Using CPAP.com as my personal DME?

[jdschooler]

I have been paying cclose attention to my EOB's (Explanation of Benefits) from my Blue Cross of ND insurance regarding the prices my DME is charging them for my CPAP stuff.....They are outrageous, of course. Anyway I am thinking of doing all of my purchases through CPAP.com and personally submitting my own insurance form (HCFA 1500) to Blue Cross to save me some money (and save BC) because let's face it. Blue Cross pays 80% of their allowable and I have to pay the rest so I can save us both alot of money by getting my stuff on-line.

I am very familiar with billing insurance companies and medical coding because of my job functions as a Paramedic and doing the IT stuff for our billing software at work. However, I know how insurance companies can be with documentation. I have approval from Blue Cross to submit my own HCFA 1500's and am wondering if anyone out there is doing the same. What are your experiences? Where did you get your ICD-9 or CPT codes from so they match your dignosis from the sleep lab? Can anyone on the forum from CPAP.com give me advice or resources?

Later
Jeff

[Liam1965]

My only warning to anyone who does this is:

Make sure your policy doesn't have "preferred providers". I couldn't do what you're talking about, because my insurance company has HORRIBLE coverage for out of network providers (something like $1000 deductible and then 80% coverage up to a maximum benefit of $700).

(I take that back. When I say I "couldn't" do that, it actually still worked out cheaper for me. The part I "couldn't" do was get any money out of Cigna for it.)

Just make sure you run the numbers and understand everything. Even with no coverage, some people find that their equipment will be cheaper on line. But don't let the "out of network" bite you!

Liam, once bitten, twice ... mildly turned on.

[Maskedmechanic]

The code for the diagnosis "obstructive sleep apnea" is 780.53.

[jdschooler]

Just talked to Blue Cross of ND....they said I can purchase my equipment wherever I want and can get reimbursed at their allowable amounts but would be liable for any costs over their allowable. All I have to do is send in the invoice for the supplies and if I want to speed up the reimbursement I can complete the HCFA 1500 myself with the ICD-9 code and the appropriate procedure code for the supplies. Hopefully I can save some money instead of paying my 20% coinsurance for a $100 hose from my current DME that I can buy to $10.00 on CPAP.com. I wonder how much they charge for a $120.00 mask or a $5.00 filter.

No wonder health insurance and medical costs are skyrocketing. The insurance companies can't keep up with the providers outrageous charges!

[Liam1965]

Yeah, you sound like you have all of your numbers and can make this work. My warning message was more aimed at others who might read your post and think "Hmmm. If it works for him, I should try that."

There's a lot of thought and information gathering that have to go into the decision you're making, and my only point was to help point people towards some of the information they needed.

Best of luck to you!

Liam, blogging his guts out.

[TXKajun]

Be sure you have your ducks ALL in a row before you buy! Also, if you can get a representative of your insurance company to fax you an authorization for the reimbusement before you buy, that may be a good idea.

I hadn't met my insurance company's requirements for the deductible ($2500) for the year, but had a cafeteria plan and another $750 that my company put into a flex plan. So, after negotiating for a few days with my insurance provider, I got the ok to buy from cpap.com (in writing, of course! But I'm a belt and suspenders kinda guy. LOL) with the understanding of how the reimbursement would work. To make a long story short, cpap.com, my insurance company and I all worked together and the end result was that my insurance company saved almost $1000, I got the APAP, humidifier and software that I wanted and it all was reimbursed from cafeteria and flex plan.

[glassgal]

Hi Folks,

I just have to chime in here and let you know what is going on here in sunny California.

Our family business employs 30+ employees. Our medical insurance premiums run a little under $20,000.00 per month. In June they were slated to go up 20%. As a result, our copays have been raised considerably on everything to keep it at the 20K number. I have chosen to foot the bill for my OSA equipment, although the insurance did cover the sleep study. I am, in my own little way, trying to keep the premiums from ballooning further.

From a small business point of view, the medical costs are skyrocketing, as well as workman's comp insurance -- don't get me started on THAT! It makes it very hard to stay in business and keep valued employees among the employed!

There is something very broken in the system that we have. The hospitals say that they can't make it with the amount that insurance pays, the docs the same, the businesses that have to purchase insurance have to make some very hard choices, and individuals with no insurance are out of luck. The vast majority of trauma units in So. Calif. have closed because of lack of funding and overuse by folks with no insurance who have no where else to go. This looks like a lose/lose situation to me. The insurance companies and lawyers seem to be the only ones happy with the situation.

Maybe this isn't the right thread to post this on, but it got me thinking!

Sorry for the rant -- I thought that a slightly different point of view might help understanding. There are many valid points of view on this!

[wading thru the muck!]

Jeff,

I did just what you are thinking of doing. All went well with one exception... make it painfully clear when you file your claim that the equipment has been paid for in full by you and that any reimbursement is to go to you. My stupid insurance company issued the check to cpap.com even though the statement I sent with my claim said "paid in full."

Jane,

This is just the place for your rant. The kind of things you have done and Jeff is looking into doing are what will help to bring premiums down. We (on the forum) are a perfect example of how when you get the consumer of medical services involved in the purchasing decisions, the costs can be reduced dramatically. No need to spend extra thousands to have a local DME hold your hand if it is not necessary.

