so how shocking will it be what my ins co is billed cpap??

[Junebug999]

i'm wondering....i went to cpap.com yesterday to figure out how much outright it would be to get the intellipap auto with smartflex and heated humidifier....etc. that i want...it's going to be interesting how much the dme will charge for it.

[Janknitz]

Don't worry about what the DME charges. It's all fictional. The insurance company is going to pay what the insurance company will pay, and hopefully your co-pay will only be 20% or less of the insurance company's contracted price.

The DME puts down on the bill what it wishes it would get (and sometimes some poor stupid schlemiel paying out of pocket actually gives them that much!) but it has nothing much to do with what they will actually get. It's all a shell game.

Be happy you have insurance, and if you have a large deductible (especially if the CPAP is a rental and you have to meet it next year, too) or copay, be sure to make sure you are better off with a DME than buying it out of pocket online.

[Junebug999]

thank you, and i'm very thankful to have insurance, i do have a 20% copay (will be going up higher than 20% in the future). I'm thinking about lease to own, and insurance company told me the other day to keep track of it and work with the insurance company or the DME will bill them forever, even after it is paid for. Soooooooooo would maybe my insurance company be willing to buy it for me outright from say cpap.com?

[jmcd]

Cpap.com does not accept insurance assignment. If you buy from them you will need to pay for the machine and submit a claim to your insurance carrier. Your policy will determine if they pay anything toward the machine. But keep in mind that many carriers will not buy the machine outright. Many require a rental period and periodic review of compliance data. Rather than speculate and ask members on the list what your insurance will cover, I'd get on the phone with them and find out what they'll cover. These are all valid questions and you're doing the right thing by educating yourself about CPAP equipment and some of the challenges that users face, but only your insurance carrier can give you specifics based on your particular plan.

[Emilia]

Hi Junebug..... I seem to recall that you said your doctor wanted you to get the IntelliPAP, which is great..... I wonder though, if the copay you have will cost you more out of pocket over the course of the 'rental' period than if you were to buy the machine outright for yourself. You really need to do the math on this one. If, for example, you have a 13 month rental period (pretty standard) and your copay each month is $40, you will have paid more in rent than you could have spent buying the machine for yourself without having to deal with the DME. Now, couple that with the fact that the year is almost up, a new deductible period is starting Jan. 1, and your copay is increasing..... and you can see how this might be a no-brainer to buy it for yourself. As I mentioned to you in my PM the other night, you can get a fabulous deal on the IntelliPAP Auto w/Smartflex with the humidifier included. Be sure to calculate it from all angles before committing to having the insurance handle it. In my case, my insurance would not even consider an auto machine for me so I bought my own; however, they do provide me with my mask and supplies as needed.

If you do decide to use the DEM/insurance route.... be sure they give you the latest version of the IntelliPAP AutoAdjust with Smartflex. Even the previous models without the Smartflex can be upgraded via firmware to include this new feature. The DME should be upgrading any machines they may have in stock w/o Smartflex for their clients.

[elena88]

I wouldnt wait to find out, I wish I would have known before the dme billed my insurance how much it was going to be..

I would call the dme and have them fax you the bill they plan to send to the insurance company, and then call the insurance
company as them what they will allow before its a done deal and you get stuck with a huge copay for five times what the machine
is worth..


there are horror stories, I dont know if they linked them yet, of people assuming the cost would be close to the online cost and discovering
that the insurance allowed five times the cost of the item or more, so they had an outrageous copay they could have spent less buying the item
outright online..

[jonquiljo]

If, for example, you have a 13 month rental period (pretty standard) and your copay each month is $40, you will have paid more in rent than you could have spent buying the machine for yourself without having to deal with the DME.

That is an excellent point. This is how insurers make it seem like you are getting something for your premiums, when you are getting little or nothing. Unfortunately the most vulnerable to this are the people who don't have spare cash lying around. DME's also emphasize their "service" to cash customers. I would like to add that when looking for a machine - the DME's quoted prices that included service that would have allowed me to easily buy a second machine as a back up rather than pay their inflated prices.

