ARGH! Insurance!!

[khauser]

Hi,
First, I'd like to say hello to you all. I've been reading the forum here for quite some time, but haven't had the opportunity to post until now. What a great community!

So, I'm a long time xPAP user (well, not THAT long, but not a newbie by any stretch). I'm on my second machine and who knows how many attempts at finding "the perfect mask". I'm a nasal pillow only type. Thinking about trying Aloha. Swift FX is the best I've found so far, but after very little time, even as little as a month, I'm fighting a downhill battle with leaks. Nasal masks force my nostrils closed and make breathing a real challenge, ESPECIALLY if I have a cold, allergies, etc.

My sleep study set 16cfm as the pressure, though with APAP of course that's now part of a range.

Anyway, my humidifier recently stopped working, and apparently the problem is not the humidifier itself (switched one out and had the same problem). The symptom is a random period of time after going to sleep the machine shuts off, beeps once and the humidifier light is blinking. If I don't use the humidifier (or even set the control to 0) this doesn't happen. If I am lucky I can make it through the night with the humidifier set to 1 ... probably depends on ambient humidity. So looks like its time for me to get a new machine! Choice (for me) is easy ... I like the RemStar line and will stick with them (even if that was the equipment that failed, I just like their feature set). The S9 is nice too, but for me I think I prefer the Series 60. My local DME and I don't get along and I've decided to part ways with them. As I am now on a high-deductible insurance plan, I'd most likely end up paying more through the local DME anyway, so I am quite seriously considering buying online ... probably from the sponsor of this forum.

I *tried* to get numbers from my insurer, but all of their replies state what I already know: In-Network reimburses at 90%, Out-of-Network at 60%, and I have a deductible to satisfy first. It's February (barely) ... I'm not close to that deductible being satisfied. So I think the reimbursement rate doesn't matter. What I think matters is how much the local DME would charge vs. what I can get it online for. But the local DME can only charge me the "agreed-upon" rate. That number is what I am after, and despite providing insurance codes, etc, I am told that it depends on the contract between the DME and the insurer (BCBS, by the way. I think BS doesn't mean Blue Shield, though, if you catch my drift).

Hence my frustration ... but I bet that the online price will still beat it. Anyone think otherwise?

[Edited to remove equipment list, now that its in the profile]

[Pugsy]

Getting the allowable amount for a machine from your insurance company is going to be extremely difficult as you have found out.
I don't know why insurance companies won't simply tell a person what their "contract" allowable amounts for equipment are but they just don't seem to want to do that.

Generally speaking...online prices are going to be much less than any contract allowable amounts. If you had Medicare we could get a real close estimate of the amounts that would be allowed because that information is public.
If your insurance company happens to go with reimbursements rates that mimic Medicare reimbursements I can get you those.

Your DME could find out exactly if they would just do it. It would involve a bit of work on their part though.

[JDS74]

How long have you had the machine? If it is less than 2 years, Philips-Respironics will replace it at no cost. All you have to do is convince your DME to send it in for evaluation. PR will do the rest.

[deerhound]

One thing to be aware of, is some insurance plans (mine unfortunately) have two deductible amounts. One for in network and another one for out of network. They are separate and one doesn't count towards the other.

[LSAT]

Our host...cpap.com...has a great sale going on. Check this out (this includes the humidifier)

https://www.cpap.com/cpap-machine/respi ... -flex.html

[khauser]

Thanks for the comments, all.

According to the DME it's been more than 2 years.

And yeah I have two different deductibles, but if I buy from the local dme it'll still cost way more. Not worth it in my opinion, especially as I am not happy with the DME.

I pulled the trigger and asked my doctor to send the prescription to cpap.com. He's going to send it Monday.

[BostonGal]

Hi - I'm in the boston area and my DME is homecarenewengland.com not sure if they service NH or are an approved provider for you, but i have no compliants about the cost of the supplies. I find them to be the same or slightly lower than the online prices. Granted, i know it depends on what they have contracted with my insurance company (united healthcare), but maybe you can give them a call. i have a high deductible plan too, so i know the pain. If you have to pay similar money...might as well have it count towards your deductible. I had to pay the total for the humidifier and the cpap machine portion is payable over 10-12 months. They came to my house to set it up. Nice people, though I still struggle with finding the perfect mask. and since i only get one mask per six months from them...i have spent a fair amount at cpap.com to try others. good luck.

[bjcyorkiemom]

The only big draw back to what you are doing is the amount you are spending will not apply toward the deductible, so you are still stuck with that.

[khauser]

HomeCare New England is a bit of a trip for me. One reason I like the idea of using cpap.com is I think I'll get overall better service. There are three people in my house currently making do with one car. If I require sole use of that car it completely upsets the other two people that have jobs. I try to schedule such things on days when they are off (I'm a software engineer with a relatively predictable daily routine, they're both currently in retail, one with a predictable schedule and one that changes every week). It's incredibly difficult for me to know ahead of time when it's safe to grab the car. What I am getting at is a DME that ships is going to be able to service my needs much faster than a local DME that won't. Bizarre but true!

As for the deductible issue, it's a bummer, but I can't afford the higher cost local DME's are going to charge me, even if that goes against a different deductible.

Again, thanks for the comments. I have made the decision and will be using cpap.com for the time being. At least I am able to support a company that provides a great service to this community!

[SethW]

Around 8 months after I was told by Lincare that I would own the machine after renting it for a certain number of months, and that I could not just buy it outright, they changed their tune and told me that I would never own the machine. If anybody deals with Lincare, get the details about ownership of the machine in writing. I now wish I had just bought the device from cpap.com. I think it would have cost more than what I was originally told the total cost of the rentals would be, but I doubt cpap.com would be calling me back 8 months after I bought it to tell me I actually didn't own it.