A $$ question

[elmunc]

Hi all,

I could use a little advice about the cost of a CPAP machine and interaction with insurance. Here's the deal. I got my S8 Escape a year ago through Lincare. (This machine is available for $720 through online sellers.) I paid rent on the machine monthly, with a portion covered by my insurance. Then in July -- just in time for the annual reset of my deductible -- the health insurance company decided it was time to stop renting the machine, so they bought it for me, as it were. The result: I now owe $600 for the machine -- my portion of the absurd charge of like $2700 or some such thing that Lincare charges the insurance company. The number is that high because I hadn't yet met my deductible.

This is all feeling like a big scam. Am I wrong to think of it that way? I've ended up paying more for the machine out of pocket (the $600 plus the monthly rent for 9 months) than I would have paid if I could have just bought the machine outright at the start.

If anyone sees anything fishy in this, or has any advice, I'd certainly appreciate it!

--Eric

[Irene P.]

Wow! You really go taken. You have the lowest end machine there is. It gives no helpful information on your treatment whatsoever. I just checked cpap.com, and you can get a good auto machine, the Intellipap, for $435.00. With it or several other available machines, you can track your treatment, and you also have the option of using the auto feature. I think I'd turn in the machine if it's not too late and buy one outright on the internet.

[nobody]

Of course it's a scam. That's what happens when you have capitalistic health care.

[Hawthorne]

You (and your insurance) were waaay overcharged, especially for a machine that does not give any data how long and how often you used it.

I paid about $700 for new PR System One Auto with humidifier, online in March of this year and that's Canadian funds! Our dollar was pretty close to par then but still below the US dollar.

[M.D.Hosehead]

Have you paid yet?

Have you ever agreed to buy it?

Are there any escapes in your contract?

Can you dispute the charge on your credit card?

Can you call the insurance company and tell them you don't want it and they can save $2700?

If none of the above work, you can write the BBB, the state insurance commissioner, the consumer protection office in your state and tell them your DME and insurance company are conspiring to charge you $600 for a used machine that's worth maybe $150. You can find out what it's actually worth online.

[Janknitz]

I think you need to call your insurance company immediately and find out if that additional charge is legitimate.

It sounds like your insurance company was paying for the machine as a "capped rental" which is how Medicare typically does it. In a capped rental, the insuerer sets an allowable monthly rental fee, then they pay their portion (i.e. 80%) and you pay the remaining portion (i.e. 20%) of the ALLOWABLE FEE, not whatever the DME feels like charging. At the end of this capped rental period (for Medicare that's 13 months), the machine is yours, you don't owe another penny.

I don't know if that's the deal your insurer has with your DME, but I'd certainly find out before paying the DME another penny. And if it's not the case and you really do have to pay an additional $600 to own the machine, I second the suggestions to return the brick and get a great machine of your choosing, with data, online for less than $600. Don't give that DME any more money!!!!

[Uncle_Bob]

Wow you got screwed over something rotten.

[jonquiljo]

I would check with your insurance company as to what they are trying to do. Frankly, unless you agreed to buy it when you rented it (by signing something, etc - maybe when you picked it up), you have no obligation to buy it whatsoever.

If all this is what your insurance company will cover on a CPAP - I would not buy the machine (if you haven't agreed to buy it) and go out and buy one online.

[sleepylady]

Unfortunately, this sounds quite in line with insurance companies and DME's. I would look at the agreement you signed when you picked up the machine to see the terms you agreed to. If it doesn't say anything about purchasing it outright then give them the machine back and say thanks but no thanks. I bought my first machine through a DME and my insurance company, but never again. You're finding out that using insurance and a DME is much more than just purchasing it online using a valid prescription. I was in the same boat you were, in that I didn't meet my deductible, so the amount I paid for my first machine was more than double the SAME machine I purchased through our lovely forum host. Good luck...

[mattman]

There are a few things going on here.

First - Get out of the habit of comparing the pricing from an online cash sale to going through Insurance. It's apples and oranges right out of the gate.

Next - it is standard practice for most insurance companies to rent a CPAP for a year and then switch to purchase. This is the norm.

Okay, so with that out of the way -

There is one thing jumping out at me that does seem wrong - the lump sum payment. I would ask about that. Typically from what I've seen you will have a capped rental that simply switches over to a purchase at the end of the term. It's essentially a "rent to own" process. I have not seen very many situations where there is such a large sum due. In the cases I have seen anything due it's usually been the combined rental fee for the last 2 months which still shouldn't be that high.

Something else to keep in mind is that there are 2 prices frequently thrown around when dealing with Insurance Companies. There is a "submitted amount" which is the amount the provider bills the insurance company. Then there is the "allowed amount". This is usually somewhere between 40-60% of the submitted amount. This is how insurance works. They only pay a small portion of the billed amount, so the "submitted amount" has to be higher to account for it. It's all bassackwards.

Additionally, the Insurance Company actually sets the allowed amount and often the submitted amount as well.

So make sure the 600 dollars isn't just the submitted amount.

Unfortunately in some cases copays are based on the submitted rather than the allowed amounts which really puts the screws on patients too. Ugh.

So check on that amount and find out what's going on there. But yeah, Ins rates will always be massively higher than cash rates. Partly because of Insurance Companies but also partly because it's VASTLY more expensive for someone to provide equipment via an insurance company (Taking a year or more to be paid and then the requisite 7-10 years of carrying the info depending on your state) versus just selling it to someone and being done with it.

It doesn't forgive not finding a way to make both types of healthcare work just an insight into it.

mattman

[wjp]

Call your insurance company directly and find out what is covered.

Don't believe what the DME is telling you. The person you are talking to is likely a salesperson, not an expert on your insurance coverage.

In my experience with Aetna, the deal was a rent to own. Ten months of rental payments and the machine was mine.

My DME kept referring to it as their machine and wanted to charge a maintenance fee every six months, but I got that stopped quick.

Good Luck

[Janknitz]

Elmunc, Keep us posted.

[mattman]

Call your insurance company directly and find out what is covered.

Don't believe what the DME is telling you. The person you are talking to is likely a salesperson, not an expert on your insurance coverage.

In my experience with Aetna, the deal was a rent to own. Ten months of rental payments and the machine was mine.

My DME kept referring to it as their machine and wanted to charge a maintenance fee every six months, but I got that stopped quick.

Good Luck

FYI - depending on how your insurance has setup the capped rental, that's actually quite common. In fact, I'd even go so far as to say in my experience it's by far the norm.

[kempo]

In my experience with Aetna, the deal was a rent to own. Ten months of rental payments and the machine was mine.

Thats the way my insurance works.

[jnk]

Re: A $$ question

Oh, NOW I get it: I was supposed to read that as "A money question." Those are dollar signs! I misread that at first as being two capital S's, signifying a question especially for me!