THIS is what is wrong with health care....

[WilsonVilleUSA]

Here is an example of what is REALLY the problem with health care in this country.


When I was first diagnosed with OSA my insurance covered DME at 80%. Same coverage in network or out of network, just had to have the medical documentation. My sleep doc was a network provider and was going to get me all the hardware. A mask, hose, RemStar Plus (basic machine), humidifier, carry case, etc. Told me up front what the costs were going to be (about $1800), insurance allowed about $1400, he would write off the difference as required, and my 20% would be $280. I talked to a couple of other in network DME's and was surprised I could not get an answer when I asked "How much is a RemStar Plus?" They all said the same thing, "who is your insurance?". When I go to a store, they offer things for sale at a price. Now some prices may be negotiable, but they at least advertise a starting point. I've never asked how much is this and been told it depends on who I work for.

After several calls to insurance for info on allowable charges and educating myself, I found cpap.com. I learned I could buy from them a better mask, a better machine (RemStar Auto), and everything else the doc was going to provide and also get a card reader and Encore software for a total of about $1200. The only problem was I had to front the money and then get reimbursed. I did so and paid $240 out of pocket, saving myself $40 and getting better gear. Additionally, the insurance folks saved $160.

As time has gone on, my insurance has changed as they try and steer folks to network providers (and the limited offerings/lower end options they have). They now cover 85% DME with a network provider and only 65% if I go out of network. I found an out of network provider that will bill insurance directly, and accept their payment in full, I pay nothing out of pocket for masks, hoses, etc. I am shocked at what they submit for charges (and equally shocked by what insurance allows). For what I could buy at cpap.com for $220 (and be reimbursed $143 so $77 out of pocket), my insurance gets billed over $500, and allows $440, paying $286 to the provider.

I hate doing it, but I am playing the game the way they set it up. If they still paid me the 80% reimbursement they used to, they would be saving money and I would be happy paying a reasonable share of the costs. Over the course of a year, insurance is spending over $900 MORE than they would with the old model. Extrapolate this across the industry and you see why health care costs are so crazy.

The system is seriously broke, but I don't think they are paying any attention to the real problem.

[LSAT]

You seem to have done OK with your insurance....How else can you explain all these surplus items????
THIS is what is wrong with our health care system.............

viewtopic/t52573/Clearing-out-new-unuse ... gains.html

[Not me]

LSAT, you are sooo right! Folks order extras they don't need and then resell, because they can scam the insurance and government right back. Is this good or bad?

[Wulfman]

LSAT, you are sooo right! Folks order extras they don't need and then resell, because they can scam the insurance and government right back. Is this good or bad?

Depends on which side of the equation you're on.
It's the way this damn system is set up.
It's good for the DMEs who charge an arm and a leg for the equipment, but bad for the people who are paying higher premiums for those users who go along with the DME "replacement" schedules. For the unknowing, unsuspecting users who do what their DMEs tell them, they just accept the "stuff" the DMEs send them and probably throw away perfectly good supplies.

The "health care" system can't be fixed without addressing the systemic problems within.......costs and stupid policies.

I always cringe when I read the words "My insurance pays for.......".

I'm also not disparaging "WilsonVilleUSA" for how he came by his surplus supplies or that he's trying to help out others by selling them at reasonable prices.

In the whole scheme of things, what waste, fraud, abuse and overcharging we see by the DME and insurance industries is a drop in the bucket compared to the whole "health care system".


Den

[WilsonVilleUSA]

Wow, kinda surprised by the hate.

For the record, I PAY for my insurance benefits. While I may not pay out of pocket direct for the surplus supplies I have, they were not "free."

The place I get them from won't just send me the amount I use, they send the amount allowed. That is how they make their money. How often do you folks change your mask and hose? I don't use a new hose every month. I don't need a new mask every three months. I don't need two cushions a month. I clean my equipment regularly and take care of it. I rotate through a couple of different masks and they last me 10-12 months, cushions last 6 months or more.

I suppose I could just use all the stuff they send, which I am entitled to, and then just toss the lightly used, serviceable equipment on a regular basis even though it still works just fine. That's what landfills are for right?

