Insurance company taken for a ride? BCBSIL

[n9yty]

Hi All,

Three weeks or so into this, and finally starting to see some of the financial numbers come in. It seems like the insurance company is being taken for a ride, and me right along with them.

I have a friend who received his CPAP machine just about a year ago, and he hasn't been able to get a clear indication from BCBSIL (Blue Cross Blue Shield Illinois) on when, if ever, he would "own" the machine, he was paying monthly rental. No matter who he called, he couldn't get a straight answer.

Now I'm in the same boat. The paper work I have showed an initial monthy charge of around $790 for an initial mask, set of tubes, filters and included a $245 ONE MONTH RENTAL FEE for the REMstar Auto machine. Heck, I can buy one of those online for about two and a half months worth of rental, so why on earth would an insurance company pay such high rates?

And, of course, I have a combined deductible/out-of-pocket liability to the tune of about $2500/yr, so I am not OK with it just getting pushed on and ignoring it. Heck, It'd be cheaper for me to NOT submit it to insurance and just buy my own.

Sorry if my message isn't completely clear, but I'm somewhat frustrated and still trying to make sense of this all, and straight answers seem to be in very short supply. I am having an appointment with the sleep doctor in two weeks to presumably talk about progress to date since I was fitted with the machine. I haven't received results yet, nor a letter of medical necessity, both of which I will press for at this meeting hopefully to be able to make purchases in the future if I need to without going through these rip-off companies.

Thanks for listening.
Steve

[SleepFast]

Seems like a boat load of money to me too. I am waiting for the BC/BS accounting to come in for my first CPAP. I was told it was a purchase and I would owe $320 including a mask. If I am paying 20%, the total cost should be about $1600 for something I could get on-line for under $1,000. Pretty good mark up for a drop-ship type of deal. But not nearly as bad as what you are seeing. When the bills arrive I'll check in.

[Goofproof]

That is why I tell folks to check https://www.cpap.com/ for the best price and make your own decisions. Question is that company BCBSIL or is it IMBCBSIL, sorry, that was just too easy. And that's not called taken for a ride, it's a drive-by. Jim

[boston]

i called my insurance (aetna) and told them they were getting raped, they basically said "so".
i told them i could buy online and would gladly pay the 20% if theyd pick up the rest, was told not to worry about it.

[n9yty]

And this is magnified in every transaction that happens in the medical realm, I'm sure... Maddening.

Yes, we need health care reform here in the USA, but it must be a reform of what passes for health care in administration and insurance company policies, not simply finding a means to pay the existing infrastructure with government money.

If Obama touches this sticky wicket, I hope he does it right and address the problem with why it's so expensive instead of the question of why people can't afford the rates and help pay them without question.

[jules]

3 years ago my insurance was billed about $3k for a cpap, humidifer, mask, hose, filters etc. This was rent to own but that was the total. The DME had a contract with them for 80 % of what they billed.

Now take into consideration inflation and see how far off this will be?

[boston]

thats it, im quiting my job and selling xpap machines. and i will give everyone the clinicians manual. damn, i probably wont get invited to the DME ball, oh well.

[Debjax]

Not sure if the paperwork is from the DME or an explanation of benefits from your insurance.

One thing to keep in mind is that what the DME bills is very frequently NOT what the insurance pays. I know that with my insurance (Tricare), often the amount that they will pay is a fraction of what is actually billed. I have not received my explanation of benefits yet, but I know that my DME is probably not going to get the full $130 per month they will be billing them for my machine.

I know that by the time the rental is paid for my machine and it becomes mine, insurance will have paid more for it than I would have paid if I bought it outright here or they had bought it outright from the DME. But, consider that the DME has probably already paid for the equipment, and now is getting their money back over a number of months. Usually if I pay for something over time, I pay an additional charge, such as my car payment to cover the loan from my credit union.

