DME funny money

Zees Pleez · Post by **Zees Pleez** » Mon Mar 07, 2005 1:40 pm

I thought my DME's prices were rediculous, but I found something interesting going through my detailed info at my insurance site. DME billed $461 for apap trial and accepted $85 from insurance company. DME billed $180 for Nasal Aire II and accepted $65 from insurance company. Sleep lab also accepted about half what they billed. The DMEs are not as big 'a bandits as I thought...

wading thru the muck! · Post by **wading thru the muck!** » Mon Mar 07, 2005 1:46 pm

Zees Pleez,

Are they going to bill you for the balance? Or was your copay figuired as a percentage of the reduced amount?

The question that comes to mind is, If they are willing to accept these low prices from the insurance company, why don't they sell to everybody at that price. They would lose the evil DME label.

Zees Pleez · Post by **Zees Pleez** » Mon Mar 07, 2005 1:56 pm

wading thru the muck! wrote:Are they going to bill you for the balance? Or was your copay figuired as a percentage of the reduced amount?

My portion is zip/nada/nothing! Medical equipment and diagnostics are paid at 100% by my insurer.

I have had two nights at the sleep lab, a 5 night trial of APAP and a prescribed APAP machine. So far I am out $15 for the copay of the single office visit with my GP that kicked this all off. My GP has handled all the follow up over the phone. Did I mention how much I like my GP and my insurance company?

Zees Pleez · Post by **Zees Pleez** » Mon Mar 07, 2005 1:59 pm

oh yeah, I am also feeling a little more compassion toward my DME seeing what they actually are getting paid. I can understand why it is hard for them to provide much better service than they do. I still wish they did have better service.

meister · Post by **meister** » Mon Mar 07, 2005 2:04 pm

Well, the insurance companies DEMAND a significant discount from
the DMEs (and all medical providers), so these guys mark things up
60 to 80% so they can then give the big Insurance companies a
nice 40 to 60% discount, and make them happy. In that way the
big Insurance companies are happy that they are getting a big
discount, and the Doctors are making their nice cut (you know
those huges houses and the Lexus/Porche are not cheap). Don't
just think it is only in the medical business. Do you know how much
that jewelry or those clothers are marked up, so they can be
marked down at a big sale? As more and more folks get diagnosed
with OSA, the prices will come down. So get your Mom/Dad, sister/brother,
aunts, uncles, and cousins in to the Sleep lab, ASAP, so we can all
enjoy the economies of scale!!

Janelle · Post by **Janelle** » Mon Mar 07, 2005 5:28 pm

The last sentence may seem strange but Sleep Apnea is hereditary (I suppose the brain wave, physical obstruction part to some extent). I know I suspect my father has it, and my son was diagosed at my insistence shortly after I was, and I read somewhere on the internet about it being hereditary.

Bullwinkle · Post by **Bullwinkle** » Mon Mar 07, 2005 6:21 pm

Sigh, so, DME's are just like the hospitals; they are willing to take the reduced amounts so they can get the insurance cos. business.

Leaves those who are uninsured or underinsured and can least afford it paying the most and making up the difference so the DME's can meet their profit targets.

-Jeff

eblack · Post by **eblack** » Mon Mar 07, 2005 6:32 pm

One of the resons that some DME's discourage anything but the cheapest cpap is that they are often only able to collect from the insurance companies a set amount that has to cover all machines regardless of their cost. (One code fits all) My DME showed me some invoices that were amazing. They make so little on insurance company sales, that I am surprised that they are able to stay in business. Not that this is an excuse for providing anything short of professional service! It is however a fact of life when dealing with insurance companies. I consider the insurance companies the real thieves. They want it all and from everywhere they can get it, their customer's health being secondary.

Do I dislike insurance companies, or what?

jdschooler · Post by **jdschooler** » Mon Mar 07, 2005 6:33 pm

I have also worked with medical billing and helping configure charges to meet the overhead costs and such in my profession. Alot of experienced coders and medical billers that are well trained and kept up to date with all the requirements are needed. These people also cost money to employ and offer benefits. Alot of charges and allowable amounts come down to HCFA (Health Care Finance Administration). It's kind of like going shopping and filling your cart then telling the cashier what you are ALLOWED to pay. We figure our charges in healthcare by what HCFA will allow and then increase them to cover the cost we incur so that when the allowable is set and then further reduced by a percentage we are not going broke. Unfortunately private uninsured citizens take the brunt. This is why so many people say that they cannot afford the tests and equipment. It's a catch 22. HCFA constantly reduces the allowable because cost are going too high and in response medical providers increase their charges so they can recoup what they need to stay in business and as a result insurance rates go up.

When I found out how my my DME was going to charge I found CPAP.Com and called my insurance co to see if I could purchase and submit my own claim to save them the money. They advised me that I could but it would be best if I just let the DME do their thing and they would get paid significantly less anyway.

Liam1965 · Post by **Liam1965** » Mon Mar 07, 2005 6:39 pm

Well, I can only speak to my insurance company, but... Every DME I called quoted the "NH price for a CPAP machine" and the "NH Cigna price for a CPAP machine", with no difference at all between models.

The NH price for a CPAP machine, with no H/H or hoses or mask or anything is $1850. The Cigna price for the same machine is 10 months of rent-to-own at $125/month or $1250. For a machine that I can buy WITH the hoses from cpap.com for about $500.

