Can I avoid local DMEs and go online?

[Muse-Inc]

I've always thought Mattman was one of the "good'uns"...

Ditto!

[GumbyCT]

I thought Insurance Co. were in business to make money and just don't believe that if they were to insist that cpap items were marked up 5x more than reasonable that they would increase their profits. But then I'm not good at math either

[SleepingUgly]

Greg, I have seen a post from someone (name escapes me) whose DME allows them to try mask upon mask upon mask... IF you found a place like that, that would be ideal. I doubt you will, but trying any masks before buying would be much better than buying over the internet and randomly picking a mask based on other people's reviews only and trying to guess a size (the sizing guides help, but they aren't perfect)....although ultimately you may have to do that too.

If I were you, I would call the Stanford Sleep Clinic in Palo Alto and ask for a recommendation of a DME. Then call that DME and ask them how many they stock of whatever kind of mask you're interested in (eg, "We have 2 nasal pillows: the Swift LT and Opus 360, 2 full face masks: the Quattro and the F&P 432, etc."). If they have a mask you're interested in trying, why not try it? If they have many masks to try, even better. You can ask them their return policy. My DME would have ordered what I selected from the internet, even if they didn't stock it, but I would be stuck with it for 3 months until my insurance paid for another mask.

My DME has not been particularly helpful with the obstacles I've faced and they think I'm a nut that I want to see the daily details in my downloads so I call for a download every week. But at the same time, I could not solve my rainout problem with fleece covers and other techniques and they offered to swap my machine out for one that doesn't suffer from rainout. I wouldn't have known what machine to ask for and I could not have gotten that done online. This is a huge deal because I would have been out of commission if I couldn't get the banging in the hose to stop. In the 5 months I've been dealing with them, they've "given" me 2 nasal pillows, 2 full face masks, and she's slipped me an extra pillow for one of the nasal pillows. My insurance pays for a new mask every 3 months, so they've basically eaten 2 on my behalf. None of these ultimately worked, so I just ordered a mask online that I paid for out of pocket. In a month I'll be able to get another one through insurance again.

Hope this helps. Sorry so long...I'm not a good editor when I'm tired!

P.S. You're right by Stanford! You're so lucky! Did you have your sleep study there?

[zgeggy2k]

Guys,

You have all been great, and trust me, I appreciate all the help you provide, no matter which side of the fence your heart sides with.

Continuing my homework today I did call a few DMEs that were listed as "In-network" (Anthem BlueCross PPO plan) and they basically gave me the same info: "well you have to send us your Rx, with a copy of your insurance card front and back, and we'll start the process and get back to you with an appointment".

None of them actually wanted to discuss much before "getting the process going". Basically, they only know how to do this process one way - it's like a state machine and if you get out of the mainstream, they get lost. I guess they figure once the patient has started the process with them, they're kind of hooked and won't back out (since most of them are like me, i.e. newbies, wrt the whole cpap system).

SleepingUgly: I did not do the study at Stanford.

The study I did a few weeks ago was in Sunnyvale (by Mary & Fremont). The study I did a few years ago was at Sleep Med on Winchester in San Jose.

I am happy to call Stanford Sleep Clinic to ask for a DME recommendation, but again I fear the bias of an organization that may have motives that aren't quite aligned with my goals. I don't want to sound ungrateful - they may be great! I'm just trying to be cautious and collect info from "real people" rather than businesses.

Now, I guess the tricky part that really requires local interaction is mask tryout/fitting. If only I could find places where I could try masks before ordering them online (I'd _pay_ for that service!).

Thanks again for all the support guys, you're great!

Cheers,

-- Greg

[rjjayrt]

As far as insurance billing gos, if you have BCBS or Medicare and they pay 80% then your cost for a CPAP machine will be approximately 215.00, your cost for a FFM will be approx 37.00. Of coarse you have to remember that medicare pays over 13 months, so divide the 215 by 13 and that would be your monthly charge. I don't have the cost for humidifiers at hand but its the same differential. Prices are set by contract with most insurance companies. From personal experience I can tell you that we have no right to negotiate the price, the insurance company tells you what they'll pay and you either agree and become a provider or you don't. Changes are occuring within the DME community, I think its getting better, but all I have to go on is this forum and those businesses within my community. Medicare is now requireing that DMEs be bonded. I agree that there are bad DMEs out there more than I'd probably like to admit, but I also know that there are many good DMEs out there. Its a shame that you have to hunt so hard to find them, but if you can I believe its a plus to work with them, its another resource to use for your treatment and its a conveinient way to obtain equipment. Like I have said on many threads if you happen upon a bad DME report them to there state regulatory board, there accredidation agency and to your insurance company.