Some people don't have insurance, some people don't have extra money hanging around. I think half price (or less- you'll note I said offers accepted) for brand new and unused equipment that I have to box up, pay postage on, and send out is a fair deal.

Sure, I could just continue to buy what i need from cpap.com, and pay even more out of pocket than my premiums. It just doesn't make much sense to not use an insurance benefit you pay for, and then pay even more out of some misguided moral principal. Does anyone honestly think doing so will fix the system? If I was into fraud I would be buying and reselling machines, not offering surplus hoses.

I am all for fixing the system. Get the allowable amounts to fair market values, get rid of the in-network/out of network scam. Provide 90/10 or 80/20 coverage and reimburse people fairly. Don't restrict folks to some second tier machine or or ineffective mask because someone in the supply chain can make an extra buck or two by forcing that one on the patient. People like me are scorned for playing the way they set the system up, while docs and DMEs are making huge profit margins in a legitimized shell game.

How many people with insurance even bother to look at what the amounts are for CPAP supplies? Sure, we know what masks and machines cost, but what about the other stuff? That reusable filter, you know the little chunk of foam? Does $19 sound a tad high? I think so, but that is what the allowable amount is. The disposable ones- the ones you can get 6 for $14.99, insurance allows $15 a piece for those little gems, and you are entitled to 2 of them a month. Hell I am lucky if I remember to change it every other month.

It is as simple as this, cpap.com can sell a CPAP machine that comes with a hose, carry bag, and humidifier for $670 (Respironics M-Series auto). Good equipment, at a fair price. I am guessing they make a profit as they are a business and seem to be doing well. They don't want the hassle of dealing with insurance and because they avoid that, they can offer great prices to their customers. If I buy it out of pocket and get reimbursed at 80/20, I pay $134 and the insurance folks pay $536. Simple, reasonable, and fair.

Now that same machine through a network DME and the insurance bureaucracy, goes like this:
CPAP E0601NU billed- $900, allowed- $700, paid $560 co-pay $140
Heated Humidifier E0562 billed-$425, allowed- $350, paid $280, co-pay $70
Carry case E1399 (misc) billed- $125, allowed- $100, paid $80, co-pay $20
Tubing A7037 billed-$30, allowed- $20, paid $16, co-pay $4

Add it up, and for the same thing, I would pay $234 and insurance pays $936, for a total of $1170, almost twice the fair market value of the equipment. The kicker is, I would pay the $234 and insurance would pay the $936 REGARDLESS of what actual machine I got. I picked the high end Respironics auto. cpap.com also has a base model M series with humdifier for $299. The billing codes are the same, the amounts billed by providers are the same, and the allowable amounts are the same based on billing code regardless of which make/model of machine you get. In this case a DME would be getting almost four times the fair market value.

Note that every machine comes with a hose and a carry case. Since there are billing codes and allowables for these items they are itemized anyway and it further pads the profit of the DME and the increases the costs to the insurance. They don't care though, they are just doing the paperwork, it is the customers who are paying the actual bills. Insurance companies make money, I don't fault them for that. NONE of this is fraud, it is the accepted way that the system works. That is the real problem.



It isn't the end customer that is working the system, it is the system itself driving the waste and abuse. Who pushed for the replacement schedule to be what it is, the users? I am pretty sure it was the manufactures who want to sell more of their goods, followed by the DME folks who want to sell more of those goods, followed by the insurance companies who want to show being liable for additional costs to justify additional premiums, etc. It is a vicious circle, but we are not the ones spinning it.

Insurance is really only a benefit when you have a catastrophic loss. If I added up my premiums, my co-pays, my deductibles, my dis-alloweds, and other out of pocket expense, then looked at the real, fair-market cost of the services and equipment I use on annual basis, I am pretty sure I am paying top dollar and getting screwed well at the bottom line. Now if I happen to get hit by a car or have a catastrophic illness I will certainly come out ahead (assuming I can still work and pay the premiums and don't get dropped), so basically it is a gamble.

