New machine and mask $$$$$

[rws]

So, I've been waiting patiently for pre approval from my insurance company for my new machine and mask. My DME said they faxed the forms in and it should take about 2 weeks.
I thought I'd check my claim status myself by going on-line, just to see where it's at. I could not believe the price my DME has requested; M Series Auto CPAP with A-Flex - $2,700.00, Ultra Mirage Face Mask - $495.00, accessories - $35.00.

Yep, $3,200.00 and I'll be sleeping fine! The claim has been approved @ 100% but I'm still disgusted at what Canadian DME's charge for equipment. On the other hand, I can't blame them if the insurance companies are that stupid. My DME is not aware that I've checked their submission so when I go in next week I'm going to play dumb.... maybe some caviar and a limo ride home..... jeez.

Rick

[Terminator]

Yes, it IS amazing. Sad part is, you're almost a captive audience and those are YOUR tax dollars they are robbing you of ...

T

[jules]

why are you surprised - lots of DME's in the states will bill insurance more than that

just insurance might not pay that much - contracted rate for in network is probably less

but the DME might bill the poor peon without insurance that

or the person who isn't in their network get hit with that and has to pay the difference between that and what token amount their insurance will pay an in network DME

[bearded_two]

I just ordered three ComfortGel masks from cpap-supply.com (an online DME) for $65 each, including shipping. The only hassle is that I had to fax them my script this time because they have started requiring scripts for masks.

[MoneyGal]

Nope, no tax dollars involved. The OP has private health coverage. Public health coverage doesn't work that way in Canada.

In my province (same as the OP's), public health insurance covers a portion of the uninsured cost. My doc told my DME to charge me no more than $500 for my setup, including all accessories. The remainder was paid by tax dollars. So, no real profit for my DME in my case, thanks to the intervention of my prescribing physician.

[rws]

why are you surprised

I'm new to the DME / Insurance escapes but since I've just recently joined the forum and have checked pricing for the exact same equipment at cpap.com....... ya, it surprises me

[jules]

it is called overhead and credit (cash up front for cpap.com)

cpap.com sells for 1/5 - 1/3 the price of a brick and mortar DME for many items

in Oct 2005 my insurance was billed over $3000 US for a mask, pro 2 tank, and humidifier - they billed for the hose, the filters and the mask was billed in pieces - my insurance allowed 80 % of what was billed so they allowed over $ 2400

consider how much medical costs have risen over these past 4 years - consider the current exchange rate

the cost doesn't surprise me but not all DME's will charge as much but I was in a captive market out here on the WA coast

[mattman]

Remember - the DME does not set those prices you see. That's all determined by your Insurance company. The DME has no control over those prices.

The single biggest obstacle to price shopping is the bassackwards way the Insurance Companies have this all setup.

They set a price for an item, let's say a CPAP. Maybe $1,600.00. Then they turn around and say they are only going to pay say, 50% of whatever price they've set. The theory behind is they feel they should get a volume discount. This is why there are 2 dollar amounts involved in every Insurance claim.

The one you'll get quoted if you call them or look it up is the submitted amount. That's the high price.

Then there is the allowed amount, the discounted price that they actually pay. It will usually be 30-60% of the submitted amount. So the actual payment would be $800.00.
A patient generally won't see that until you get the Explanation of Benefits after a claim is filed.

Usually no one at the insurance company will actually tell you what your allowed amount is. They all seem to be completely incapable of figuring that out.

The real problem for a person who just wants to buy a CPAP is that the Insurance Companies require DME providers to charge cash-sale customers the same amount they submit to the insurance company. So the uninsured person is the one who really gets the short end of the deal.

Nice totally backwards system huh?

[Jason S.]

So, I've been waiting patiently for pre approval from my insurance company for my new machine and mask. My DME said they faxed the forms in and it should take about 2 weeks.
I thought I'd check my claim status myself by going on-line, just to see where it's at. I could not believe the price my DME has requested; M Series Auto CPAP with A-Flex - $2,700.00, Ultra Mirage Face Mask - $495.00, accessories - $35.00.

Yep, $3,200.00 and I'll be sleeping fine! The claim has been approved @ 100% but I'm still disgusted at what Canadian DME's charge for equipment. On the other hand, I can't blame them if the insurance companies are that stupid. My DME is not aware that I've checked their submission so when I go in next week I'm going to play dumb.... maybe some caviar and a limo ride home..... jeez.

