Submitting claims directly to insurance company?

[Wayne02]

My wife and I are both long time bipap users and have Aetna insurance. For the longest time we had the greatest sleep doctor, but three or four years ago he retired and the doctor who purchased the practice is not nearly as user friendly. Quite frankly, I don't like the new guy at all but am unwilling to travel the distance required to see somebody else.

Anyway, he is always pushing us to replace our head gear, hoses, etc but the prices for this stuff when going through him (even with insurance) seem awfully high. Not to mention the hassle factor. Just about every time you call him he is pushing for another $$sleep study$$. He has the classic attitude, "well you have insurance so it is not a big deal". We are well aware that having insurance is a blessing and we are very thankful for it, but that doesn't necessarily mean the equipment gets provided for no cost.

Maybe it is my imagination but in the little research I've done so far it seems almost less costly to purchase these items retail over the net then it is to purchase them from the doctor?

So I'm wondering if I purchase bipap items retail can I submit a claim for them myself directly to Aetna?

Also, will the insurance company tell me exactly what they will cover in terms of bipap supplies and equipment? At the detailed level, like 'hoses, pillows, mask' etc? Is this kind of thing usually available on their website for patients? I'm not seeing anything like this on the Aetna site so far.

Thank you
Wayne

[Maryland_Mike]

Call Aetna.

I just got off the phone with my insurance (Blue Cross/Blue Shield) and was directed to their online manual and claim form.

[Wulfman]

Hi Wayne.

I guess the first question(s) I have is "How much is your deductible and do you usually meet it?".

Many (most?) insurance providers have procedures for reimbursing for out-of-pocket expenses.....fill out a form and submit copies of the receipts.

You'd need to do the math, but depending on the deductible, costs, etc......a person can purchase a lot of "stuff" from places like CPAP.COM compared to the amounts that the brick & mortar places charge. In the case of CPAP.COM they will ship "free" if the invoice is over $100. So, that's what I do (have done).

Den

[spacetoast]

You'll also want to find out if your insurance provides coverage (or an amount of coverage) if you go out-of-network. Places like cpap.com are not affiliated with any insurance company and so they are out-of-network. Still, crunch the numbers and see what you get. Another reason to go out of network is the ability to get exactly what you want. But you might work with your local DME to get what you want too.

[Wulfman]

You'll also want to find out if your insurance provides coverage (or an amount of coverage) if you go out-of-network. Places like cpap.com are not affiliated with any insurance company and so they are out-of-network. Still, crunch the numbers and see what you get. Another reason to go out of network is the ability to get exactly what you want. But you might work with your local DME to get what you want too.

Of course they are out-of-network. BUT......the insured/policy holder/group member SHOULD be considered as "in-network" to the insurance provider. THAT'S who they would be reimbursing......NOT CPAP.COM (or other online seller).

Den

[spacetoast]

Of course they are out-of-network. BUT......the insured/policy holder/group member SHOULD be considered as "in-network" to the insurance provider. THAT'S who they would be reimbursing......NOT CPAP.COM (or other online seller).

Den

I agree! But too bad that's not the case. Insurance companies and service/goods provider companies (like DMEs) sign contracts with each other and work out discounts and whatnot. The In or Out of network refers to the supplier. I just spoke to my insurance (GreatWest) at length last week and if I went in-network, my DME is covered at 80%, after deductible, but if I go out of network, DME is covered at 60%.

Of course, insurance policies are different across the board and it would be a good idea for someone to call their insurance company and get a clear picture of how they are covered.

[Wulfman]

Of course they are out-of-network. BUT......the insured/policy holder/group member SHOULD be considered as "in-network" to the insurance provider. THAT'S who they would be reimbursing......NOT CPAP.COM (or other online seller).

Den

I agree! But too bad that's not the case. Insurance companies and service/goods provider companies (like DMEs) sign contracts with each other and work out discounts and whatnot. The In or Out of network refers to the supplier. I just spoke to my insurance (GreatWest) at length last week and if I went in-network, my DME is covered at 80%, after deductible, but if I go out of network, DME is covered at 60%.

Of course, insurance policies are different across the board and it would be a good idea for someone to call their insurance company and get a clear picture of how they are covered.

That's the same coverage I have. And, I also have GreatWest (they manage the self-insured PPO group I've been with).

AND......they considered ME to be in-network because I was the one submitting the out-of-pocket expenses.

Den

[spacetoast]

AND......they considered ME to be in-network because I was the one submitting the out-of-pocket expenses.

Den

I do know that GreatWest has different plans. My wife actually works for GreatWest and the plan is awful. She worked for another company before that that used GreatWest for their plan and it was so much better and covered so much more.

All I can say is that you must have one of the good plans. I called GreatWest and they told me I could submit my own receipts but would be covered as out-of-network. 60/40

Again, insurance plans are different all across the board. Even if they are the same provider. The best bet is to call your insurance provider and find out what your benefits are...

Hey Wulfman, wanna trade insurance cards

[Wulfman]

AND......they considered ME to be in-network because I was the one submitting the out-of-pocket expenses.

Den

I do know that GreatWest has different plans. My wife actually works for GreatWest and the plan is awful. She worked for another company before that that used GreatWest for their plan and it was so much better and covered so much more.

All I can say is that you must have one of the good plans. I called GreatWest and they told me I could submit my own receipts but would be covered as out-of-network. 60/40

Again, insurance plans are different all across the board. Even if they are the same provider. The best bet is to call your insurance provider and find out what your benefits are...

Hey Wulfman, wanna trade insurance cards

I dunno....... All insurance companies have their good and bad points......mostly bad.
Great West got bought up by Cigna awhile back (as if I have to tell you) and I'm not sure what has happened from our group's perspective. Like I said, they just manage our PPO, but our insurance group office has most of the "say-so" on what happens with our coverage. But, now that I'm retired, my deductible went from $750 to $2500. I really don't care, I only met it in 2005 when I had my sleep studies done......and have never touched it in the preceding years or since then.

http://www.greatwesthealthcare.com/Grea ... fault.aspx

Would your wife have worked in an area that I might have called for information in 2005?
(I wouldn't hold my breath on that one, but sometimes it IS a small world)

Good luck with yours.


Den

[spacetoast]

Would your wife have worked in an area that I might have called for information in 2005?
(I wouldn't hold my breath on that one, but sometimes it IS a small world)

Good luck with yours.


Den

She actually works on the financial services side. Before, she was in a department called Compliance (as in Compliance with SEC guidelines) making sure all the marketing materials they put out were up to snuff with SEC rules. But the actual marketing department stole her away several months ago and now she works kind of as an account manager for financial plans. I guess that was along way to say, "No, she didn't work in that area"

The lady I last spoke with at GreatWest Insurance a couple of days ago told me that the switch to Cigna would actually change the plan up. So, it could be that the insurance coverage improves. I guess I've been spoiled due to the health care plans my previous employers had. That, or I just never went to the doctor for anything and didn't notice.

I got a prescription for Nasonex (for my stuffy nose during allergy season), and I paid $95!!! Insurance only covered $14. Crikey.

Curtis