My insurance quest for a Bleep

[HD4Mark]

We are lucky enough to have very good insurance for a very reasonable price. However it is an HMO and they are very particular about being "in network".

All of my supplies have been through a local DME that has been very helpful and we have not paid for any. So now I am trying to get a Bleep and the ports unsuccessfully so far. The usual DME says we had them a year ago and they were a total failure. I told them from what I have read they are overwhelmingly liked and work. The answer after asking them to have their boss call me was tough you know what. They won't order one either.

Next I call my insurance company and they send me a three page list of in network DMEs. You can cross off lots that are infusion, prosthetics and wheel chairs. First on the list is Apria, a large firm from what I can see. Nope. Me: can you order one? Apria: We will call you back. I do get a call. Nope. Then a voice mail from same guy that I can order one from apriadirect.com Swell my insurance won't pay for online orders or reimburse me for any DME. I now have another smaller local DME that is suppose to call me back. Not holding my breath. I will call every one on that list before giving up.

Call back to insurance co. Why can't you just reimburse me for equipment I can buy at 1/2 the price? Never got a real answer other than no.

Right now I'm using a Dreamwear gel nasal pillow that works with the hardware from a full mask I had and it is the best solution yet. One reason why I am so intent on trying a Bleep.

I have no problem just buying out of pocket but the ports do get expensive and we are paying for the insurance already. None of the other healthcare options from my former employer are as good and if we change plans they will not let you go back to the HMO. This tells me it is not in my best interest to switch.

[chunkyfrog]

Reimbursement for direct sales is off the table.
Because other stuff happens UNDER the table.
I know because before retirement, I received "reminder" letters from BCBS
because their "pet" DME was missing me.
I was buying stuff from www.cpap.com to save money.
It saved me money as well as sanity to keep insurance out of the loop--that year, anyway.

[Janknitz]

Call back to insurance co. Why can't you just reimburse me for equipment I can buy at 1/2 the price? Never got a real answer other than no.

1/2 of WHAT price??? The answer is that you have no idea. Whatever Crapria or any other DME bills for an item, your insurance company--by contract--only pays a fraction. And they have billing systems in place so it's easy to pay. Crapria contracts for low prices and makes up profit margin in volume (and VERY rotten service!). The per item reimbursement is very likely to be much lower than you can find retail on your own. And, to reimburse you takes a lot of work and time for a paper trail relative to paying an established vendor. So there's zero incentive for your HMO insurance to "save" money by reimbursing you for your own purchase.

You give up some choice by using an HMO. If that's not comfortable to you and you have a choice, choose a PPO or FFS for you next open enrollment. You may have higher out of pocket costs, but you get more flexibility in exchange.

If you are working, you might also consider an FSA. You can pay for your bleep supplies out of that at least with pre-tax dollars.

[HD4Mark]

Call back to insurance co. Why can't you just reimburse me for equipment I can buy at 1/2 the price? Never got a real answer other than no.

1/2 of WHAT price??? The answer is that you have no idea. Whatever Crapria or any other DME bills for an item, your insurance company--by contract--only pays a fraction. And they have billing systems in place so it's easy to pay. Crapria contracts for low prices and makes up profit margin in volume (and VERY rotten service!). The per item reimbursement is very likely to be much lower than you can find retail on your own. And, to reimburse you takes a lot of work and time for a paper trail relative to paying an established vendor. So there's zero incentive for your HMO insurance to "save" money by reimbursing you for your own purchase.

You give up some choice by using an HMO. If that's not comfortable to you and you have a choice, choose a PPO or FFS for you next open enrollment. You may have higher out of pocket costs, but you get more flexibility in exchange.

If you are working, you might also consider an FSA. You can pay for your bleep supplies out of that at least with pre-tax dollars.

My thoughts on the price was based on when I asked my DME what one of my masks cost. I did a search online to discover I could buy it if I had to for 1/2. So I guess you are right and they could not sell it to me for what they paid. They are in business to make money. I do get it that you give up some things by having an HMO but with a few exceptions like this it is the best care we can get. Our company will not allow anyone to switch to the HMO and if you go to another plan you cannot go back. We are not working still. I retired 10 years ago. In a couple of years when we reach 65 I believe the company will move us to United Health Care so we will hang onto the HMO until then and try to work around little problems like this.

