllfo"]Should be an eye opener about the quality of your insurance. At that markup I would wonder if the Insurance Company isn't getting a kick back.

Put another way. IF it is cheaper for you NOT to use the DME your company insists on, it sounds like collusion between the two. I would ask my insurance company why this relationship is required?

Is that even legal? I wonder what your insurance commissioner in your state would say? For example, your insurance company owns a "shadow company" who pretends to be an independent DME, then they charge you so much, you wind up paying for the entire item yourself, PLUS the kickback to your insurance company. I would not put that past some companies. Most are reputable, but some are not.

What does it cost to ask the state?

[Wulfman]

I called the insurance company today and told them about the difference between the price from the DME and online. She said that almost certainly online retailers will be viewed as "out of network" and be subject to the $1000 deductible and 80% coverage afterward.




Another question I have is about the setup. How straightforward is it to set these things up. Does that require some sort of expertise or can I follow instructions and do a good job with no prior experience with this sort of thing.




btw thanks for the replies so far, I really appreciate it

Of course they will be considered "out-of-network"......but if YOU pay for the stuff "out-of-pocket" and then submit an invoice FROM YOURSELF as the billing party and your insurance provider as the party being billed.....THAT is what I'm talking about. You need to ask them the "right" questions.

You have to talk to them to convince them that you're going to save them a lot of YOUR premium dollars by doing this, this way. If you're in a "group" and are paying premiums out of your withholdings each month, then your insurance provider should be working in YOUR behalf and not squandering money left and right.

Den

[Wulfman]

As far as your question about the setup......my feeling is that if you can read, you can set this stuff up. I've reard stories about DME staffers that didn't set the equipment up properly, too.

Nothing to it, really.

Den

[heckler]

ahhhhh I gotcha. Is this something I should get an approval for beforehand or just give it a shot after the fact?

Since cpap.com will not be submitting any claims I will have to do that myself after ordering anyhow.