Provider charges to insurance

[mamaguinnie]

It's amazing to me that my provider is charging my insurance company over $2000 for a machine that I can buy on cpap.com for under $300. My co-pay is more than cpap.com's retail price! Has anyone else experienced this? Am I reading the pricing wrong? The machine is a fisher & paykell sleepstyle 234. Should I contact my insurance company to point this out?

[jules]

I doubt it would do any good.

It is all the cost in using a local DME.

This has been going on for years.

[Slinky]

Some insurances allow you to buy out of pocket, submit a claim w/proper coding and proof of purchase and then reimburse at "out of network" or even "in-network" rates. NOT very many, tho. It doesn't do any harm to ask.

[Wulfman]

It's amazing to me that my provider is charging my insurance company over $2000 for a machine that I can buy on cpap.com for under $300. My co-pay is more than cpap.com's retail price! Has anyone else experienced this? Am I reading the pricing wrong? The machine is a fisher & paykell sleepstyle 234. Should I contact my insurance company to point this out?

Absolutely. Also ask them if they would reimburse you for the equipment if you purchase it out-of-pocket from CPAP.COM.
That's what my insurance provider did for me. I purchased all of my own equipment and then submitted an invoice (from me) to my insurance provider and they reimbursed me for 80% of it.

Now, in reality, what the DME billed for that machine/equipment is not what your insurance provider will ultimately pay them, but your insurance will probably pay for the amount of the machine and your co-pay will probably be "gravy" to the DME.

You might want to check into whether that machine they're giving you is fully data-capable.......I doubt that it is. At some point, you are going to want to know how your therapy is working and without a machine with full data-capabilities, you're going to be in the dark.
It's YOUR therapy (and YOUR MONEY)......not theirs......they're in it to maximize their profits and keep you coming back to squeeze more money out of you and your insurance. You're just $$$ to them......they could care less about how your therapy is working.

Read this link. It's got a list of data-capable machines in it.

viewtopic.php?p=307168#p307168


Den

[mamaguinnie]

It's amazing to me that my provider is charging my insurance company over $2000 for a machine that I can buy on cpap.com for under $300. My co-pay is more than cpap.com's retail price! Has anyone else experienced this? Am I reading the pricing wrong? The machine is a fisher & paykell sleepstyle 234. Should I contact my insurance company to point this out?

Absolutely. Also ask them if they would reimburse you for the equipment if you purchase it out-of-pocket from CPAP.COM.
That's what my insurance provider did for me. I purchased all of my own equipment and then submitted an invoice (from me) to my insurance provider and they reimbursed me for 80% of it.

Now, in reality, what the DME billed for that machine/equipment is not what your insurance provider will ultimately pay them, but your insurance will probably pay for the amount of the machine and your co-pay will probably be "gravy" to the DME.

You might want to check into whether that machine they're giving you is fully data-capable.......I doubt that it is. At some point, you are going to want to know how your therapy is working and without a machine with full data-capabilities, you're going to be in the dark.
It's YOUR therapy (and YOUR MONEY)......not theirs......they're in it to maximize their profits and keep you coming back to squeeze more money out of you and your insurance. You're just $$$ to them......they could care less about how your therapy is working.

Read this link. It's got a list of data-capable machines in it.

viewtopic.php?p=307168#p307168


Den

The Sleep clinic downloads data from my machine every 6 months or so on my follow-up visits, but I don't know how to access this information myself. Does that mean it's data capable and I just don't know what I'm doing?

[Janknitz]

You're being ripped off, but not just in the way you think.

Your DME is trying to foist a brick off on you--a machine without data capability, which is almost useless unless you are someone who will just put the mask on your face and use it even if it might not be working optimally for you. I doubt that since you are asking good questions here.

Your first step should be to call your insurance company:

Find out what their ALLOWABLE charge is for the machine and how much your out of pocket costs will be. The DME can charge whatever the heck they want, but the insurance company is only going to pay the agreed upon percentage of what your insurance company thinks the charge should be. Then, depending on your contract with your insurance company, you either pay the remaining percentage of the allowable charge (good news) or you pay the difference between the DME charge and what your insurance will pay (very bad news).

