CPAP/insurance question

[geoDoug]

Since, as many of you know, I'm fairly new to the CPAP game, I have a question about how to approach my insurance company about something.

What has happened:
1. I got my prescription for a "cpap"
2. I proudly went down to Apria and, unbeknownst to me, was handed a relatively featureless machine (remstar plus w/o cflex)
3. This morning, I looked online at the EOB. Apria billed Aetna $1,021 for that setup! Aetna paid Apria $262. Seems like a low reimbursement, but Apria is also billing Aetna $173/month. (Aetna is paying $65/month.)

What I want to do (hopefully today)
Thanks to you, I've educated myself about the many features available and that I may be able to get my insurance to pay to fix this situation.
I'd like to call Aetna and say to them after explaining briefly why I'm calling: "Since then, I've learned that I can buy the same mask and more robust CPAP outright online for $x. I'd like to do that and have you reimburse me for that purchase. Since there won't be a monthly charge to you, this will save you money. The additional features will also benefit both of us, because they will increase my compliance. (c-flex and software specifically--but I probably won't go there unless I have to explain why.) if I return the cpap, humidifier, mask, and supplies to Apria, will you reimburse me for an online purchase?"

My question for you good people
I've figured out, based on features, that I want to get the M-Series Pro with C-flex. The cpap.com product page says that it has a built-in heated humidifier--and that's what the pictures there look like. However, that product page includes an online bundle offer to add a heated humidifier. Is that bundle entirely unnecessary? I think it is, but I want to make sure. I'm asking so that I can do a calculation in advance and say to an Aetna rep exactly how many months down the road this is going to pay for itself.

Can somebody out there with this machine help me out?

Thanks much!

Doug.

PS Yes, I realize that I'll also need a card-reader.

[Guest]

I'm confused.....

Two days ago, in response to this post by snoregirl:

You might also want to take a detailed look at what your are paying for the machine you have now. Copay and deductable if any.

You said:

Not an issue for me. My insurance paid 100%. It's not a rental. I'll keep that in mind for the future if/when insurance changes.

Doug.

Now you say:

3. This morning, I looked online at the EOB. Apria billed Aetna $1,021 for that setup! Aetna paid Apria $262. Seems like a low reimbursement, but Apria is also billing Aetna $173/month. (Aetna is paying $65/month.)

I guess it wasn't all what it appeared to be, huh?

Sounds like they paid for the first month's rent and it's on a rental schedule. You should be able to get out of that with the the help of Aetna.

Den

[Snoredog]

Same insurance and DME I used to have.

You are wasting your time with them attempting to get an upgrade.

Your best bet?

1. Take your script and buy the machine you want online.
2. Once you get it, keep the plain jane machine as backup for camping and travel or sell it on craigslist. You may be able to get $100 for it.
3. Use your new Autopap and think nothing of it.

Aetna paid the startup costs, of $262, then they are paying $65 per month over 10 month period or another $650 for that sub-$300 machine. So, doing the math it is $262 + $650 =$912 (oops not very good at math) for a machine that you can buy for under $300 outright.

mmm... so I guess you figured out now this medicine stuff is a racket, a legal license to steal. Its not just this industry, it is that way throughout, why do you think wall street is so involved with it, HUGE profits can be seen.

They have those jacked up prices to always cover their expenses, they keep them high due to medicare guidelines, everything is done to accomodate medicare which basically says you can't sell it cheaper to anyone else without offering it to us at that lower price. So what do they do? they rip everyone off.

While I don't speak for cpap.com, online suppliers like cpap.com say, we are not selling to medicare, we are not selling to insurance companies. We don't have all those paperwork requirements to meet, we don't have to wait >120 days to see our money, so we are going to sell products with a reasonable mark-up. The differences of that can be seen in what Aetna paid for your sub-$300 machine.

Pay any deductible? It is becoming common now where deductibles are approaching what you can buy the machine outright.

