Crazy low insurance reimbursement

[stevenal]

My insurance is using the Medicare rates. All seems fine until we get to the CPAP itself. Billing code is E0601 NU (newly purchased). It would seem that Medicare doesn't publish this particular code/modifier combination, just the E0601 RR (monthly rental rate). Anybody else deal with a similar situation? I intend to appeal. Should I tell them to multiply by 13? Should I just keep sending the same invoice nine times (9X would cover the purchase price). To be clear, I'm not dealing with Medicare, just an entity that uses their rates. Thanks.

[Sharrykb]

It has been a few years since I have dealt with this. But if my memory is correct, many insurance companies require you to rent the machine for a certain number of months before they will approve purchasing the machine. I believe this is because they want the patient to demonstrate that they will actually use the equipment before they buy it for the patient.

[Janknitz]

Do you mean the insurer is trying to only pay ONE monthly capped rental fee and call it good? That's around $100 -$150. Or will they pay the same capped rental rate as Medicare for the 13 month period???

You should request your insurer's "Evidence of Coverage" in writing. That is the contract you have with your insurer that you've never seen unless you know to look for it. That should spell out in detail what they pay, and you can talk to your insurer to clarify how they determine the Medicare rate for a capped rental item.

Look up what the retail prices for machines are. They are LESS than Medicare pays out over the course of the 13 month capped rental, but one of the reasons they charge less is that there's no Medicare mountain of paperwork, no monthly billing, no obligation to service the unit for at least 5 years (all of these are Medicare requirements).

Since you probably have to go through a DME to get your machine to have the insurer pay anything, you're likely to end up paying far more than you would if you just bought it out of pocket yourself, either through an online retailer like our hosts at cpap.com OR a used machine from Secondwind.com or someone here who sells them regularly through Craigslist. Get the information you need to weigh your options.

[LSAT]

My last Medicare purchase cost me about $12 month for 12 or 13 months.....If I paid $150 (20%) the Medicare paid $600 for a total of about $750 for the machine. I have used the same DME for many years. I paid the $144-156 in a lump sum so I didn't have to be bothered every month.

[stevenal]

I did go through our hosts, paid outright, and turned in the receipt. This has worked fine in the past, but the plan and the administrators have changed since. It definitely would have been better to go through an in-network DME.

The EOB says nothing about any repeat payments, and calling them did not disclose such information. I assume they want to call it one and done. If my appeal is denied, I'll send them eight more copies of the receipt each marked with a separate month. (nine months will cover the purchase price).

[chunkyfrog]

When calling insurance, remember, the first person you talk to
is trained to only say NO.
You need to ask for higher-ups until you get a person with a BRAIN.

[stevenal]

I received a letter yesterday saying my appeal was successful, and they will re-calculate my benefit. Just waiting now to see what they come up with.
I've noticed on some of my EOBs state they look for other lists of allowable costs when Medicare rates are not available. Anyone know where to find such lists?