[Kiralynx]

Now, I guess the tricky part that really requires local interaction is mask tryout/fitting. If only I could find places where I could try masks before ordering them online (I'd _pay_ for that service!).

Greg,

Look in your yellow pages. There are bound to be some mom-and-pop DMEs which probably aren't affiliated with your insurance. (I found a couple when I attended an AWAKE meeting.)

One of them has a very nice set-up for trying masks under pressure while you're lying down. They also have a sign. "Mask fitting: $75. Waived if you purchase a mask."

Regrettably, their prices are significantly more than online, but I suspect that they might come fairly close to online if I factored in the mask-fitting.

Thus, I will pay them if I go into their store and take their RT's time for fitting masks, whether or not I actually buy a mask from them -- and I don't view that as unreasonable.

[zgeggy2k]

One of them has a very nice set-up for trying masks under pressure while you're lying down. They also have a sign. "Mask fitting: $75. Waived if you purchase a mask."

This is exactly what I'm looking for! I'm happy to give them my $$ for this service (there's no reason it should be free, this is real value that local businesses can leverage against online competition).

The trick is to find out which one of the DMEs in my area offers this (maybe I need to be more direct when I call them and ask straight up "do you guys offer mask fitting services?").

Cheers,

-- Greg

[dogbone]

This is a "feel sorry for me" rant. Oh, how I wish I had done my research before committing to my DME contract. I followed my sleep center recommendations which I believe simply extended the cash-cow line, but what else can a know-nothing person do. I did contact my insurance company before taking the sleep studies, and they seemed to be in the dark about specifics. I was passed from customer service rep to rep until I finally got the info that they would pay 80%. Anyway I'm on a rent-to-buy contract and I don't see anyway out of it. I was told that I could return the machine within 30 days and the contract would be canceled. Unfortunately, the 30 days fell over the Christmas/New Years holidays and I didn't have time for real evaluation of what I was getting and I didn't find this forum until a couple of weeks ago. Also, I live in the boonies so it's not a short trip to services.

The good thing is that I'm learning a lot, here on this forum, that is very beneficial for getting my sleep problems under control. I thank everybody for your help.

[rayt435]

This is a "feel sorry for me" rant. Oh, how I wish I had done my research before committing to my DME contract.

Don't feel special in that regard as I fall into the same bucket.

My DME could not, or would not, give me the prices on the machine with humidifier. I was ignorant and felt stuck. So I wound up in their rental contract. My cost (after insurance adjustment) over the 12 (or is it 13) month rental period will exceed the cost had I just purchased it outright and ignored insurance. Problem is the amount I would have paid online would not be applied to my $3K deductible where the cost paid to the DME will be applied. In the end I was still between a rock and hard place. My insurance company would only consider a mail order provider, such as CPAP.COM, as an out of network provider where my deductible amount is doubled. It did me no good to go online.

I called the insurance company and explained to them that I could get the product cheaper. That when my deductible was satisfied the amount the insurance would pay would be less. I was saving them and me money. But that was not good enough.

I feel that a lot of DME's are like the ads on TV where a company will handle all your diabetes supply issues and will bill Medicare for you (I am not on Medicare). The prices are jacked up higher than they need to be for the product. The cost gets adjusted down but the DME gets the maximum allowed by insurance which is still marked higher than it should be marked up.

It is all a racket and the DME providers are in the game for the money. There is big bucks in the breathing machine business.

[dogbone]

rayt435. . . it's somewhat comforting to know that I'm not the only one taken by this scam. It's too bad that the sleep centers/doctors aren't required to alert their patients to these Buy-Beware situations. You would think the insurance companies would police this business. They're making money somehow on sleep-disorder patients.

[GumbyCT]

One of them has a very nice set-up for trying masks under pressure while you're lying down. They also have a sign. "Mask fitting: $75. Waived if you purchase a mask."

This is exactly what I'm looking for! I'm happy to give them my $$ for this service (there's no reason it should be free, this is real value that local businesses can leverage against online competition).

The trick is to find out which one of the DMEs in my area offers this (maybe I need to be more direct when I call them and ask straight up "do you guys offer mask fitting services?").

Cheers,

-- Greg

You do NOT need to get a mask fitting at a DME. Certainly, You can but don't need to.