So I understand the idea of discounts and such, yes they're taking a 1/3 cut in the price of the machine, but they're still charging well over 2 times what the machine can be purchased for. Even operating on the assumption that a smaller DME does less business, and thus, can't buy them at a bulk price like cpap.com can, they've gotta be making plenty at $1250, especially as they charge additional money for the hose, and the mask, and the heated humidifier, and.... I wouldn't be surprised if they try to charge me for the price of the air that goes through the machine.

I don't care what they tell you, a DME charging those kinds of prices that's losing money on the insurance company deals is incompetant and would lose money in any business they tried to start.

Liam, not willing to watch the blame shift entirely away from (most) DMEs.

Guest · Post by **Guest** » Mon Mar 07, 2005 7:53 pm

I happen to work for a DME company and have been for years. You would be amazed at what we actually get paid by insurance as stated in previous responses as well as the amount of effort we put in to our CPAP patients and their care. My responsibilities in an 40 hour work week consist of probably 30-35 hours of talking patients through problems and working with them on their CPAP therapy and maybe 5-10 hours of doing something that is acutually reimbursable. One thing people don't consider when buying online is that you will lose the patient care which good DME's (and believe me I do understand there are horrible companies out there) such as myself can provide. I will tell you there is nothing greater than to listen to a half hour story of how CPAP has changed someone's life which is why I do what I do but if you think about all the time your DME spends with you specifically, then multiply that times say 100 patients a week, it gets to be a lot of follow up and instruction that DME's get nothing for but the satifaction that CPAP patient will be sucessful. Also, one of the reply's mentioned not being able to try different masks and that is a huge area of loss for DME's but an essential part of CPAP therapy. So, this being said, as long as you have a good DME, we do a lot more than the insurance companies small allowable really covers. If your DME isn't meeting these expectations, speak to a representitve about it or change vendors. Your doctor may have a specific DME they prefer but the fact remains it is your care and there are certainly a lot of us out there that are willing to give you the attention as a patient you so deserve in dealing with your therapy.

wading thru the muck! · Post by **wading thru the muck!** » Mon Mar 07, 2005 8:26 pm

Guest DME wrote:One thing people don't consider when buying online is that you will lose the patient care which good DME's

I didn't lose ANY patient care by buying on-line. I can call cpap.com anytime, 8am to 10pm, 6 days a week. Do you offer your patients that kind of care?

Guest DME wrote:we do a lot more than the insurance companies small allowable really covers

If you feel you are not able to charge enough to do what you feel you need to do then you should find a different business. If you are serving your patients with the feeling you are doing charity work, you are not serving them appropriately.

Mikesus · Post by **Mikesus** » Mon Mar 07, 2005 9:32 pm

I am with wader on this. I actually gained care. The local Evil DME was not interested in providing service, just taking money. If I got the kind of service that you are talking about, I would go with a local provider. However, I think you are the exception, not the rule.

seamaiden · Post by **seamaiden** » Mon Mar 07, 2005 10:18 pm

Liam1965 wrote:Well, I can only speak to my insurance company, but... Every DME I called quoted the "NH price for a CPAP machine" and the "NH Cigna price for a CPAP machine", with no difference at all between models.

The NH price for a CPAP machine, with no H/H or hoses or mask or anything is $1850. The Cigna price for the same machine is 10 months of rent-to-own at $125/month or $1250.

I have NH Cigna HMO. Their contracted price for the same machine is $750. Same state, same insurer but they pay $500 less per machine for their hmo clients. My dme was not happy when I switched out from cpap to apap.

rested gal · Post by **rested gal** » Mon Mar 07, 2005 11:08 pm

Guest who works for a DME. It really can be a buzzsaw in here considering what poor service so many people report getting when they first get on cpap and are outfitted by their local DME's.

I do understand that there are some out there, like you, who take your job seriously and do really try to help your patients. Many times your hands are tied by insurance company issues, or the boss's need to make a profit. If you want to keep your job, you do as best you can.

I think my pet peeve with the way new patients are treated when getting their first mask is....so often they are given a Profile Lite or a Comfort Gel. I suppose Respironics must have the best sales force on the planet - getting the DME's to stock those masks. (My apologies to anyone who is using one of those and likes it...glad it suits you.) But most new users who post about a sore on the bridge of the nose - ask them what mask they are using and it is almost always one of those. I know the DME needs to make money to stay in business...but the MASK may be the single thing that causes most people to give up on cpap treatment. Just because the person doesn't come back, or complain, doesn't mean they are getting good treatment out there. That machine and mask may very well be sitting in a closet after the first week, or first month, or first three months. Those cheap masks are doing a great disservice to the new cpap user, imho.

Perhaps you, Guest, are one who steers your new patients to the better masks. If so, that's great.

I don't know what the answer is. Unless a new user finds his/her way to a message board like this, they are in for a real uphill battle trying to become "compliant". Just my non-doctorly opinion. Any DME, who, like you Guest, and like Christine RRT and MelMel who are sticking with this message board, are obviously interested in what actual cpap users are saying, complaining about, liking, not liking. If you can keep a pretty thick skin on you, I think you can get some good hints on the message boards about ways to make things better for your patients. Even small hints that have nothing to do with $$, like helping your patients figure out a way to get the air hose up our of their way.

Thanks for giving an "other side of the fence" look at things. I'll continue happily buying online, but I know many people will be walking through your doors. Hope you can really help them.

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DME funny money

DME funny money

Why the funny money