Using health insurance and bypassing DMEs...

[Rmuir]

I object strenuously to seeing my health insurance allotment used on inflated DME prices. I know that I can easily buy top-end equipment for more than half the cost online from very reputable sources. I continue to manage my own therapy using purchased software in consultation with my sleep specialist. At the moment, I'm using equipment I bought out-of-pocket and it's time to upgrade and buy a backup machine.

What strategy can I use to get my health insurance company to reimburse ME for buying all my new gear at reasonable prices? Can it be done? Has it been done?

[pulseoxstore]

You may want to see if the company that you purchase your equipment from offline can provide you with a 1500 form to submit to your insurance. This is simply an itemized invoice that is accepted by insurances to pay from. There is a place that the vendor can check stating that the customer paid up front so the insurance will pay back to the customer and not the vendor. I have a feeling that if the internet company does not offer to bill insurance, they will not be in network with any insurance companies and you will be stuck with an out of network deductable and you will be responsible for paying that anyway.

[Sillyme]

Depends on your policy. Mine will reimburse at out-of-network rate after all yearly maximums are met. I did find that, in my case, "Since you met your out-of-pocket maximum for 2010, all claims, including non-participating/out-of-network claims will pay at 100% of reasonable and customary charges for the rest of 2010". (Quote from my insurance co.) But that's just me. Call that Member Services number on your card. I bought my own machine without using my insurance but I'm using a DME for masks. I would have had to rent indefinately. I still have to pay for masks next year until I meet max. Haven't figured out what I'll do at that point.

[GumbyCT]

I object strenuously to seeing my health insurance allotment used on inflated DME prices. I know that I can easily buy top-end equipment for more than half the cost online from very reputable sources. I continue to manage my own therapy using purchased software in consultation with my sleep specialist. At the moment, I'm using equipment I bought out-of-pocket and it's time to upgrade and buy a backup machine.

What strategy can I use to get my health insurance company to reimburse ME for buying all my new gear at reasonable prices? Can it be done? Has it been done?

You should start by asking your Insurance Co. Each is different. Be sure to ask about internet purchases as those will be the least expensive. Any local purchase for cash will have to follow their DME/Insurance agreement.

Also ask if you can create your own Purchase Order for reimbursement.

[jlk]

I had deductables met until 10-1-2010. In Aug. I called my ins. co. and asked the payback rate for my out-of-pocket expenses for hcpc code EO601 Auto cpap. The rate was 70%. I purchased my unit from a popular online supplier and submitted the bill. I received 70% of their allowance of $820.50. (I paid $853) I am happy with that because my deductable is $1000 annually so it was not cost effective to rent from the dme people who charge far more than I feel is acceptable and I don't like to deal with. I spent more deductables and co-pays throughout the years dealing with the dme shenanigans than the new S-9 cost. I had no use for another entry level unit. Love my S-9 Auto! jlk

[chunkyfrog]

Remember that DME's and online vendors may attach different HCPCS codes to the same mask,
often billing for multiple codes on one item.
For instance, Swift FX warrants 3 codes at my DME, one of which is tubing
--identical to the number used for the main airline, a completely different item.
This means that even if out of network providers have a higher co-pay, the patient cost still may be less in some cases;
and the patient may not 'burn' eligibility for scheduled equipment--just so a greedy DME can wring more money out of your insurance.

[jlk]

I have dealt with 3 different dme providers and they all billed what I consider questionable to say the least. It should be fraud, but Medicare also allows it. Thanks gov. for the close monitoring of "our" money. jlk

[mamaguinnie]

JLK -
I agree completely! I'm still arguing with a local DME -- they are charging me a copay that is twice what I could buy the equipment for online -- and that's after the insurance company has paid their part! Ridiculous.

[Pfoot]

I have no answer for you regarding insurance payment. But reading your rant regarding over inflated prices struck a nerve. Like many people, I went in for a sleep study and found out I could benefit using CPAP. So I ended up with a CPAP machine and mask provided by the same company that did the initial sleep study. Based on my insurance plan, I knew that I would pay for a small percentage of the sleep study, the CPAP machine and nasal mask. After about 3 months, I received a bill for the sleep study in promptly paid it. What really floored me was a bill I just received which included the CPAP machine, nasal mask, and.... curiously, 3 seperate entries dated one month apart for "CPAP -rental (therapy service, Slxxp Mxx)" at $250.00 a pop! My only guess is this is their fee for calling me once a month to see how things were going!!!
BTW, the nasal mask and CPAP machine were both about twice as much on the bill as compared to what I could puchase them for online. And you wonder what is wrong with our health care industry???

[jonquiljo]

JLK -
I agree completely! I'm still arguing with a local DME -- they are charging me a copay that is twice what I could buy the equipment for online -- and that's after the insurance company has paid their part! Ridiculous.

That's how insurance companies pretend to cover you - and make a ton of money charging you to do so. The insurance companies don't really care who pays what - if they pay an inflated cost of 4x what a machine is worth then they just pass the costs back to you in premiums.

It happens with all goods, tests, and services in medicine - you just know better when you can buy it online from a legitimate source with proper discounts.

To the OP: If you can file a claim for out-of-pocket expenses paid by yourself - like you could 20 or 30 years ago - go for anything you can get. Just don't hold your breath.