Welcome to the world of mark-up and mark-down insurance --- and all the people that come with it! Hang around here and ask people about the terms you are offered. I have never seen a more knowledgeable bunch of people on any subject in my life - like I have seen on this board. People here won't steer you wrong.

[jmcd]

I know a lot of people feel like they've been taken by their insurance carriers. However, as everyone if recommending, do the math and look at all options. My insurance carrier (a large national carrier) requires a 10 month rent-to-own plan. I am with a big national DME as well (they're contracted with my insurance company) and my machine will end up costing me less than what I can purchase it for through the online retailers. This includes factoring in my deductible ($400) at the start of the new year. And, while we're on the topic, you really have to think about the deductible. I will reach my deductible on other things besides my CPAP and related supplies. The deductible is simply part of the cost of medical coverage just like your premiums. So while many people seem to feel taken by the fact that they have to pay their deductible at the start of the new year, you really need to look at each individual plan to determine what is going to be the most cost effective way to get your machine. My S9 Elite will have cost me (out of pocket) $577 when I'm done with my 10 month rental period - I already know that my co-pay and deductible are not increasing next year. This is a combination of a great insurance plan (my co-pay is 10%) and the contracted prices between my carrier and the DME.

Just because other people feel they've been taken by the their insurance carriers, do the math based on your plan. It is the only way you'll know where you'll get the best deal.

[Slinky]

My understanding is that insurance companies contract w/local DME providers at lower reimbursement rates than Medicare's reimbursement rates. I have no idea if that is accurate or not.

These figures are old - from 2006 - and Medicare has cut their reimbursment rates each year since then but this will give you a rough idea of how the game is played.

2006 - Resmed S8 Elite w/EPR (13 month capped rental - one month's rental figures)
DME Billed: $135.00 - Medicare Allowed $99.95 - Medicare Paid $79.96 - Patient CoPay $19.99
2006 - Accessories (outright Medicare purchase)
DME Billed: $548.00 - Medicare Allowed: $499.63 - Medicare Paid: $399.70 - Patient CoPay: $99.93
Item breakdown:
a7037 - tubing used with positive airway pressure device - Billed: $48.00 - Medicare Paid: $32.82
a7034 - nasal interface (mask or cannula type) used with positive airway pressure device, with or wi - Billed: $130.00 - Medicare Paid: $94.11
a7035 - headgear used with positive airway pressure device - Billed: $45.00 - Medicare Paid: $31.80
e0562 - humidifier, heated, used with positive airway pressure device - Billed: $325.00 - Medicare Paid: $240.97

In 2007 Medicare cut the CPAP rental:
DME Billed: $135.00 - Medicare Allowed: $74.96 - Medicare Paid: $59.97 - Patient CoPay: $14.99

You should notice that the locals bill separately for the hose which is included w/the CPAP when buying online. And also that the locals bill the mask and headgear as two separate items but online prices include mask and headgear as one item.

I have no idea what the 2008, 2009 and 2010 Medicare CPAP reductions in reimbursement were. However, for a Resmed S8 VPAP Auto (bi-level) in 2008
DME Billed: $239.92 - Medicare Allowed: $218.11 - Medicare Paid: $174.49 - Patient CoPay: $43.62

and then, of course, there were the 2009 Medicare reimbursement cuts:
2009 Bi-Level one month rental
DME Billed: $239.92 - Medicare Allowed: $148.04 - Medicare Paid: $118.43 - Patient CoPay: $29.61

Medicare pays 80% of the Allowed Amount and the Patient CoPay is the remaining 20% of the Allowed amount.

[Sillyme]

. . . many people seem to feel taken by the fact that they have to pay their deductible at the start of the new year

That deductible only really matters if you don't have other medical expenses that are out-of-pocket. Once it is met you're done for the year. I bought my machine but will get my masks from DME this year since another family member has met the combined family deductible. (They are off my policy next year.) My DME replaces the whole mask and headgear every 3 mo so I will have two by the end of the year. I may hold out next year and buy a soft piece on my own if I need to - unless I end up meeting my deductible on something else. The cost of the mask from DME is way more than CPAP.com.