[Grant I]

An amendment to the previous post from Maskedmechanic:

There are several codes for obstructive sleep apnea:
780.51 Insomnia with sleep apnea
780.53 Hypersomnia with sleep apnea
780.57 Other and unspecified sleep apnea

Clearly the difference is whether or not you're sleeping TOO MUCH (hypersomnia) or CAN'T SLEEP (insomnia). Many docs don't bother and use the "unspecified" code--especially when they fail to ask about insomnia during the history and examination

Grant

[chrisp]

I can't think of a better way to save $ for us all. Please don't ask if insurance will pay for the water to fill your humidifier ! Beware of the Evil DMEs

[wading thru the muck!]

I can't think of a better way to save $ for us all. Please don't ask if insurance will pay for the water to fill your humidifier ! Beware of the Evil DMEs

[jdschooler]

Liam,

Good point. Anyone considering doing this keep in mind that I have extensive experience in medical coding, use of ICD-9 Diagnosis codes, filling HCFA 1500s, and getting insurance companies the information they require to get them to pay. Not just any layperson can sit down and complete this stuff. And every insurance company will do anything they can to not pay as well as having very different reimbursement rates and requirements.

Glass Gal,

Beleive me I know exactly how expensive the insurance rates can get. The family health plan my employer pays for my family costs $600 per month and I am sure all of your employees are very grateful (atleast they should be) for the rates you pay. I also unfortunately work on the other side of the fence and help with billing rate adjustments at the Ambulance Service I work for. We are also forced to increase rates based on insurance company re-imbursement rate (mostly medicare and BCBS) so that we can recoup our costs, often over inflating for private insurance and gouging the people too poor to have insurance. And we are a Non-Profit entity so we aren't looking to make any more than it costs to pay us and purchase supplies, equipment and utilites. It is definitely a catch 22 health care system.

Wading,

yes I did get the printed policy from the insurance co with the requirements for personal reimbursement too. They also said that the reimbursement is sent to the address on the HCFA (mine) not the address on the invoice because they have claims on file that they already paid for purchase of the APAP. Let's hope everyhting goes smoothly like the insurance co promised.

Well everyone else,

I will keep you posted and will be glad to give tips and reccomedations if need be.

Thanx all,

[loonlvr]

I AM DEALING WITH BLUE CROSS IN MINNESOTA. i HAD A 6 MONTH WAITING PERIOD FOR PREVIOUS CONDITIONS. i WASN"T SURE WHAT THAT MEANT WITH REGARDS TO osa, SO i CALLED THEM. tWICE. tHEY SAID TO GO AHEAD AND BUY EQUPMENT AND SUBMIT BILL. sO I'M COVERED THEN? yES. bUT LIKE A FOOL i DIDN'T GET IT IN WRITING FIRST. sO AFTER WAITING THREE MONTHS AFTER SUBMITING FORMS(tHEY SENT WRONG ONES), THEY DENIED MY CLAIM. 6 MONTHS WEREN T UP. HAD I WAITIED 2 MORE MONTHS THEY WOULD HAVE COVERED IT. SO I M FIGHTING THIS ALL THE WAY. SO MY ADVICE IS TO GET WRITTEN APPROVAL FOR ALL THE EQUIPMENT, DEDUCTIBLES, ETC.

[Janelle]

Notice when ordering your own CPAP, etc. that the hose comes with the machine and is not a separate charge as it is from a DME. Ditto the headgear with a mask. Filters are also included with the machine, not charged separately. DMEs charge separately for EVERYTHING to maximize their profit and possibly because this is how the insurance wants it done.

Your invoice from CPAP.com, etc will show the insurance code for your equipment. i was told by our BC/BS that I could order my own and would be reimbursed subject to yearly deductibles, of course and the maximum allowable.

I am also allowed a new machine every 5 years and a new mask every 3 months at maximum allowable.

[christinequilts]

I think I have just about everyone beat for insurance overpaying for xPAP equipment- Medicare has already paid out over $20,000 for my Synchrony BiPAP ST and I still don't own it after almost 3 years They did finally change things this year and now BiPAP ST will be a capped rental, like most other equipment, including CPAPs & regular BiPAPs. You would think that they have paid enough, but no, Medicare is not counting any of the months prior to April 2006. It will still be rental until summer 2007, bringing the total paid to nearly $30,000 for a machine that could have been purchased from cpap.com for $2919. From a press release regarding the change- “Medicare is committed to paying the right amount for the devices and equipment provided to its beneficiaries,” said CMS Administrator Mark B. McClellan, MD, PhD. It sure doesn't seem that way, especially if someone doesn't have a Medicare supplemental insurance to pick up the 20% co-pay at around $125 per month or $1500 per year. Can you imagine paying that much for who knows how many years? For the same amount, they could buy a new machine from cpap.com every 2 years and never have to worry about having a machine out of warranty I'm just glad I have a supplemental insurance that has picked my co-pays.

The only good thing about my Synchrony BiPAP ST still being a rental at this point, is that I'll be able to switch to the new VPAP Adapt, which is also classified as a BiPAP ST, without any problems from Medicare or my DME (already talked to them about it). Since I'm not sure what date Medicare will use for the 5 year replacement date, when I originally got my first BiPAP ST in December 2003 or April 2006, I figure its a good time to get a new one.