Before you decide you'd rather pay out of pocket online, think about whether you really want that bottom of the line machine with no data capability? More than likely, the allowable charge for any CPAP machine (bottom or top of the line, data capable or not) is going to be the same with your insurance company, and your out of pocket costs will be the same no matter what machine you choose either.

So, pick the machine YOU want that will do the best for you. Then calculate your out of pocket costs with insurance and by going online. In that case, you may find that the DME is the better deal.

Now, the DME is not going to like this. They were thinking they were about to pocket a lot of cash from your ignorance. So they will give you 101 reasons why you cannot have another machine. But if you ask your insurance first and come to the DME armed with knowledge and a well-written script from your doctor (or better yet, go to a better DME that won't treat you that way if your insurance covers other DME's), nobody is going to pull anymore wool over your eyes.

[Janknitz]

The Sleep clinic downloads data from my machine every 6 months or so on my follow-up visits, but I don't know how to access this information myself. Does that mean it's data capable and I just don't know what I'm doing?

This machine is NOT data capable. All they are doing is checking to see if you're really using the machine--most insurance companies require this information to pay for the machine. It's big brother checking to make sure you're using it, but it tells nothing about how well it's working for you. If you have a problem, the machine can't tell you why or how to fix the problem. The only way to tell is another sleep study. But if you have a data capable machine, you and your sleep doctor can look at the data and make informed decisions about how to manage your care.

They are just foisting a bottom of the line cheap machine on you and making a hefty profit.

[Wulfman]

The Sleep clinic downloads data from my machine every 6 months or so on my follow-up visits, but I don't know how to access this information myself. Does that mean it's data capable and I just don't know what I'm doing?

This machine is NOT data capable. All they are doing is checking to see if you're really using the machine--most insurance companies require this information to pay for the machine. It's big brother checking to make sure you're using it, but it tells nothing about how well it's working for you. If you have a problem, the machine can't tell you why or how to fix the problem. The only way to tell is another sleep study. But if you have a data capable machine, you and your sleep doctor can look at the data and make informed decisions about how to manage your care.

They are just foisting a bottom of the line cheap machine on you and making a hefty profit.

I agree. And, like a high percentage of other users, you're getting fleeced.


Den

[mamaguinnie]

[quoteYour DME is trying to foist a brick off on you--a machine without data capability, which is almost useless unless you are someone who will just put the mask on your face and use it even if it might not be working optimally for you. I doubt that since you are asking good questions here.][/quote]

Yeah, I don't know about that. It's taken me 2 years to ask the questions. This came up because my husband was put on cpap a year and a half after I was, and he was given the same machine as mine. Meanwhile, I STILL haven't found a solution to my problems and he sleeps like a baby without colic! I've been looking at mask options and stumbled upon this site. While setting up my profile I went to cpap.com to find my machine, and lo and behold, there was that price. I'm livid. We're still paying off my husband's charges for monthly "rental" of the machine (my insurance company's choice, so I was told), mask, humidifier, etc. We owe over $800 after insurance! I think I'll refuse to pay.

OK - rant over for the time being.

[Wulfman]

Your DME is trying to foist a brick off on you--a machine without data capability, which is almost useless unless you are someone who will just put the mask on your face and use it even if it might not be working optimally for you. I doubt that since you are asking good questions here.]

Yeah, I don't know about that. It's taken me 2 years to ask the questions. This came up because my husband was put on cpap a year and a half after I was, and he was given the same machine as mine. Meanwhile, I STILL haven't found a solution to my problems and he sleeps like a baby without colic! I've been looking at mask options and stumbled upon this site. While setting up my profile I went to cpap.com to find my machine, and lo and behold, there was that price. I'm livid. We're still paying off my husband's charges for monthly "rental" of the machine (my insurance company's choice, so I was told), mask, humidifier, etc. We owe over $800 after insurance! I think I'll refuse to pay.

OK - rant over for the time being.

They could very well ruin your credit rating (or worse) if you take that avenue.

If you haven't found it yet, look at http://www.cpapauction.com for some good deals on data-capable machines. It's also owned/run by CPAP.COM.