So what they "bill" or charge don't really mean much. What they get paid is what counts and you want to compare.

I can tell you right now, you are NOT going to change the policy of those companies on your own. It is your health, what is that worth to you?

What I want to do (hopefully today)
Thanks to you, I've educated myself about the many features available and that I may be able to get my insurance to pay to fix this situation.
I'd like to call Aetna and say to them after explaining briefly why I'm calling: "Since then, I've learned that I can buy the same mask and more robust CPAP outright online for $x. I'd like to do that and have you reimburse me for that purchase. Since there won't be a monthly charge to you, this will save you money. The additional features will also benefit both of us, because they will increase my compliance. (c-flex and software specifically--but I probably won't go there unless I have to explain why.) if I return the cpap, humidifier, mask, and supplies to Apria, will you reimburse me for an online purchase?"

Only thing flawed with that theory is you are dealing with two good ole-boy huge conglomerates. They have policies already in place for this, you are just a newbie in therapy to them, but trust me they have been through this before.

Unless you get any promises from them in writing, you can take what they tell you over the phone with a grain of salt, because what they say don't mean anything.

Go read your AETNA policy, it should be available on line where you got that EOB.

It states their requirements for CPAP and DME. It spells out what they will pay for, what is needed for diagnosis, and how they will pay for it. Only exceptions to those rules is if you had an underlying condition which dictates a different therapy approach such as for Bipap or Bipap ST. If you had a stroke or heart failure you can bypass the "CPAP trial" portion. But your doctor has to write a letter of medical necessity even for that. It is all covered in your policy, read it.

Same for example if you want an Autopap, they will pay for it but you must fail your cpap trial first (reason they put it on a 10-month rent-to-own plan). Then they (insurance company) look at compliance rates for this therapy at about 40%. Well if the compliance is that bad, why do we want to purchase these machines outright, if you give up on therapy after 3 months, they are only out $262 +$65 x 3 instead of $262 +$65 x 10. That DME Apria making more than 3 times their cost will take that machine back. They give you a brand new machine (if you are lucky) and if it fails, you get a used machine from someone that returned one due to non-compliance.

Like I said, you are spinning your wheels trying to change the system, there are roughly 15-million of us in the USA alone ahead of you, if you catch my drift.

[Slinky]

These Respironics (and most) xPAPs do NOT come w/a built-in humidifier. They do come w/what is referrred to as an "integrated humidifer". Looks like it built-in once attached and made specificially for all the M series machines. BUT the humidifier, whether integrated, stand alone or passover, is a separate billing. And they are purchased outright. So if you "rent" an xPAP and need a humidifier you have to "buy" the humidifier outright. The same holds true whether out of pocket or insurance paid.

Yup, you are learning. There is a Billed (or Billable) amount, an Allowed amount, and a Paid amount. There might also be a Co-Pay and/or a Deductable amount.

[geoDoug]

I guess it wasn't all what it appeared to be, huh?

Sounds like they paid for the first month's rent and it's on a rental schedule. You should be able to get out of that with the the help of Aetna.


Den

You noticed the discrepancy. I'm impressed.

"Wasn't all what it appeared to be" would be a good way of putting it. When I was at Apria they said to me that insurance "would pay 100%." As far as I knew that meant that it was my machine and Aetna was paying for it. What Apria did not tell me that that included full insurance coverage of a monthly rental agreement between them and Aetna. Glad I'm at least trying to be an informed consumer!

Doug.

[Slinky]

A great majority of the time these xPAPs are placed on a "capped rental" basis, meaning once you've proven compliance (one to 3 months of use at least or over 4 hours per night) the xPAP is rented for a set number of months and then the xPAP has been purchased and becomes the sole property of the patient. i.e. "rent to own". The rest of the equipment is generally an outright purchase and not returnable beyond the 30 day mark.