I don't understand why health insurance is tied to employment. Car insurance and house insurance isn't. I also don't understand why health insurance covers damn near everything instead of just the unexpected or catastrophic things. People should be responsible for their "regular" day to day costs. Just like you pay for your gas, oil, and service for your car or the maintenance and upkeep of your home. I WILL use the system provided. Make a better system, I am happy to use it. Give me a crappy system that is awash with waste and abuse, and that is the only one I have to use. Don't blame me, I didn't make the system and I am powerless to change it. All I can to is point out what I think is wrong.



LSAT- Yes I've done "OK" with my insurance. I pay for the coverage, and I use the coverage that is provided. If you can afford to pay for things you don't want or need to use than I guess you are better off than I am. I get a $30 cushion that I don't use, sell it for $15 and after packaging and postage I "make" enough for a burger and a coke. I am really living the high life huh? Maybe I should quit my day job. I hope you share your disdain with the manufacturer who made the piece for a nickle, the DME who made a 100-150% profit over wholesale, the insurance money changers who financed the transactions and their bean counters who document them for a "modest" fee. Oh, and don't forget to hate person who bought from me and saved $15. After all, they worked the system just as much as I did.

Maybe your angst would be better directed at those created and run the system instead of those who follow it.



Wulfman- Thanks for getting the point I was trying to make.

[LSAT]

Have you thought of telling your DME to STOP SENDING SUPPLIES unless you order them?????????????????
This is costing all of us with higher insurance premiums and fewer/lower benefits. Only the DME is coming out ahead!

[Kevin G.]

My DME suggests replacement of tubing and masks much more often than the manufacturer. I say no. A mask can last me several years and still be very servicable.

There is no reason why you have to accept the supplies that you do not need. As a minimum you should notify the DME when you need replacements and refuse additional items. If they refuse your instructions report them to your insurance company.

Be careful how you dispose of additional supplies. There are limits on the resale of prescription devices. In addition you might unwittingly be guilty of insurance fraud.

[brain_cloud]

"I didn't make the system" and "Others are getting away with much worse than me".

You act on the same principle as any of the bigger players, that of using the system for as much gain as you can get out of it.

[WilsonVilleUSA]

Have you thought of telling your DME to STOP SENDING SUPPLIES unless you order them?????????????????
This is costing all of us with higher insurance premiums and fewer/lower benefits. Only the DME is coming out ahead!

You've fallen for the "Be responsible and we all save" lie. The system is what it is, if I buy what I need from cpap.com and go through the reimbursement route it saves the insurance company and costs me. They DON'T pass those savings on. When I started cpap I did a lot of foot work, looked at all the options, and ended up saving myself money. For every dollar I saved, the insurance folks saved four. It wasn't easy and trying to get information from customer "service" with the insurance company was like pulling teeth. I spent about 30-40 hours talking to insurance, network DME, doing research on prices, looking at other options, etc. It was a very eye-opening process.

The "thanks" I got was being told I should just use the in network provider and avoid the reimbursement process. I looked into this and instead of having my choice of any mask on the market, I had my pick of exactly three options, one nasal mask, one full face mask, and one nasal pillows. I also had a plethora of two machines to choose from, and I would only have to pay about 20% MORE out of pocket for this "benefit". I kept going out of network, kept saving myself money, and kept saving the insurance folks money. What did they do next? Over 3 years they reduced coverage from 80% reimbursement for out of network down to 65% reimbursement and upping the in-network coverage to 90%, again trying to force you into using the network where they inflate the prices and limit the options. It is now at the break even point where I can buy from cpap.com and get the item I want at about the same price out of pocket as an in-network provider and being stuck with what they want me to have.

The "write off" amount you see on insurance billing is a false benefit. In my example above, insurance was billed $1480 and allowed $1170, with $310 written off as a fake "benefit" of using the network provider. If something is being overcharged in the first place, they are not doing you a favor by "discounting" a portion of the overage. On top of that, when they charge premium prices for lower quality products, you are being raped a second time.

