Buying online or use a DME – help me make a decision please

[Wulfman]

I purchased all of my initial stuff from CPAP.COM......THEN, billed my insurance provider (with an invoice from me as the billing party and them as the party being billed) and they reimbursed me for 80%......because, they considered ME to be "in-network". It works the same for other out-of-pocket expenses......and can be listed on a form and submitted for reimbursement or applied to the deductible.

I discussed these options and procedures with them beforehand (which I believe is important for anyone wanting to use this option).
By the way, I don't have BC/BS, but quite a few others on the forum who have BC/BS have done the same thing with success.


Den

[ycartf]

If anyone doesn't mind sharing, I'd love to know how much you paid for the equipment you got when it's all said and done, DME or Online/Insurance. Thanks.

I was diagnosed and started PAP therapy in September 2006. I used the DME ran by the same Dr's office that I had my PSG done (I figured it would reduce "who I had to call" if I had questions later) and I have not gotten any prices at any local DME other than that one since then. I was prescribed/issued a Resmed S8 Compact (no data, no EPR, strictly CPAP, plain jane machine) along with the humidifier for it, one tubing, and a Medium Ultra Mirage FFM.

My insurance was/is BCBS of Alabama. The total submitted to them for reimbursement was $2,445 ($2,045 for CPAP unit and $400 for FFM/tubing). I was responsible for a $300 deductible and a 20% copay. The amount that BCBSAL recognized as "usual, customary, and reasonable" was $1501.68 ($1,200 for CPAP unit and $301.68 for FFM/tubing). The total I paid was $540.34 ($300 deductible and $240.34 20% copay) and the total my insurance paid was $961.34.

The original CPAP unit I got is now relegated to a back-up (last back-up) as it does not record data. I use three RemStars now (one at home and one each at my Fire Department and Ambulance jobs) that all record data. Before shipping, I paid $300 for the M Series APAP one at home, and about $100 each for the other two CPAP ones at my jobs (one an M Series Pro and the other a Legacy Series Pro 2). I get a Quattro FFM here and there when one is going for around $70 on cpapauction.com and get tubing from cpap.com (several at a time). While I hate to feel like I am not "using an available benefit" of my insurance, it is actually a lot less expensive for me to carry on buying the stuff myself as I have been. To keep from raising our premiums, the municipality I work in has raised the deductible from $300 to $500, with 20% copay still on DME. Since I only buy maybe 3 tubings and 3 masks a year (AT MOST) at a cost of "maybe" $250, I would not even be approaching my $500 deductible (now that I have my machines I need - all three of which combined were less than the first one, and around my now $500 deductible). I told that to the Physician's Assistant that saw me last time at the Sleep Dr. (about it making more sense for me to buy on my own) and she just kind of shrugged it off as OK, saying something about if I am ever in a position where I have met or almost met my annual deductible for some other treatment or problem and want some new equipment, just to let them know and they would get me everything I was "eligible for" at that time (which would be a new everything right now as none of my purchases have been filed with insurance due to them being used or from auction or else very inexpensive like tubing). I am in charge of my therapy enough to know what is working for me and track my progress, and I doubt I will ever rely on a brick-and-mortar DME as long as I can keep a couple of running machines and buy masks/tubing online.

Just my experiences.

Tracy

[PetrusKy]

I purchased all of my initial stuff from CPAP.COM......THEN, billed my insurance provider (with an invoice from me as the billing party and them as the party being billed) and they reimbursed me for 80%......because, they considered ME to be "in-network". It works the same for other out-of-pocket expenses......and can be listed on a form and submitted for reimbursement or applied to the deductible.

I discussed these options and procedures with them beforehand (which I believe is important for anyone wanting to use this option).
By the way, I don't have BC/BS, but quite a few others on the forum who have BC/BS have done the same thing with success.

Den

Wulfman, I have never heard of such practice before it presents a very attractive Option #3 for me. You acted as your own DME and they allowed that? I will call BCBS and ask about this option and how to go about proceeding. What if they say NO? What argument can I use to pursue the matter? Thanks for the enlightenment.

