BCBS MA "insurance speak"

[brucelegs]

I don't have my appt with the sleep doc to go over my titration results until March 11, but I have checked on my DME benefits and found this kind of disconcerting paragraph:

"These benefits are provided for the least expensive equipment of its type that meets the member's needs. If Blue Cross Blue Shield determines that the member chose durable medical equipment that costs more than what is needed for the medical condition, this health plan will provide benefits only for those charges that would have been paid for the least expensive equipment that meets the member's needs. In this case, the member pays the provider's charges that are more than the claim payment."

Now if my doc writes the prescription for (i'm not really choosing per se, just asking the doc to agree with me and select <g>) the Remstar M Series Auto w/c-flex (or similar data capable machine) does this mean BC/BS can come back and say it is not the least expensive of its type that meets my needs? I want to be armed just in case. I figured I would argue that a fully data-capable machine will allow me (and the doc) to better monitor the therapy, etc., etc. Has anyone else had to fight with BC/BS for not accepting the "least expensive equipment of its type" ?

[Gerryk]

I have BCBS of Illinois and I never read anything that talked about what was covered. I was told by my DME and I also called BCBS. I have had no problems with the insurance. I have double insurance. My wife works and has almost the identicle plan I have. Mine is primary and hers is seconday. What mine doesn't cover hers usually does.

[Wulfman]

Get ready to ask some more questions and "do the math".

What percentage does your insurance provider pay for DME equipment and supplies?

If they pay 100%, then an upcharge of a couple hundred dollars may not be a bad deal.

If they pay 80%, the other 20% of a highly-inflated amount may make it advantageous to purchase your equipment online.

TRY to find out what is going to be paid by your insurer (if they have a standard or normal amount) for whatever they consider is within their "least expensive equipment" price range. (they may not tell you)

Do they "require" monthly rentals for a certain number of months before purchasing or will they pay it all, outright?

Do they consider YOU to be "in-network"? (in case you are able to do the following)

Will they reimburse YOU if you purchase your equipment online and then submit an invoice from YOU to THEM for reimbursement?
(you would have to make out an invoice making yourself as the billing party.....to them as the party being billed)
This way is less expensive for both of you. Many insurance providers consider their group members as "in-network" and will reimburse them for out-of-pocket purchases (at various percentages).

Many people have reported that BCBS is pretty flexible about reimbursing their group members for out-of-pocket purchases.

If all else fails and you want the machine they won't give you, be prepared to purchase the whole works from an online supplier like CPAP.COM.

Den

[rested gal]

Now if my doc writes the prescription for (i'm not really choosing per se, just asking the doc to agree with me and select <g>) the Remstar M Series Auto w/c-flex (or similar data capable machine)

I know that was just "as an example", but if you do happen to decide on a Respironics M series Auto, I'd specify this one..
Respironics REMstar Auto with A-Flex M series
Not the one with just C-flex. The A-Flex machine has both C-Flex and A-Flex in it. More versatile. For me (not necessarily so for everyone) A-Flex feels even better, smoother than C-Flex.

Anyway, in auto mode you can use either of those two Flex features -- can't use both at same time. Or can turn them off. Lots of ways to use that machine.

[OldLincoln]

I know that was just "as an example", but if you do happen to decide on a Respironics M series Auto, I'd specify this one..
Respironics REMstar Auto with A-Flex M series
Not the one with just C-flex. The A-Flex machine has both C-Flex and A-Flex in it. More versatile. For me (not necessarily so for everyone) A-Flex feels even better, smoother than C-Flex.

Anyway, in auto mode you can use either of those two Flex features -- can't use both at same time. Or can turn them off. Lots of ways to use that machine.

And the A-Flex is only a few bucks more (~$40) if you have to pay the difference. Believe me it's worth it.

[brucelegs]

thanks everyone for your expertise and thoughtful replies.

I'm going to call and see if they will tell me what that magic dollar amount is with their "least expensive" wording. I do know I have a $400 deductible (which I have probably already met by doing the sleep study, the ENT consult and titration study (and a wonderful first-time colonoscopy last week since I'm 51) - then they cover 90% I have an maximum cap of $900 for the year before they cover 100% of my medical expenses. I don't think that will be a issue either;-) I chose an in-network provider and will visit with them in a week or 2 to feel them out to see if I think they will meet my needs. As for the machine itself, I have conflicting statements - the first BC/BS rep said they rent the machine, the one I spoke to today says "it depends".

