BCBS w/co-insurance or Online + OOP - please help me decide

[Char1ieJ]

I just talked with the "preferred" DME regarding the prescription written for me, as well as how the insurance company pays and my financial responsibility. I need some advice on how to proceed.

Prescription:

• Bi-PAP/VPAP
  Settings: 17/14
  Heated humidifier
  Full face mask

Insurance:
BCBS of SC

Benefits:
My deductible has been met; No DME deductible
Co-pay = 20%
NO supplies for "rental" period + 2 months (or one year total)
After one year, supplies/machine replaced under Medicare-type guidelines (3 mth, 6 mth, etc) w/ normal 20% copay

DME:
Ordered a Respironics System One 60 Series Bi-Flex Pro w/ matching heated humidifier; 6ft hose and my choice of mask
I asked why not the Auto and was told that most physicians only order Auto's for 2-3 mths to get a proper range, then switch to a "normal" CPAP or Bi-PAP.
She said the Pro was the next in line to the Auto. I have not researched the Pro vs. Auto, so I'm not 100% sure. Advise?
(I told them I may or may not accept that, but would let them know by Monday).

DME Billing:
1st bill = "20% of setup" = ~$150-$175
My monthly bill (x9 mths) = ~$70.00/mth
Replacements/Supplies = 100% OOP
Normal warranties apply
30 day exchange on mask w/ no fees
At the end of 10 months, I own the machine

Here's how I see the math coming out on this:
$175.00 setup
$630.00 ($70 x 9 mths)
----------------------------
$805.00 OOP to own the machine
+
$??? Cost of 2-3 replacement masks
$??? Cost of 3-4 replacement tubes
$??? Cost of other supplies (filters, etc)
=
$1300-$1500 OOP for the first year (with insurance paying their part)

QUESTION: Would I be better off buying a machine online, along with supplies since I'm apparently going to be stuck with so much OOP expense anyway?
The DME would not provide prices over the phone for replacement masks, tubing, filters, etc. Actually, she said she didn't know all the prices off hand, but could try and get them for me by our appointment time Wednesday.

Many of you have already been through the start-up to saturation point for expenses. I would appreciate advise on which way to go -- stick with the DME; buy online and turn in receipts for insurance reimbursement or something different altogether.

As always, THANKS for your learned advice.
Char1ieJ

[chunkyfrog]

You need to speak directly to the INSURANCE people, the DME may be guessing or lying.
(anything is possible) Never take the DME's word for anything--EVER!
If you prefer the Auto, either dig in your heels or get the doctor to write a specific RX for it.

[Pugsy]

Does your deductible start all over in January? So that your monthly "rent" is deductible bound? That would increase the out of pocket expenses for the first year.

Push for the BiPap Auto... You can change modes with it to straight BiPap (like the Pro) or cpap. 3 machines in one.
The BiPap Pro can't do Auto but will do cpap..2 machines in one.

[purple]

CPAP.com sells that machine for $1339.00, although they sell another bipap for $775.00.

If you buy the machine online, then your current DME may not be very helpful in adjusting the machine, or with other problem issues later on.

Let me put that another way; When I first started up with my DME the RT was willing to drive an hour to visit at my house, Any mask I wanted to try (I was years over my first 30 days). Yak about problems, issues, call any time and at least she would get back to me in a few hours.

I buy a machine online, instead of from DME, and they will not help me to set it. Friendly RT does not seem get a message to call me back. and so on. After a few months they were still willing to let me try out masks for free. When it did not work out, they just wrote price of mask off.

I bought System One Auto for $650.00. DME wanted $1300.00 and I could pick whichever of the machines (humidifier included) in that class I wanted, including the S9 Autoset (about what cpap.com charges for the S9 Autoset) . Insurance was not involved. Both prices were cash in advance, no rental or time payments. I do not see how a machine for cash over the internet could be less than 20 percent of a DME price.

You have another piece of homework to do. There is a difference between how Resmed does Bi-Level and how Respironics does. Anyway you can demo the two different styles for a few nights?

Any of those of you who have used both algorithms want to chime in?

[Wulfman...]

DO NOT believe anything/everything the DME tells you! As the green frog said, get the truth from your insurance provider.

Here's another option: Ask your insurance provider if they will reimburse YOU for a large percentage of the purchase if you buy the stuff out-of-pocket. BCBS used to be real good about that as many on the forum reported.