[Pugsy]

https://bleepsleep.com/our-partners/

Places where you can buy the Bleep at the above link. Not all will file insurance but the latest that will is Aeroflow.
Now whether your HME will work with them is doubtful but if you don't ask the answer is always no.
I ran into this with my own DME being a hard ass and my insurance which isn't a true HMO (but it is a half assed HMO) and Nationwide was out of network. Aeroflow just came on board a few months ago and I haven't checked with them yet.

If your DME would contact Bleep...they don't get quoted the same price we see in the retail market. It all depends on how big the order is. Now it is possible that they won't make as much money as they would like but they could still make money and do it for you if they just would but my DME won't. It gets billed out for insurance purposes with the same billing HCPCS code as any nasal mask and the replacement ports get billed out like a replacement nasal cushion. I have no idea what your insurance allows for each of those billing codes.

My DME flat out lied to me and said that my insurance (Medicare) wouldn't cover it which is total BS. I haven't been back to them.
Now they might not make as much money as they want with it but they didn't even try and it really pissed me off and then they lied to me which is a fatal mistake when it comes to keeping my business.
Now I could change Medicare Advantage plans I suppose but I just haven't done that. I keep threatening to but to change just to figure out one that is in network for one of the suppliers that will file insurance and supplies the Bleep....it's been more work than I have had the energy to do and I didn't do it again this year. I plan to try again after the first of the year with Aeroflow and I feel sure they won't be in network either but I may appeal to my insurance and bring up the fact that my DME refuses to get it for me. Maybe light a fire under them via the insurance. Appeals can sometimes be made and out of network coverage can be granted. We just went through all that because my mom needed a very special kind of home care and no home care company within the network offered it and the insurance finally approved and paid for an out of network home care.

A7028 is for the ports and a box that covers 2 weeks of use is the same as one replacement cushion
or A7029 could be used which is a replacement nasal pillow code.
Even Medicare allows 2 per month. Most but not all insurance will follow Medicare replacement guidelines.

The mask frame/hose part of the Bleep is A7034 billing code.

[babydinosnoreless]

Call back to insurance co. Why can't you just reimburse me for equipment I can buy at 1/2 the price? Never got a real answer other than no.

My thoughts on the price was based on when I asked my DME what one of my masks cost. I did a search online to discover I could buy it if I had to for 1/2. So I guess you are right and they could not sell it to me for what they paid. They are in business to make money. I do get it that you give up some things by having an HMO but with a few exceptions like this it is the best care we can get. Our company will not allow anyone to switch to the HMO and if you go to another plan you cannot go back. We are not working still. I retired 10 years ago. In a couple of years when we reach 65 I believe the company will move us to United Health Care so we will hang onto the HMO until then and try to work around little problems like this.

United is a HMO and it sucks big time. My company is forcing the switch January 1st and I already have all kinds of headaches from it.

[HD4Mark]

https://bleepsleep.com/our-partners/

Thank You for that link.

It appears that my insurance will not pay for anything that ends in .com. I did go to their site and search for in network DME providers but got the same list they emailed me. Next I will have to expand the search area to 125 miles, get a new list and start calling. I'll also compare Bleeps partners list with my insurance list but none ring a bell so far.

If I can't find a way to have it covered I will just buy it myself. I have to try it due to the rave reviews here and the fact that a nasal "mask" is working better than all the other tries.

[Pugsy]

Good luck to you.

HMOs are a different beast. Having a strict in network system forcing a limited list of providers within the system is how they keep the costs down and offer more attractive premiums.
Pros and cons to everything.

My Medicare Advantage plan is sort of like an HMO without being blatant about it. The pro to it is it doesn't cost me anything each month...the con is they also aren't going to want to pay for my cpap stuff even through and online supplier that would file my insurance for me. Compounded by the fact that my usual DME doesn't want to try to help me out and simply order the Bleep wholesale. They could if they just would but I get BS answers when I try.

So I have to weigh how much it would cost to have a plan that would allow me to order online and they file insurance vs the no monthly premium for what I have now and what it does cover for me. I always do the math...cost of insurance to cover something vs just buying it myself out of pocket. For me to have some sort of coverage in addition to what traditional Medicare would cover if I wanted to return to traditional Medicare....simply would cost me more each month than what just buying the Bleep ports each month would cost me.

I understand that you are caught between a rock and a hard place right now and your choices are limited. It is what it is. You pay for your insurance and you want it to do its part of the contract but HMOs being what they are....they get to make their own rules and you have no say so in the matter.