[geoDoug]

These Respironics (and most) xPAPs do NOT come w/a built-in humidifier. They do come w/what is referrred to as an "integrated humidifer". Looks like it built-in once attached and made specificially for all the M series machines. BUT the humidifier, whether integrated, stand alone or passover, is a separate billing. And they are purchased outright. So if you "rent" an xPAP and need a humidifier you have to "buy" the humidifier outright. The same holds true whether out of pocket or insurance paid.

Thanks! That's exactly what I wanted to know!

Yup, you are learning. There is a Billed (or Billable) amount, an Allowed amount, and a Paid amount. There might also be a Co-Pay and/or a Deductable amount.

I learned long ago (because of unrelated chronic medical conditions) to understand all the fun columns on EOBs and read them closely. What I'm learning is how different the DME game is. It's an education.

Doug.

[Babette]

Welcome to the world of DME's who are clueless and/or evil and will knowingly or unknowingly mislead and outright lie to you.

Sorry Doug. Sounds like you're not fairing any better in Olympia than I am in Tacoma. I've decided to approach my insurance and go directly with CPAP.com, if insurance will reimburse me. At this point, I really don't even care HOW MUCH they will reimburse me. I'll put it on the credit card and eat it.

I'm so hacked at my current DME I plan to buy a new machine, and drop their machine off and make them sign a note TYPED BY ME that they took it back. I will then forward that to the insurance to prove to them that they should NOT pay any more rental or other fees to them. Grrrrr....

BEST OF LUCK TO YOU!
B.

[Brookbank]

Good luck with your return, I am going through the same process now although it is a few months too late.

Sounds like you are on the right track. My only suggestion based on my experience - Look at your original set up and make sure you were not billed separately as part of the set-up for tubing, the humidifier chamber, and the filters. I was so as a result will be keeping these as spares. The charge for these (which are included in the package from the manufacturer) was $153.00 - 33% of the CPAP.com total machine cost.

My Sad story for others to learn from

WHen originally started, I was told the DME had checked with the insurance company and the company would not cover the full price because they were not part of the PPO arrangement. I was assured the DME would honor the price the insurance company would cover and that would be my bill. My insurance has a high deductible so I was concerned.

They finally billed the insurance company after 3 and one-half months and the EOB was received with 4 days left until the 4 month anniversary. I was able to return the machine after only 4 monthly rentals of $260 (insurance indicated full payment was due) Billing included $195 for the machine and $65 for the integrated humidifier. Total CPAP.com cost for the same machine $450.00.

Over the four month period I spent $1193.00 for a $450 machine - everyone needs to make a profit but that is a bit excessive. Assuming CPAP.com sells the equipment at cost, the internal rate of return on this little transaction was over 100% Assuming they throw the returned machine away and do not sell or reuse it.

My DME had a 30 day trade policy on masks. ALthough I did try to return it within the 30, they talked me into trying a loaner and after the 60 days when the loaner was up, I could not bring back the original mask even though I decided the loaner with a chinstrap was a much better fit. They advised me to keep the original full face mask for when you have a cold. Original mask plus headgear was $330 plus $70 for the headgear. CPAP.com price $189.

My advice to new patients, make sure your DME does not delay the original bill, personally check with the insurance company before hand, and try not to be taken advantage of as I was. A pricey lesson but I am sleeping much better so it does work.

[Babette]

Hey Doug! Who'se your insurance? I've got Premera. Maybe we should compare notes...

EDIT - Idiot girl didn't read. Aetna. Clearly says AETNA. Sorry Doug! Nevermind....
B.

[Guest]

I guess it wasn't all what it appeared to be, huh?

Sounds like they paid for the first month's rent and it's on a rental schedule. You should be able to get out of that with the the help of Aetna.


Den

You noticed the discrepancy. I'm impressed.

"Wasn't all what it appeared to be" would be a good way of putting it. When I was at Apria they said to me that insurance "would pay 100%." As far as I knew that meant that it was my machine and Aetna was paying for it. What Apria did not tell me that that included full insurance coverage of a monthly rental agreement between them and Aetna. Glad I'm at least trying to be an informed consumer!