I bypassed the brick & mortar DMEs seven and a half years and purchased my initial equipment out-of-pocket from CPAP (dot) COM and then submitted an invoice (from me) to my insurance provider........and since they considered me to be "in-network", they reimbursed me for 80% of my purchase........which was MUCH cheaper than if they would have had to pay the inflated prices the DME would have charged. It was a "win-win" for everybody. I also got the equipment I wanted and didn't have the hassle with the monthly charges, co-pays and all the other issues I've seen others go through on the forum.
I did alot of prior research and picked the "correct" mask right off the bat, so I didn't have to go through a bunch of masks to find the right one.
In the ensuing years, due to the fairly large deductible I had (and never met), I always purchased any other machines, masks and other supplies out-of-pocket and never submitted those to my insurance.


Den

.

[mayondair]

Second Windcpap has a used PRSYS1 auto bi pap for 719$ and a Resmed Vpap auto for 835$ , as for supplies, shop around. I worry about support from a local DME, you can adjust it yourself. They aren't usually very supportive anyway . I haven't used Resmed like Pugsy, but did acquire a PRSYSBIpap auto from Craigslist,( 400$ , low hours) that I like a lot, very smooth and comfy. Only use my auto for back up and naps now. Kathy

[Posey]

CharlieJ, This is helpful. As it happens we also have BC/BS of SC. My husband works for a HMA hospital and they use that company.
When the "preferred" DME didn't call after the doc said they would, I called them. 1st they said they hadn't received anything. I called the doc and they said it had been faxed. After a while the doc called back and said BCBS DENIED it because the justification for a BIPAP wasn't done right.They got it corrected and now the DME will be calling me.
I looked at the BCBS website for what the bene's were for medical equipment and found nothing.I emailed the questions I found on this forum regarding how it would work but all I actually know so far is "80/20"

Like yourself, I am to have a BIPAP (or Bi level) because I couldn't tolerate the CPAP. I would keep the mask on for a few minutes then have to take it off. After a little while the tech said let's try something else. She had to call her supervisor to get permission to try me on a BIPAP. It was a world of difference and I went to sleep in 10 minutes(?) according to the reading.

I'll follow what you do about your DME to see if it is working for you.

[Xney]

Not sure what BCBS is exactly (I would definitely check by calling!), but they were pretty much straight up deductible and then 80/20.

This means if your DME charges a lot you're paying 20% of it.

(This was for the PPO, a few years ago)

[Janknitz]

Not sure what BCBS is exactly (I would definitely check by calling!), but they were pretty much straight up deductible and then 80/20.

This means if your DME charges a lot you're paying 20% of it.

MOST insurers set an "allowable fee" and then pay 80% of that. Usually you only have to pay the additional 20% of the allowable fee, not the remainder of the full retail amount the DME would like to get for the machine. E.g., DME says the piece of equipment should be $980. Insurer says allowable fee on a piece of equipment is $100, they pay $80, you pay $20, not $900 (exaggerating, but not by much!).

The only way to know is to ASK. CALL your insurance company and find out exactly what they pay, how they pay. Do they pay by HCPC billing codes or do they have a formulary for specific equipment (usually only HMO's do this)? May the DME charge you over and above the allowable fee, and if so, under what circumstances? Does the insurer require you to rent to own, or will they buy the equipment outright? Will they reimburse you if you buy OOP online?

Don't assume that because Jane Doe's BCBS policy paid one way that your BCBS policy will do the same. Every plan is different, unless you live in the same state, get your insurance from the exact same employer and have exactly the same plan options. You need to know what YOUR plan will cover, and how.

[codinqueen]

Don't you have an Out-Of-Pocket Maximum for a year? I have reached my OOP maximum now, 2 yrs in a row, and once you meet that max OOP amount for the year, you should not have to pay any co-payment for the rest of that calendar year, except for maybe the rent. Your additional supplies this year should be at 100% your insurance pays, I think, if you have reached maximum out of pocket this yr. Didn't you tell us you had a heart attack and were hospitalized recently? Did you reach OOP maximum? If you don't know, ask your insurance company at what amount that kicks in, and how the payments for your OSA device and supplies are figured with max OOP in mind. I had my knee replaced this year and met OOP max by June, so I have no co-pays now for supplies, but stilll have to pay Dr and Rx co-pays.
Not every insurance is the same, maybe you have a book you can get the info from, or perhaps go on-line, but if you can't find the answer, give the ins co or your human resources dept a call if your insurance is thru your job.
Good luck. BTW I also have Fibromyalgia (diagnosed in '88)and OSA treatment has helped to relieve some of my pain, and a great deal of the brain fog I used to have.

[MidnightOwl]

Things to consider.