Should you end up trying the Bleep out of pocket....the mask/frame part of the mask will last a long time with common sense care so that potential expense is rather small over the long term. I used my original frame component for nearly 2 years before I retired it mainly because it was yucky looking (all silicone will change color given enough time) and the fact that I switched to the new hose early last summer when I trialed it. The ports are the biggest recurring expense but that can be lessened by buying in bulk when buying out of pocket.

To be honest if it were me I would just buy a kit out of pocket and give it a try and make sure that I wanted to continue using it before I put forth much more time and energy finding a DME locally that would supply it and file with your HME and is in network.
But of course the choice is yours.

[HD4Mark]

Good luck to you.


To be honest if it were me I would just buy a kit out of pocket and give it a try and make sure that I wanted to continue using it before I put forth much more time and energy finding a DME locally that would supply it and file with your HME and is in network.
But of course the choice is yours.

Thanks for the luck and all of the info. I agree that it is best to give it a test drive before getting too wound up. Sometimes it gets to be the principal of the matter with me. It is a good feeling when you can beat the system. Or should I say make it work more like it should.

I now have a larger list to try. I'll scratch off the DMEs that don't appear to have CPAP supplies first then just sit down and call. One problem I have run into is that the person who answers the call knows not much, has to ask someone else and call you back. Then of course you never hear from them.

If I can find a DME that is helpful it will become my supplier. Not that will be that big a deal for them but I will be sure to tell everyone else about them.

[ChicagoGranny]

If I can find a DME that is helpful

A few years ago, I had some problems with our local network DME not wanting to order an Innomed Hybrid mask. I called my insurance company and asked to speak to a supervisor. Long story made short, the supervisor called her manager contact at the DME and straightened his ass out in a hurry. Often, these DMEs don't want to be struck from an insurance company's network supplier contracts list.

May you be lucky to find a helpful insurance supervisor.

[Deborah K.]

While you are figuring your insurance issue out, you can purchase the DreamWay Connector Kit and the DreamPorts at Amazon. This is cheaper than buying them both together as a kit, plus on Amazon you don't need a prescription. Here they are:

https://www.amazon.com/Bleep-LLC-DreamW ... 230&sr=8-2

https://www.amazon.com/Bleep-Dreamports ... 230&sr=8-4

[HD4Mark]

While you are figuring your insurance issue out, you can purchase the DreamWay Connector Kit and the DreamPorts at Amazon. This is cheaper than buying them both together as a kit, plus on Amazon you don't need a prescription. Here they are:

https://www.amazon.com/Bleep-LLC-DreamW ... 230&sr=8-2

https://www.amazon.com/Bleep-Dreamports ... 230&sr=8-4

That is my plan. Funny I had the starter kit and ports open in two other tabs on my notebook already.

[Dreaming1]

You can also try MakeSleepEasy.com. They have promo codes for all their bleep gear. Dreamway and ports for around $60.

[Bobby269]

Aerospace Healthcare takes Humana HMO. They were even kind enough to help me get a VA Doctor to issue a prescription for the Bleep
equipment.

[Janknitz]

Sometimes it gets to be the principal of the matter with me.

Insurance companies and DME's both have the same goal in mind--the bottom line. It's just an inconvenient truth that they have to provide us with supplies or care in order to make the money. They are not our advocates, and they don't give a flip about whether we have what we WANT. Their contractual obligation is to provide a mask. Whether it's the mask you want is not their concern.

I belong (reluctantly) to an all-inclusive HMO--Kaiser. They provide everything according to their formulary and there is NO going outside their system if you want them to cover it. That includes (when I had coverage for CPAP and supplies) the masks. They have a formulary for masks. This formulary no doubt came about through their negotiations with Crapria which is their only supplier. If it's not on the formulary and supplied by Crapria, it's not covered. PERIOD. I was actually grateful when I lost CPAP coverage under our ACA plan, because now I can buy whatever I want, whenever I want, and the little more I pay out of pocket is worth not having a hassle with Crapria every step of the way. I source supplies from cpap.com (our hosts), Amazon and eBay. And often I pay less out of pocket than the co-pays would be.

Not all HMO's are closed systems like Kaiser (you have a lot of DME choices and a supposedly unlimited choice of masks). But all HMO's negotiate hard to whittle down the costs from suppliers, so the DME's that contract with them have very narrow profit margins.
What we have been seeing in the past few years is that DME's are restricting their stock, so that they can maximize their profit margins. This makes it really difficult find a DME willing to go the extra mile for something that makes their profit margin even narrower.

Just so you know what you're up against. The only principle they care about is money.