If you can't lay down with your mask at FULL pressure when you try on any mask then I would find another place. Your face WILL change shapes whenever you lay down. Anyone who tells you it doesn't matter is not helping you and prob doesn't know what s/he is doing.

Mask makers offer a 30day exchange (at not charge to anyone) if your mask doesn't fit/work. Be sure to ask BEFORE you buy. This mask exchange would prob be the single biggest reason to purchase from a DME. But then there are other less costly ways you will find when reading this forum.

Greg,
The short answer is Yes, ...Check with your sleep center - many of them offer mask fittings cuz it is a billable service they can provide to you. Getting a mask to fit properly is the key to success.

The rest will involve reading here at the very best forum on the internet.

Wishing you the very best.
Good Luck

[rjjayrt]

Again: The DME can "charge all he wants for a product, but if insurance is involved then that insurance company has a set price it will pay, if the DME agrees to accept that price then they become in network or a preferred provider. The DME has no input as to the price the insurance will pay, the only decision the DME has is to agree and become a provider or to opt out. If the DME is a preferred provider or in network then they have agreed to accept that price, irregardless of the listed retail price. In other words we're a preferred provider for BCBS and you are getting an item from me which retails for 100.00. BCBS has a contract with me to pay 50.00 for that product. You will be responsible for 20% of 50.00 (if your insurance pays 80%) Case in point and these are actual numbers. Our retail price for a cpap machine is 1900.00. Medicare pays 1078.00. Your responsibility is 215.00. As the DME I have no control over what Medicare pays, my only decision is to accept or not to accept, and by the way if you accept on one item you have to accept on all.

[Kiralynx]

One of them has a very nice set-up for trying masks under pressure while you're lying down. They also have a sign. "Mask fitting: $75. Waived if you purchase a mask."

This is exactly what I'm looking for! I'm happy to give them my $$ for this service (there's no reason it should be free, this is real value that local businesses can leverage against online competition).

The trick is to find out which one of the DMEs in my area offers this (maybe I need to be more direct when I call them and ask straight up "do you guys offer mask fitting services?").

Greg,

Yes. Sometimes you can out fox yourself by not asking for what you want directly.

Now, as has been noted -- you can probably do your own mask fittings once you know what you're doing, but some of us are cowardly, and want theoretically expert help at the outset. Just be aware that while there are capable and helpful people out there (like the one referenced below), it's wise if you have some idea of the parameters of the masks you are interested in, so you have some idea of whether the person you are working with is competent, or a moron. You can ask what people think about specific masks right here, and get a variety of opinions.

I admit that I'd been reading this Forum before my titration, but after my diagnosis, and called my sleep center and asked to try on masks before the titration. Their mask person was very helpful, as well as very competent, and the mask I ended up with for my titration proved to be one that I still use, 16 months later. (It's the Comfortlite 2, in case you're wondering, and I like it because you can switch between two kinds of nasal pillows and a regular nasal mask on it, which really helps in the early days of adjustment to xPAP.)https://www.cpap.com/productpage/Comfor ... -Mask.html is the link.

[rayt435]

This is a real world example of the insanity of the DME's and their billing to the insurance companies.

The cost of a RESMED S8 II Elite with the humidifier is 639.00 on CPAP.COM. I will not include the cost of the hose and the mask as they are not rental items and are considere supplies.

My insurance company is being billed for two items, the CPAP machine and the humidifier. The billed amount is $145.00 (112.00 for the machine and 33.00 for the humidifier). The program is a 13 month rental. That works out to $1885.00 over the life of the rental contract if the full amount was paid.

My insurance company says that only $54.56 should be paid each month for the both of those items because of the network provider discounts. My total cost over the 13 month is $709.00. Actually fairly close to the CPAP.COM amount. So the DME is not a too bad a deal. I will have to pay all of that due to my high deductible account ($3000.00).

But what I fail to understand is why the rental cost, if not billed through an insurance company, is $1100.00 more. Why don't the DME's bill the insurance company close to the rate that they are going to get paid? Since a contract is involved should not the DME know what the contracted amount is going to be?

That is one of the major problems with healthcare in this country. There is no standardized billing amount for anything. And there is no way to find out what the amount that is going to be paid will eventually become. It is all a guessing game. Had I not had insurance I would be paying 2.6 times the going rate that those with insurance would be paying. That is insanity.

I can understand the reduced costs of CPAP.COM over a DME. The overhead is lower for several factors.

[Sergey45]

Per my experience with local DME Company Apria nothing positive you’ll learn from them, no real help. Just financial rip-off and total ignorance of your needs as a patient.