Rick

Well, I just paid $585 (one-fifth of $2700) out of pocket for the exact same machine. This should be a surprise to no one. It happens with every test, every procedure, every surgery and piece of medical equipment. The DME's are not stupid. The insurance companies are not stupid. They have more cash than any corporation in the USA. It is the system which allows it that is stupid.

[carbonman]

I just got a new mask from the Big A.

Item-----------------------------Billed--------------------Paid
Mask frame----------------------$936---------------------$102
Seal------------------------------ $403---------------------$38
headgear-------------------------$236---------------------$22
Total-----------------------------$1575--------------------$162

This little "in network discount" is what needs to be changed.
Not how are we going to pay for this.

The insc., medical and drug industries are not going
to let this golden goose slip away without a fight.

What happened to providing an honest service/product
for fair compensation.....period.

[SleepyInIndy]

mattman,

I used to work for an insurance company. When it came time to set pricing for the next period of time (usually a year) we ranked the submitted charges for a particular item (HCPCS code) in decending order. Then we selected a certain percentile of the whole and that was the allowed price for that period. Negotiated discounts then went below the allowed amount.

The point is, the range of submitted amounts for the service would set the base for the allowed amount. Thus, if providers (doctorc, or DME's) keep submitting higher charges, they will eventually see an increase in the allowed amount. If enough physicians charge $100 for a $20 allowed office visit, eventually the allowed amount rises.

John

[WindFlyer]

I just got a new mask from the Big A.

Item-----------------------------Billed--------------------Paid
Mask frame----------------------$936---------------------$102
Seal------------------------------ $403---------------------$38
headgear-------------------------$236---------------------$22
Total-----------------------------$1575--------------------$162

This little "in network discount" is what needs to be changed.
Not how are we going to pay for this.

What happened to providing an honest service/product
for fair compensation.....period.

This is what I've always wondered about. If I buy a brand new mask out of pocket from an online vendor, it costs about the same as what my total co-pay would be to my insurance at some DME's. All that extra $ the insurance co is paying is for what, again? I have been to a couple different DME's in my ins co's network that don't charge exorbitant amounts of money like that- and that's the other thing I don't get is why there's such a disparity on which DME charges what amount. DO some DME's not know that they can charge ins co's whatever they feel like and get away with it? Are these just kickbacks or something?

[apnez]

...The DME's are not stupid. The insurance companies are not stupid. They have more cash than any corporation in the USA. It is the system which allows it that is stupid.

Right on!!!

The more of the GNP is spent for health, the more insurance companies get profit out of it. They have a direct interest that you are charged the highest possible amount. 20% of 3,000$ is more than 20% of 1,000$! They have no risk doing so as the ultimately sent you the bill through insurance rates and costs.

This is why canadian insurance companies will prefer that you buy from canadian DME 3 times the price, rather than CPAP.com, a US based commerce.

This is also why there is an acute need to stop those gimmicks. The only way to do it is to introduce governmental controls as there is no competition in the private sector that can solve that problem.

What is unbelievable is sleep study at 5,000$ when the real cost could easily be reduced to 500$, equipment sold at 2,000$vb that really cost somewhere near 600$ etc... This is total abuse and rip off. Why do you think Resmed protect tehir Canadian market by not authorizing US commerce like cpcp.com to sell to Canadians?

[jdm2857]

I just got a new mask from the Big A.

Item-----------------------------Billed--------------------Paid
Mask frame----------------------$936---------------------$102
Seal------------------------------ $403---------------------$38
headgear-------------------------$236---------------------$22
Total-----------------------------$1575--------------------$162

This little "in network discount" is what needs to be changed.
Not how are we going to pay for this.

The insc., medical and drug industries are not going
to let this golden goose slip away without a fight.

What happened to providing an honest service/product
for fair compensation.....period.

Carbon --

Go back to Apria, and demand that they revise that bill.

They forgot the charges for the instruction sheet and the plastic bag.

[WindFlyer]

Carbon --

Go back to Apria, and demand that they revise that bill.

They forgot the charges for the instruction sheet and the plastic bag.

LOL