Understanding the DME - Insurance, Out of Pocket Costs, Etc

[Swim_Bike_Run]

As I learn more and more, thanks to this great forum and it's resources, I spent the day looking more into where I will be buying my CPAP machine and all of the goodies that go with it. I have learned that ordering from some online stores offers significant savings, but unfortunately buying online would be considered "out-of-network" and I would then be subject to a hefty $2k deductable. My insurance in through United (UHC), btw. If I choose "in-network" then my insurance covers 80%. I called the DME that is close by and wanted to attempt to have a sincere (if possible) conversation as to why I should buy from them as opposed to buying online, knowing full well that I would be answered with relevance to the DME being able to provide better service, dealing with problems with EQ, just basically having a local resource availble....all that I basically agree with. My understanding was primarily that buying only would be significantly less expensive, thus making my 20% co-pay less expensive. However, after speaking with the DME and then calling my insurance provider it was determined that the reimbursement for the insurance codes were the same regardless of where I buy the EQ as long as it is though an "in-network" provider. My 20% is based on their reimbursement amounts, not what the DME has the machine retail priced at. I guess my question is, if my out of pocket is pretty much already pre-determined, it would seem the main challenge is getting the DME to give me the EQ that I want and not taking no for an answer, provided the script will allows it, correct? I was told the reimburseable amount for code E0601 (CPAP Machine was approx. $598)..just a FYI.

I do have a question - machine wise. It has been recommended that I go with an "Autoset" machine. I am looking at the S8 Autoset II. If I am supposed to have a CPAP with pressure of 10, will it be ok to get a APAP for this...I assume it has a CPAP mode? I really need to read more about masks. I am a stomach and side sleeper and I had thought that I would sleep best with a Swift LT or Breeze - pillow type mask, but the DME said that he thought the nasal mask would all me to sleep better with less leaks. Decisions, decisions.


Brian
SBR

[provider]

Brian/SBR,

First it appears you are discovering one of the most confounding things about medical care. The insurance company sets the pricing, AKA the "allowable" as it is called in the industry. Insurance will not pay any more than this allowable to any DME regardless of the DME pricing. Sometimes the allowables are cost or just below cost. But sometimes they are above cost to cover the DME's expenses. Truthfully I've never seen an exorbitant allowable, especially not for Medicare or Medicaid. Your co-payment will basically be the same anywhere that is in network with your insurance.

So if you've decided to use a brick and mortar DME choose on the other factors you mentioned such as service.

In reference to your machine an auto machine can be set at straight pressures. I always recommend the auto since you can more easily gain data in the future.

Basic types of masks are:
- Nasal (triangle cushion fit over your nose)
- Nasal pillows (pillows in your nares, like the Swift LT)
- Full face mask (triangle cushion fit over your nose and mouth, typically used for mouth-breathers)
- Hybrid
- Oral (don't do it!)

Most masks have a manufacturer comfort guarantee if the mask is fit by a trained clinician.

For side sleepers I've seen a lot of success with the Fischer and Paykel masks with the glide http://www.fphcare.com/userfiles/file/O ... hure_E.pdf. Or of course start with the nasal pillows. Some people at moderate pressures don't like pillows, but I've seen plenty of people with your pressure (CPAP 10 cmH2O) do well with nasal pillows. Now for the nasal masks it seems a lot of our patients don't like the Respironics Optilife pillows, so I'd start with the Resmed Swift LT or the F&P Opus 360. Otherwise we seem to have many patients that are very successful with the Respironics masks.

Good luck!

[sronsen]

Brian,

Find out from the DME and insurance company exactly how much you will pay after deductibles and limitations. Do not be surprised that you will be charged more than paying out of pocket from an on-line provider, from whom you can get exactly what you want and probably a lot quicker. I know that seems unlikely, but when you see the $2500 bill for a basic CPAP you'll see what I mean.

Steve

[Swim_Bike_Run]

Yikes! How is this possible? I have met my deductable for the year...how else could the bill jump like that other than my 20% co-pay?

[sronsen]

You may have better insurance than I and a better preferred DME. I'm just suggesting that you need to be careful, as the players are not expecting you to question anything, including the bill. Know what the on-line costs of your desired equipment are before you speak to the DME.

[rested gal]

I do have a question - machine wise. It has been recommended that I go with an "Autoset" machine. I am looking at the S8 Autoset II. If I am supposed to have a CPAP with pressure of 10, will it be ok to get a APAP for this...I assume it has a CPAP mode?

You're correct, Brian. All autopaps have a CPAP mode and can be set in CPAP mode for the single prescribed pressure.

So, the DME could give you an autopap set for CPAP mode and be filling your doctor's Rx fine. And yes, the billing code for "CPAP" - E0601 is the same whether the machine is a plain CPAP or is an "autotitrating CPAP" (autopap.)

However, in actual practice, it might be like pulling hen's teeth to get most DMEs to give you the more expensive machine (autopap) for your "CPAP" therapy, even though they could set it for "CPAP" mode. They may not even know it could be set for CPAP mode, and might argue that "autopap" is not what your doctor prescribed, in which case they'd make an issue of how your doctor would have to prescribe "autopap" before they could give you that kind of machine. They're wrong, but they are probably not used to thinking about "autopap" being used as "CPAP."

Bottom line is -- it will be about their bottom line. The less expensive the machine they get you to accept, the higher profit for them.