[PetrusKy]

My insurance was/is BCBS of Alabama. The total submitted to them for reimbursement was $2,445 ($2,045 for CPAP unit and $400 for FFM/tubing). I was responsible for a $300 deductible and a 20% copay. The amount that BCBSAL recognized as "usual, customary, and reasonable" was $1501.68 ($1,200 for CPAP unit and $301.68 for FFM/tubing). The total I paid was $540.34 ($300 deductible and $240.34 20% copay) and the total my insurance paid was $961.34.
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.
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ycartf, thank you for sharing those numbers. They help me out a lot.

[Wulfman]

I purchased all of my initial stuff from CPAP.COM......THEN, billed my insurance provider (with an invoice from me as the billing party and them as the party being billed) and they reimbursed me for 80%......because, they considered ME to be "in-network". It works the same for other out-of-pocket expenses......and can be listed on a form and submitted for reimbursement or applied to the deductible.

I discussed these options and procedures with them beforehand (which I believe is important for anyone wanting to use this option).
By the way, I don't have BC/BS, but quite a few others on the forum who have BC/BS have done the same thing with success.

Den

Wulfman, I have never heard of such practice before it presents a very attractive Option #3 for me. You acted as your own DME and they allowed that? I will call BCBS and ask about this option and how to go about proceeding. What if they say NO? What argument can I use to pursue the matter? Thanks for the enlightenment.

No guarantees, but the worst they can say is "No". Is your plan a PPO or something else? I was (and still am) in a self-insured PPO.
I just talked to them beforehand and explained that I could save us (collectively) a bunch of money by doing it this way and they said that I would be considered "in-network". They also have forms to submit for other types of out-of-pocket medical expenses. In this case, I just used a multi-part invoice and basically duplicated the sales invoice I received from CPAP.COM because it had the correct insurance codes listed on it with the items. I also sent them a copy of that invoice so they could see that the figures I submitted were correct.
They (nor any other insurance provider) would consider CPAP.COM to be an in-network DME. However, many providers will consider their group members as in-network for the purposes of reimbursement.


Den

[brazospearl]

I have BCBS in Texas. It's hard to get a straight answer from any of the folks I've talked to there, and they've never sent anything in writing, just tell me to review my benefit book. The local DME/sleep center wanted to "give" me (their word; they were gonna charge me for this) a machine with no data reporting or exhale relief (although they had done the titration with exhale relief. Go figure.) Anyway, I decided the ease of use outweighed any potential money savings since I wasn't very impressed with the skills at the DME. So I ordered all my stuff from CPAP.com, got the return insurance and LOTS of great customer service. It was a breeze. And since I don't deal well with morons in customer service positions, I'm glad I went that way.

[PetrusKy]

I have BCBS in Texas. ...

Hi brazos, it's interesting you live in TX. I live in CA and when I called BCBS last week to give them the heads up that I might order from Cpap.com and submit claims to them. They wanted to know where Cpap.com was. I said Houston. They said I would have to submit claims to the TX office, not CA.

[PetrusKy]

No guarantees, but the worst they can say is "No". Is your plan a PPO or something else? I was (and still am) in a self-insured PPO.

Wulf, yes my plan is PPO.

[finchy]

I recommend going through a DME provider, less headache and hopefully they have someone knowledgable with sleep, this would be very beneficial with any problems you have. I work for a DME and am a respiratory therapist as well as a sleep disorders specialist and help patients frequently to become compliant and overcome any obstacles they may encounter.

[PetrusKy]

Update: I opted to go the online route and so glad I did. Got a sweet deal on the S9, humidifier, climate tubes and Swift FX. Sent in my paperwork to BCBS certified mail. 15 days after they received it, I got my check in the mail. There was no hassle whatsoever and I got the machine and mask I wanted. I will recommend doing this to anyone.