The DME provider I use now is a better deal for me. I get what I want and at less out of pocket costs. I gave the insurance company a chance, I explained my journey through the process to one of their customer service supervisors, "disinterested" doesn't even begin to describe her concern. I complained to my employer, who is self insured and only uses the insurance company to manage the system. They were equally disinterested, even though they have a pretty strong campaign of being an "informed" user of benefits and making "wise" choices for "everyone's" benefit.

Yup, in the same time frame that my coverage for DME went from 80% to 65%, my annual deductibles went from $100/per person $300/family to $300/person and $900/family and in-network coverage went from a 90/10 split to a 75/25 split. Quite a significant "thank you" for trying to be a responsible user of benefits.

There is one thing I can say with absolute certainty, it is NOT "us" (end users/customers) who is causing the higher premiums and lower benefits. It is the people running the system to line their own pockets, absent the actual fraud cases, "we" are just the deflection they use to try and avoid anyone from noticing.

[Kevin G.]

I will not defend the insurance companies but what they do is generally within the law. I believe that the moment you resell new items purchased using insurance company (or your employer's) money you cross a legal line and may be guilty of insurance fraud. I can guarantee you that inspite of the fact that they profited from this relationship if the authorities come looking the insurance company will deny all responsibility and let you take the fall.

You may think that you are getting back but you may be the one getting the shaft.

[dtsm]

Wilson:

Btw, I've also posted individual items on both cpaptalk.com as well as cpapauction.com, and bought from both.....so not objecting to your attempt to "take advantage of the forum."
But you have way too much free time writing this stuff - why not start your own blog and support it from the sales of the items you''re selling on your other thread

You may think that you are getting back but you may be the one getting the shaft.

Well said!

[WilsonVilleUSA]

It is a miserable rainy Saturday in Seattle. not much else to do LOL.

For those who think I am trying to "profit" and to alleviate any fraud concerns, I'll say this, the stuff I have as surplus was originally ordered with the intent to use it or have available as back up. I did not get it with the intent of reselling it or committing any sort of fraud. I am not asking nor expecting fair market value, and believe the the prices to be nominal. I am not a lawyer nor an insurance investigator, if someone on the board is and wants to educate me about the nuances please feel free to do so off list.

I have already posted the following in my other thread:

"I am not a business, I looked at cpapauction and it seemed to me it was set up for those who have a regular supply of things to sell. That is not my case, these are surplus items that I thought someone might have use for instead of just sitting in my closet. If the legitimate moderators or list owner want to kill my post, I don't have problem with that. As for the self-appointed list Nazi's, find another hobby.

I am well aware cpap.com provides this forum, I also well aware that there are a lot of folks with limited funds, no insurance, or no benefits available that might need what I have or want to try a different mask and can't afford to, even at cpap.com's fair prices.

In my other thread I have been accused of fraud and trying to profit from my insurance by selling these surplus items. Feel free to to read that thread for my thoughts on those topics.

As for these items, if anyone is truly in a hardship situation, PM or email me and we can discuss getting this stuff to you at no cost. If you are interested and can afford to pay, make me an offer. If you are not interested, please start your own thread to complain about me."

[dtsm]

It is a miserable rainy Saturday in Seattle. not much else to do LOL.

Lake Stevens is an hour from Seattle, no?

[WilsonVilleUSA]

It is a miserable rainy Saturday in Seattle. not much else to do LOL.

Lake Stevens is an hour from Seattle, no?

About 30 minutes from Seattle proper, a couple of miles due east of Everett.

[plr66]

WV, I glazed over & stopped reading everything you apparently had to extensively say on this thread, at the points of scanning your words of "entitlement" and "misguided moral principals" in your first post. There are few truly constructive posts on this forum which consist of half the space you have rattled on with here; and I think this kind of verbosity usually indicates rationalization and justification on the part of the author which creates drama but has no value. I am one who finds your kind of justification of system abuse truly despicable. "Entitlement" or not, you are the huge part of "the problem." Please spare us from your "pointing out what is wrong" with the system, while fully taking advantage of it for profit---even though you"hate" doing it....... Geesh!! Give us a break.