Den

[Janknitz]

Yeah, I don't know about that. It's taken me 2 years to ask the questions. This came up because my husband was put on cpap a year and a half after I was, and he was given the same machine as mine. Meanwhile, I STILL haven't found a solution to my problems and he sleeps like a baby without colic! I've been looking at mask options and stumbled upon this site. While setting up my profile I went to cpap.com to find my machine, and lo and behold, there was that price. I'm livid. We're still paying off my husband's charges for monthly "rental" of the machine (my insurance company's choice, so I was told), mask, humidifier, etc. We owe over $800 after insurance! I think I'll refuse to pay.

Oh No!!!!! Sorry!

I don't think you can refuse to pay, but maybe you want to print out this thread and take it to the manager of your DME and demand an explanation and credit on your bill???? You should also complain to your doctor if he/she referred you to this lousy DME and hasn't checked to see why you are still having problems after two years. BTW, are either of you on Medicare? If so, there may be other remedies.

Meanwhile, STOP your husband's rental, give him your machine, and search for a good data capable machine for yourself online (CPAP.com or the auction site or maybe a good used one) so that you can see why you're still having problems.

[mamaguinnie]

Yeah, I'll be talking to both the Insurance company and the DME about this issue. It may not get me anywhere, but they'll know how I feel about being screwed over. My Nurse Practitioner (I've never seen the MD) is really good and caring. But it is troubling that the DME is next door -- not legally connected but I'm sure there's a relationship there since all the DME carries is CPAP equipment! I wasn't forced to use them, just given the opportunity to take advantage of the "convenience". I don't want to stop seeing the NP, but when I go to my next visit with educated questions and complaints about this issue, we'll see what her reaction is, and then I'll know if I have to switch medical providers. The DME is definitely on my sh.. uh, black list. Thank you all for your information and suggestions; I'll be lurking here & there, learning all I can, and researching mask & machine options.

~Jan

[GumbyCT]

Yeah, I'll be talking to both the Insurance company and the DME about this issue. It may not get me anywhere, but they'll know how I feel about being screwed over. My Nurse Practitioner (I've never seen the MD) is really good and caring. But it is troubling that the DME is next door -- not legally connected but I'm sure there's a relationship there since all the DME carries is CPAP equipment! I wasn't forced to use them, just given the opportunity to take advantage of the "convenience". I don't want to stop seeing the NP, but when I go to my next visit with educated questions and complaints about this issue, we'll see what her reaction is, and then I'll know if I have to switch medical providers. The DME is definitely on my sh.. uh, black list. Thank you all for your information and suggestions; I'll be lurking here & there, learning all I can, and researching mask & machine options.

~Jan

What you need to do is turn in the last machine you got from the crooked DME to avoid entering into another "contract to pay this supercharged fee". Else you will be locked in again. Any doc that will only refer you to the "next door DME" likely has a financial interest. Ask the doc for you prescription so you can choose where you spend your money. You will need the script to buy online or anywhere else.

If the doc refuses or gives you a hard time I would request ALL of your records (in writing) and find another doc, this one is not helping you and sounds like a money mill to me.

Good Luck

[mamaguinnie]

I'm not sure turning in the last machine will do anything, since mine is all paid for, and hubby's 10 month rental period is up; insurance has paid their part and we owe the $850 co-pay for a $300 machine and a $60 mask. I think both machines are ours, whether we want them or not. I do want to point out to the DME, insurance company and Doc the overcharge, though. As I said in the post above, the NP didn't insist on using the DME next door, just offered the "convenience" of fitting onsite; she has offered to write my script for use anywhere. It just chaps me to know now what I should have known 2 years ago -- insurance was overcharged to the level that our co-pay is over 2x what I could have purchased the same crap cpap machine for online.

But! I've just thought of a new twist! (sorry, the brain is a little foggy these days)MY insurance carrier is now different from what it was when I first began the therapy, so I should be eligible for a new machine! I think I'll ask for what I want, try it out for a 30 days, then return it and purchase online for less than my insurance co-pay would be. Is it right to do that to the DME? Maybe not, but what they did to me was clearly wrong. Paybacks, you know.

Now, which machine do I ask for....????? And masks -- I can try a few before settling on one and being stuck with it. I just want to ask the right questions at my next visit, and get the sleep I've been missing out on.

*yawn* I think I'll go back to bed now.