Doug.

Part of it comes from watching sleep-deprived patients get screwed by these outfits for the last two years.

Ahhhhh......the "cost of education".....

I'm not that familiar with Aetna so I don't know how flexible they are.....sounds like Snoredog is though.

Hang in there, Doug.

Den

[Slinky]

... My advice to new patients, make sure your DME does not delay the original bill, personally check with the insurance company before hand, and try not to be taken advantage of as I was.

Bear in mind that Medicare and most all insurance companies will NOT accept or pay a billing until compliance is verified and this compliance period is generally 1 to 3 months depending on the insurance.

And Brookbank, I would definitely write a letter to both your insurance company AND your state's licensing division regarding the untruths and shoddy practice of this DME.

The black mark on that DME's "record" is worth the effort of writing that letter even if nothing is done to correct the situation. Probably nothing will be done with the excuse it is your responsibility to KNOW your insurance coverage benefits before contracting w/a supplier. But enough complaints to the insurance company and/or state licensing division can and often does make a difference eventually. The government works slow.

[geoDoug]

Thanks to a lot of luck and great advice from you guys, I made a lot of headway today. Even though I'm not all the way there:

First thing I did was call Aetna. Our plan won't cover out-of-network providers. (Damn. Forgot about that.) So the online thing is out of the question unless we decide to change our insurance plan and wait for that to take effect in a couple of months.

Change gears to the exchange option:

I called Apria. And told them exactly what I want (M-Series Remstar Pro c-flex, M-Series heated humidifier, AND cardreader) and asked if I can exchange it. The nice person (Somebody from a DME who's nice!) said that they do have that exact machine and if I get an Rx for that specific machine and if the insurance will approve it then no problem.

So I called the sleep clinic and told them exactly what I need. They gave me zero problems and said they'd write the Rx and have it out to me next week. (Doctor is out this week.)

In other words, I'm gonna get that Rx. Then fax it over to Apria. Apria will then call Aetna to get approval and we can exchange.

Phew! Deep sigh.

Doug.

[Guest]

Thanks to a lot of luck and great advice from you guys, I made a lot of headway today. Even though I'm not all the way there:

First thing I did was call Aetna. Our plan won't cover out-of-network providers. (Damn. Forgot about that.) So the online thing is out of the question unless we decide to change our insurance plan and wait for that to take effect in a couple of months.

Change gears to the exchange option:

I called Apria. And told them exactly what I want (M-Series Remstar Pro c-flex, M-Series heated humidifier, AND cardreader) and asked if I can exchange it. The nice person (Somebody from a DME who's nice!) said that they do have that exact machine and if I get an Rx for that specific machine and if the insurance will approve it then no problem.

So I called the sleep clinic and told them exactly what I need. They gave me zero problems and said they'd write the Rx and have it out to me next week. (Doctor is out this week.)

In other words, I'm gonna get that Rx. Then fax it over to Apria. Apria will then call Aetna to get approval and we can exchange.

Phew! Deep sigh.

Doug.

The question that patients don't (usually) ask their insurance provider is whether YOU are considered in or out of network. If the insurance provider will reimburse YOU for out-of-pocket medical/DME expenses, then you could purchase the machine you want from CPAP.COM, submit an invoice from YOURSELF to your provider and they will reimburse YOU at "in-network" rates..

This is what I and many others have done.....purchased our equipment from CPAP.COM, created and invoice from ourselves to our insurance providers and they reimbursed us (usually at abour 80%, which is typical for DME items). This method saves everybody a good bit of money and allows a patient to get the machine they want.

In any case, it sounds like you're going to get a machine that will help you monitor your therapy......just thought I'd throw this other option out to you or anybody else who may be reading and looking for options.

Den

[Slinky]

I wonder if anyone has tried that w/Medicare and been successful??