[KatieW]

Brian, do the math very carefully. I recently had a house guest who has a new Resmed S8 Elite II. He told me that it cost $3000 and his 20% co-pay was $600. That same item is $438 at cpap.com. His cpap is data capable, but the Smart Card was not enabled, and he had no idea that he could check his leaks, AHI, AI, HI on his LED screen, nor that software was available.

Best of luck to you, and welcome to the forum.

[Swim_Bike_Run]

This raises a very important question, as I'm not sure my insurance rep was 100% accurate.

What figure is my 20% co-pay based on? Is it the reimbursement amount ($598 for the CPAP machine) or the amount the DME charges??

[cflame1]

depends... if your DME is willing to settle for the agreed upon price between them and the insurance... then it'll be 20 percent of the agreed upon price.

If not it may be 20 percent plus everything over and above the agreed upon price.

[Swim_Bike_Run]

cflame..thanks for the info. Will the DME tell me the amount of the machine while I am there? I asked on the phone and they said that the cost is really based on an agreement between the DME and my healthcare provider. Seems shady.

[Muse-Inc]

My co-pay (10 month lease-purchase) for a dumb CPAP was $890...I coulda bought it online for about $350 at the time. I was clueless and taken. Check carefully! Lieing is an oft reported problem.

[Swim_Bike_Run]

So the bottom line is that the DME is going to charge for additional amounts above and beyond the reimbursed amount they receive from my insurance company. I was somehow thinking that it would be like any other in-network reimbursement that I have had in the past. My dental for example - if I need a crown and my insurance covers 80% for an in-network dentist, then the dentist can only charge $1200 then I am responsible for $240 (20% of $1200) and not a dollar more. I can see that this is not going to be a pleasant experience with the DME.

[akcpapguy]

It's ALL dependant on the contract (or lack thereof) your Insurance has with the DME, there reall is no wiggle room. For example if your insurance contracts with your DME for a CPAP paid at $600 allowable AND (here is the kicker that most people get caught by) NO balance billing, than you would pay your co-pay on the $600 ($120 if it's 20%) and the rest of the bill goes away. At that point it doesn't really matter if the DME billed $1,200 or $1,200,000 for the CPAP, they will only get $600 TOTAL. Now if your insurance doesn't have a NO balance billing clause in the contract and the DME billed $1,200 than you would be responsible for the 20% ($120) and the other $600 as well. Often times DME's who are contracted with Medicare/Medicaide or Tricare will have a "no balance billing" clause in their private contracts as well because the private companies already know they are willing to take "no balance billing" contracts. They use this point as leverage with DME's and win because the DME would rather take a lower reimbursement than no money at all because the insurance company contracted with another DME.

[bighead]

My DME is being paid by United, over a 12-month lease-purchase, around $900 or so for my S8 Elite II w/ humidifier. Looks like they are paying the DME retail-ish price for what is available online for about $400 less. On the plus side, I was surprised to find that my insurance was covering everything at 100%, even masks every 90 days. I might call United and ask if there is a way to buy online outside of the DME and get reimbursed, but looks like the answer will probably be "no."

I suppose that for something as critical as a CPAP it is preferable to see someone in a brick and mortar location to discuss options and usage. I'm normally allergic to buying anything at retail and do all of my research and purchasing online, but my DME was actually quite helpful and willing to work with me. I was completely clueless as to the market for these devices, and was thankful they were there to explain it all. I'm sure the higher price my plan is covering includes all of those pesky costs associated with having PEOPLE helping you instead of a web server doing the work.

The only thing I could complain about was their position on home use of the data card and ResScan software. I'm sure that the girl was just repeating the official policy, but said that it wouldn't take much looking to find additional information online. She was right.

[Doze]

My very recent activity with that same insurance provider may be relevant to your concerns. Keep in mind we may not have the same plan. We almost certainly don't actually, because I too have met my deductible for current year, and they are paying all in-network claims at 90% since then (vs the 80/20 split you mentioned).


My sleep study billed at like $2500 or so, contracted rate was more like $900, and out of pocket $90. No balance billing. Simple. Listed to show the similarities and contrasts with below.


My DME handed me a bill for something outrageous. Don't know if i have enough time tonight to add it all up (ha-ha). Several pages of curiously separate line-items: hose billed separate from the machine? (i watched them pull it out of the same box) the SD card is a rental, and separate from the CPAP rental? really?! charging me individually for the included filters? etc, etc... I was told to sign the full, multi-page bill, and despite some trepidation, complied. It seemed absurd since both insurance and the DME were also telling me I'd only actually be paying relative to the contracted rates... so why make me sign this irrelevant bill then? ugh. whatever. part of it was a rental initially and I'm sure they want legal bases covered for someone walking out the door with all that gear which they still legally own a major portion of.

Well, it's all been processed now, and sure enough, the crazy numbers were brought down to earth, and my 90% post-deductible coverage kicked in. For the machine itself, the conversion rate after a short rental was mid-$500s, the humidifier and some of the incidentals came in at $200-ish and the mask and some more incidentals $250 or so. There's a small rental period included in there somewhere too. Overall it came out to $1000. More than I would've paid here at CPAP.com, but not outrageously more, considering the gear. And only $100 to me due to my family's prior medical expenses this calendar year. DME has not requested any balance billing, at least not yet anyway. I think both insurance and DME are getting fairly treated on this transaction. It's probably less margin than the DME is accustomed to, since I got one of the newest autos on the market, but they still certainly came out in the black. And at $100 out of pocket, I certainly can't complain.