There is also the cost of handling te paperwork each month (yes, it does cost to pay the people that do that job), and expense that most online vendors do not have. For those of us with insurance, we don't have the option in most cases to use an online vendor and get reimbursed. Sorry, but I'm not made of money, and if the insurance company is going to cover it, I'm going to let them. The DME's have to play by the insurance company's rules. I know that my insurance company has rejected the claim at least twice, forcing the DME to resubmit...nothing the DME did wrong, just the insurance company's way of delaying payment. I'm not going to vilify the brick and mortars for billing a bit more, knowing they are getting paid alot less than they are billing.

[rested gal]

One thing to keep in mind is that what the DME bills is very frequently NOT what the insurance pays.

Very good point, Deb.

[Goofproof]

thats it, im quiting my job and selling xpap machines. and i will give everyone the clinicians manual. damn, i probably wont get invited to the DME ball, oh well.

First you must be trained properly, you need to serve 3 month as a French Fry Cook, at McDonalds, with maybe a side order of cash register training. (The one with the Pictures on the Keys)

Then buy a shed, and become a DME. Jim

[hobbs]

i called my insurance (aetna) and told them they were getting raped, they basically said "so".
i told them i could buy online and would gladly pay the 20% if theyd pick up the rest, was told not to worry about it.

The numbers have nothing to do with what the insurance company ACTUALLY PAYS. Bill for my wife's hip replacement was $79,000.00 the insurance paid the hospital $21,000 and the hospital accepted it as full payment!

[boston]

ive seen the statements, i dont recall the exact numbers, but they are going to pay around 7 times what cpap.com is selling the IDENTICAL setup for. and that is after their deductions and allowances.

[n9yty]

I received my EOBs. . . More to come, but so far:
$103 for initial doctor visit, $80 allowed.
$294 for initial sleep-lab doc visit, $194 allowed.
$149 for "emergency medical visit" in conjunction with the above appointment. $149 allowed.
(now that one has me scratching my head.....)
$3,100 for a one-night sleep study - $3,100 allowed.

So, that is $3646 billed so far, $3523 allowed, and it hasn't accounted for the upcoming follow-up visit, OR the equipment.

I have very high (in my not so humble opinion!) deductibles of $2000 to $2500 depending on how things are billed, so it isn't going to be cheap for me even WITH insurance.

Tell me why it costs $3100 to have someone watch you sleep for one night..... Or $443 for a fifteen minute office appointment to discuss having a sleep study done in the first place.

If I didn't have insurance, you can bet that I wouldn't have even pursued this because as bad as $2500 is for me to pay out of pocket, it is clear the the costs are still rising.... There is a pending claim from the DME for $700 for the first month (presumably) of CPAP rental and initial supplies, we'll see how much of that they allow.

[mdbarthe]

I just purchased a new machine through my health insurance carrier. I had the same experience (it is also BCBSIL). I could get the machine I just received through CPAP.com for roughly $1,000. I even offered to buy it myself at that price and just have BCBSIL reimburse me for their 80%. The answer was no - go through your DME.

BCBSIL has a flat fee maximum that they will pay for a CPAP device. They apparently would rather pay out their flat fee maximum (I don't know exactly what that is but it is far more than $800) than save me and them some money. I'll get stuck paying the 20% of the total but that will still be less than if I had outright paid the $1,000 myself and not involved BCBSIL.

As for the costs of the sleep lab, analysis and the doctors' appointments, I can relate to you what I was told by my physicians: "You're paying for the equipment that takes and analyzes your results; my education and experience in interpretting the results; the power and overhead of operating the lab, the office, etc.; the nurses that take your vitals before the doctor comes in; the receptionist that scheduled your appointment; our liability insurance for frivilous malpractice claims and insurance, etc., etc."

[LinkC]

I have BCBS-Federal. I paid nothing initially for the equipment. I pay a "co-pay" of 23.45 a month. I've been told I'll own it at some point, but like the original poster, exactly when that point occurs is hazy.

Of course, I've messed things up entirely by getting a data-capable machine three months into the deal. I'm guessing both the DME and BCBS aren't gonna like it. (On second thought, the DME will...)