I'm thankful for this forum and the tips on how to make the purchase outright with cpap.cm if it is the better deal. Looks like our flexible spending account will be wiped out pretty quick with just my medical stuff nevermind the husband and kiddos. I knew I should have put more into that. It's been a busy medical year and I'm not even 60 days into 2009

Mary-Ellen
(already planning my hose management solution - thanks Rested Gal for all those links!)

[danw61]

I have an EPO through BCBS of MA but my coverage is better than yours. DME coverage is 100% up to $1500 a year. I tried to talk BCBS into letting me buy from CPAP.com & reimbursing me, but they refused. Local DME refused to give me the M-Series Auto I wanted without Dr's specific prescription for auto. Dr refused to give prescription for auto. I talked DME into the M-Series Pro. I refused the M-Series Plus they tried to give me. Insurance ended up paying twice as much for the Pro as an Auto would have cost through cpap.com, what a waste. But the CPAP, mask, & supplies didn't cost me a penny. It's been a year & a half & I'm doing great. Just recently I went ahead & bought the M-Series Auto w/Aflex from cpap.com out of pocket & use the Pro as a backup.

My contract also had the "least expensive" wording but it hasn't been a problem. My Dr was the problem.

Refuse any machine that is not data-capable.

Dan

[Slinky]

I wouldn't even bother to talk to BC/BS about the brand or model of xPAP. What I WOULD talk to them about is what local DME suppliers they are contracted with. The more options of DME suppliers you have the greater your bargaining/negotiating power. All bare bone straight CPAPs, all fully data capable straight CPAPs, all auto PAPs and all fully data capable auto PAPs are insuranced (HCPCS) code e0601. (The bi-levels, SVs and auto bi-levels & auto SVs, etc. are an entirely different HCPCS code). Most all insurances contract and pay by HCPCS code, not brand and model. So - use your "bargaining/negotiating" chip and "shop" hour various local DME supplier opitons. You might likely find that one of them will want your business bad enough to provide you w/at least a fully data capable straight CPAP (the data capability is more important than the auto capability in my not so humble opinion). Also look for and insist on a lenient mask exchange policy. Once "they've" got your pressure right THE MASK is THE KEY to CPAP therapy success.

[nobody]

I have to fight with bcbsm for everything

[Sleepy Boy]

I went on line yesterday to see what Wright & Flippiss is charging BCBS for my equipment? They haven't charged them anything yet. I've been on cpap since July, I'm on my fourth mask (2of the same) and cant find a bill from them to BCBS. This seems kinda strange. I found my sleep study charges & the Dr. reading them, but nothing on my equipment. I haven't paid anything either...Does this make sense?? Thanks, Larry...

[Wulfman]

I went on line yesterday to see what Wright & Flippiss is charging BCBS for my equipment? They haven't charged them anything yet. I've been on cpap since July, I'm on my fourth mask (2of the same) and cant find a bill from them to BCBS. This seems kinda strange. I found my sleep study charges & the Dr. reading them, but nothing on my equipment. I haven't paid anything either...Does this make sense?? Thanks, Larry...

Since JULY??? Yikes!
I've seen posts of an incident or two of this type of thing happening. You either "fell through the cracks" (and you'll never see it in a billing), and/or they're terribly inept in their bookkeeping and at some point, you may have a big "surprise" waiting.

You're on the "horns of a dilemma"......do you keep quiet and stay hidden in the cracks or do you say something and get whacked with a whole bunch of billing that may be in a previous (insurance) fiscal year and could cost YOU.....BIG TIME.
Logic would seem to indicate that you shouldn't be penalized for their ineptitude, but in other parts of our economy, "logic" doesn't mean diddly squat these days.

I'm not sure what to tell you.


Den

[Slinky]

Ah yes, Wright & Filippis. They were my first local DME supplier. Our relationship wasn't particularly "satisfactory". I was stuck w/Medicare and my secondary insurance paying them for my capped rental of the Resmed S8 Elite for 13 months - BUT - w/in 5 months I switched to Sheldon Medical for my mask and all future local DME purchases. I've been very happy w/Sheldon - won't say anything good about Wright & Filippis.

As for W & F's billings: I picked up my original Resmed S8 Elite w/EPR on 08 October 06. Wright & Filippis did not submit first CPAP billing to Medicare until 01 Mar 2007.

[roster]

.............
Refuse any machine that is not data-capable.

Dan

Don't overlook Dan's point. And that should be fully data capable so that later you can get a card reader and software to monitor apneas, hypopneas and leaks.