A ten month rental is likely to run into another plan year. Will you meet your deductible on other expenses next year?

Are you happy with the mask you used at the sleep study or are you likely to need to try multiple masks?

You don't need to get your initial setup and your replacement supplies at the same place. You can start with the local dme and buy your replacement supplies online anytime that is cheaper.

No supplies covered at all for the first ten months seems odd. Is it possible that your insurer thinks those supplies are included in the rental?

[Char1ieJ]

First, and foremost, THANK YOU all for your advice. I took your questions and called the insurance company. Here are the answers. PLEASE continue to help me make an informed decision. There are a couple notes that you need to know at the bottom, so please read all the way through.

Insurer: BCBS of SC
Q> Does your deductible start all over in January?
A> January, 2013. In-network deductible = $750.00
I would have a 20% co-pay til December. Then, I would pay full payment until the $750 deductible is met.

Q> Ask your insurance provider if they will reimburse YOU for a large percentage of the purchase if you buy the stuff out-of-pocket.
A> Normally, a 10 month contract. Any item over $500, must be rented. So, no reimbursement if I buy OOP/Online.

Q> Find out exactly what they pay, how they pay. Do they pay by HCPC billing codes or do they have a formulary for specific equipment?
A> HCPC code for payment. My coverage is 80% / 20% whether in the employer network or just BCBS network.

Q> May the DME charge you over & above the allowable fee? If so, under what circumstances?
A> In network, no. Outside network, yes -- actually, there is NO benefit out of network.

Q> Does the insurer require you to rent to own, or will they buy the equipment outright?
A> Yes - rental for any item over $500.00 (required)

Q> Will they reimburse you if you buy OOP online?
A> No benefits on out-of-network purchases.
BCBS says supplies are reimbursed at 80%/20% during the rental period -- as part of the rental; not separately.
In network, BCBS will pay 80% / 20% every 6 mths on replacements & supplies after the initial rental period.
[This is contrary to DME's word. They said NO reimbursement from insurance on anything for first year -- replacement parts or supplies would all be OOP, according to DME.]

Q> Did you reach OOP maximum? If you don't know, ask your insurance company at what amount that kicks in, and how the payments for your OSA device and supplies are figured with max OOP in mind.
A> Deductibles:
Normal employer; 750.00 // Paid = 750.00+ = YES
OOP employer & BCBS; 6000.00 // Paid 3300.00+ = NO

The "preferred" DME is set on giving me the REMstar System One 60 Series PRO. It's a fine machine, I know. No issues with that. However, I told them I want the Auto. They have not outright refused, but said they ordered and were setting up the Pro. I told them to hold off on that because I might not accept it or might switch DME's IF they wouldn't work with me on the Auto. They didn't seem to like that idea at all, but didn't offer to switch to the Auto. I'm going over to the local DME this morning to talk with him about the ResMed (the brand he sells) S9 VPAP Auto.
At this point, without being able to try both and figure out which algorithm is best for me, I am pretty satisfied with the idea of either brand's Auto. But, as others have mentioned, I think the Auto would be best for my situation. CORE CONCERN: IF ANYONE DISAGREES, and thinks I'm making much ado about nothing in not accepting the Pro (insisting on the Auto), then just tell me. I'm learning -- and definitely relying on more experienced wisdom than my own. IOW, I don't want to die on this mountain, holding my ground (so to speak) if the difference is just a molehill.

Anyway, I talked with my cardiologist this morning. I told him about the anticipated weight loss, reminded him of the fact that I need Bi-PAP, along with my logic for justifying the Auto (based on what I've learned here). And, I told him how the "preferred" DME reacted. He told me to call his office and relay all that information to his nurse. He would have the staff re-write the prescription, if needed, for the AUTO -- and he would sign off on it today or tomorrow. My question about that is -- would BCBS need to pre-approve the new script (the original was already pre-certified)?

Based on these questions and answers, what is YOUR advice on how to proceed?

[Pugsy]

Well number one... the PR System One Pro 60 series machines is NOT a bilevel machine. It will NOT meet the requirements of the RX that your doctor has prescribed. It is a fixed single pressure machine. I would not accept that machine under any circumstances. The Auto model the PR S1 60 series APAP model 560 still does not satisfy the RX for bilevel pressures because it again is a single pressure machine.

At your pressure needs...zero in and accept nothing less than a bilevel pressure machine (either the PR System One BiPap or the S9 VPAP). Regarding the "need" for the auto adjusting pressure models of either machine...that is an unknown but it is sure nice to have it just in case.

