Another question for the insurance savy

[Sleepless-in-Tonawanda]

Hello folks, thanks for the great forum. I've been lurking here for the past week and trying to learn as much as I can. You all have been very helpful.
A little background...
I had my sleep study and was diagnosed with OSA. My physician faxed my script to a DME and I went in for my meeting and left with a CPAP (not sure which one). I was never able to make it through the night wearing it. I was bothered also by the "big brother" card used for compliance. My deal was:
I rent the unit for 10 months at $50/month and then it is mine. The insurance also pays the DME $50/month (50% copay plan). I went online and saw I could buy one outright for about the $500 they were charging, and I figured that since I would likely fail the compliance check, I just returned the thing after 1 month.
Then I found this website. Some of the testimonials were compelling. My motivation for starting the therapy in the first place was that I was affecting my wifes sleep with my snoring. I didnt really think that I would/ could feel any better after a full nights sleep. I have gotten used to functioning with little sleep. Anyway, based on what I learned here lurking, yesterday I ordered a Respironics REMStar Auto M-Series CPAP with A-Flex and integrated heated humidifier. I also obtained a copy of the software. I figure that perhaps the tech/gadget lover part of me will help me get over the hurdle of getting used to sleeping with this if I can at least monitor whats happening (better me than big brother insurance company anyway).
But, I am rambling, my question if you are still with me is this:
I called my insurance company (Independent health HMO) and they said they would only pay 50% of the cost if I purchased it from an approved DME supplier. I gave them the names of several online supliers (including CPAP.com) and they said none of them were covered. It's no big deal since I am out of pocket little more than I would have been through the DME, but, do you have any advice for how I might compel my insurance company to reimburse me for some of the online purchase price?

[oceanpearl]

With my insurancce I had to prove compliance before they would reimburse me anything. I finaly figured that it was simpler to go to the local dme.

[Gerald]

If you consider your time worth anything, it's probably best to buy your own equipment, accumulate your own proof of compliance, and send the insurance company a letter asking for reimbursement.

The insurance company will run you in circles......requesting that you jump through 16 hoops....barking twice as you jump through each one....and request that you roll over and show "submission" at the end of the run.

If you can get some sort of reimbursement back from the insurance company....that's fine. But if it takes you 20-hours of time and hassle trying to get two or three hundred out of them, it ain't worth it.

[Wulfman...]

The way I did it 2 1/2 years ago with my initial purchase was to ask my insurance provider if they would reimburse ME. (I'm considered "In-network" with 80% reimbursement for DME)

Uploaded my prescription to CPAP.COM and purchased my equipment with a credit card.

When I received my stuff from CPAP.COM, I used their invoice to make out one from myself (as the billing party) to my insurance provider (as the party being billed).
Sent the invoice (and a copy of the CPAP.COM invoice so they'd know I wasn't trying to pad the invoice) to my insurance provider and they sent me a check for my 80%.

I have since purchased two additional REMstar Auto machines and additional supplies out-of-pocket.


Den

[Splash51]

[ but, do you have any advice for how I might compel my insurance company to reimburse me for some of the online purchase price?

_________________

Try holding a gun to their head or refuse to pay your premiums [just kidding ] Good Luck

[Wulfman...]

[ but, do you have any advice for how I might compel my insurance company to reimburse me for some of the online purchase price?

_________________

Try holding a gun to their head or refuse to pay your premiums [just kidding ] Good Luck

Maybe the same answer as "Splash51".

Is this a "group" insurance situation?
If so, they have written policies. If they consider YOU as being "in-network" and will reimburse for out-of-pocket (medical) expenses, you probably have a chance. Tell them that you can save them a considerable amount of money.
Considering your amount of co-pay, you'd be better off terminating your contract through your DME (make sure your insurance provider is onboard with this) and purchasing out-of-pocket. Even with a 50% reimbursement from them, you'll still save money.

Den

[oceanpearl]

Every insurance company that I have dealt with requires PROOF OF COMPLIANCE. Try that if you want to learn about jumping thru hoops.
On my last try I took my card into the sleep doctor and had them print and sign the compliance data. Then the insurance co. wanted to know why I was using a Bipap machine instead of the Cpap that was prescribed. Finally gave up and ate it.
BCBS was good insurance if you played exactly by THEIR book. I haven't even tried going for an online purchase with Cigna. I only know that Cigna rented my machine from Apria for 3 months and then purchased it after proof of compliance from Apria.

[Highnote]

HMO's tend to be restrictive and only cover things from in-network suppliers. An HMO that lets you go out of network is usually called a POS plan (point-of-service, not the other meaning!). If you really have an HMO and not a POS you may be SOL for re-imbursement. You need to find out you plan provisions for going out-of-network.

Let me add my vote to the proposition that the brick-and-mortar DME markup is so high and the insurance hassles so many that bypassing both can work out better.