Normal procedure is to do an up front purchase of the humidifier (not a rental).
The blower part of the machine will be over $500 so it will fall under the rent to own thing and the January deductible starts all over again. The cost of the machine will obviously help you satisfy the 2013 deductible. If you routinely meet your deductible then obviously that out of pocket meeting of the deductible will help with further expenses next year.

Do the math. Which is better for you long term? 20% of the allowable amount after deductible is met or just buying the whole thing online?
Need to try to find out allowable amount...that is hard to do sometimes.

[mayondair]

I assume the HCPC code for bi level and bilevel auto are the same, so if your doc is willing to RX auto, and your ins pays by code, the DME has no choice but to give you the auto. Your insurance won't care as its the same code. I'd crunch the numbers and decide what works best for you, out of pocket or ins benefit. I would hold out for the auto. The older SYS 1 bipap auto is a very nice machine, I wouldn't worry about a heated hose.

[Char1ieJ]

UPDATE: 3:05pm - New info in brown below. Talked with local DME (so-called "preferred DME") is 2 hours away.

Well number one... the PR System One Pro 60 series machines is NOT a bilevel machine. It will NOT meet the requirements of the RX that your doctor has prescribed. It is a fixed single pressure machine. I would not accept that machine under any circumstances. The Auto model the PR S1 60 series APAP model 560 still does not satisfy the RX for bilevel pressures because it again is a single pressure machine.

Being a newb, I wrote that out wrong. The exact name the "preferred" DME gave me is: "Respironics System One 60 Series Bi-Flex Pro".

Update: Local DME offers both Respironics and ResMed. He didn't push me one way or the other; even saying that the code is same for the Pro or Auto models.
He says he is paid on the HCPC code for VPAP = E0470. To him, both are good machines.

Regarding the "need" for the auto adjusting pressure models of either machine...that is an unknown but it is sure nice to have it just in case.

That's what I thought. After talking with a Respiratory Therapist (a personal friend & coworker), he said the same thing. Auto may not be a necessity as this point. However, it's better to have it and not need it, than to need it and not have it. Anyone have a reason to argue against that point? If so, I'd like to hear your logic.

Update: Local DME agreed with logic of Auto being an acceptable idea in my case.

Normal procedure is to do an up front purchase of the humidifier (not a rental).

Ya know, I didn't even ask BCBS nor the DME about the humidifier. Looks like I'll be making another couple phone calls for clarification.

Update: Local DME says humidifier is a one-time purchase; not a rental. He is allowed to bill $237.04-$278.87 dependent on insured's coverage. My part would be 20% of the billable amount -- or roughly $52.00

The blower part of the machine will be over $500 so it will fall under the rent to own thing and the January deductible starts all over again. The cost of the machine will obviously help you satisfy the 2013 deductible. If you routinely meet your deductible then obviously that out of pocket meeting of the deductible will help with further expenses next year.

With the meds I take, I do normally meet my deductible. Your logic makes sense -- and since I'll be paying the $750.00 anyway, why not accelerate getting that "done", so I'll reap the benefits of the 80% insurance copay.

Update: Local DME showed me insurance "schedule" for BCBS on this. Code E0470 is billable at $201.93-$237.00 per month for 10 months. My part is approx. $44.00 per month for 10 months.

Do the math. Which is better for you long term? 20% of the allowable amount after deductible is met or just buying the whole thing online?
Need to try to find out allowable amount...that is hard to do sometimes.

This is where I'm scratching my ol' bald head. I have no real idea of how to crunch the numbers. Here's my idea... tell me if I'm way off base. DME vs Internet/OOP

Update: Well, if local DME is telling it straight, I have that amount now (see above).

"Preferred" DME
Payable amount based on HCPC code (my part of that) = $
"Setup fee" = $175
Monthly co-pay (for 10 mth rental) = $630/yr
Replacements @ 20% co-pay = $
Normal supplies @ 20% co-pay = $
== Figure on a one year basis ==
~$805.00 + ?? for replacement mask & normal supply costs

Update: Local DME
Machine rental = $440.00 ($44 x10 = ownership)
- Mask included
Humidifier purchase =$52.00
Replacements @ 20% co-pay = $
Normal supplies @ 20% co-pay = $
== Figure on a one year basis ==
~$500.00 + ?? for replacement mask & normal supply costs

NEITHER of the above scenarios account for the portion of my $750 deductible that will have to be paid through the VPAP billing for FY2013 (starting in January).

Internet/OOP
Cost of machine = $
Replacements = $
Normal supplies = $
== Figure on a one year basis ==
$ ???

THANKS again for all your continued assistance.