Insurance question related to CPAP

ScottGA · Post by **ScottGA** » Tue Jan 17, 2006 9:08 am

I just received a call from my equipment provider and they told me that since I had recently changed group insurance providers and that since they were not in that insurance company's network, I would have to get new equip. from a different provider they were referring me to and I would then have to turn in my equipment I got from the original provider. I had thought that last year when I got my equipment that the insurance company had purchased this equipment on my behalf, but the equip. provider informed me that they had merely paid 3 months rent on the equipment. I later asked how much it would be to just purchase it and not bother with changing companies, etc. and they told me about $1200. Of course, I priced the same equipment for about $898 online new, so I know me and/or my ins. company is probably being ripped off but I was attempting to minimize inconvenience.
Has anyone encountered this? Is most equipment really merely 'rented' by the ins. companies? Do I really have to deal with these providers or can I buy online? they probably will hassle me at the Dr. office before they will give me a copy of my presc. as I don't have a copy presently. My equipment is the Remstar Pro w/CFLEX, heated humidifier, and Comfortgel mask. It may not be a great fitting mask, but I have learned to adapt to it. Anyone have any info, advice, recommendations?

DRG · Post by **DRG** » Tue Jan 17, 2006 9:36 am

I have a similar question. I have been diagnosed with OSA and my doctor prescribed the REMStar Auto with C-Flex. I contacted my insurance company because my policy indicates that they will pay 80% of DME. I want to purchase my machine because they are charging the insurance company $200/month (I pay $40/month) when the machine only costs $760. When I contacted my insurance company, they indicated that they will only pay for rental and not purchase. Has anyone sucessfully challenged their insurance company on this issue and won?

DRG

Wulfman · Post by **Wulfman** » Tue Jan 17, 2006 10:40 am

The insurance providers and DME suppliers seem to be in cahoots with each other (for some reason) in this area of medicine. Usually, it's set up as a "rent-to-own" agreement where the insurance pays them an inflated price for the equipment for a set number of months (usually 10 or 12) and then it is considered paid for. Also, your co-pay will usually come close to paying for the cost of the equipment and the DME pockets at least 100 to 200% of the cost of what the equipment really costs them.
MOST insurance providers will reimburse you for out-of-pocket expenses (usually at the in-network rate of 80% or more). If they will do that, you can save yourselves (and them) lots of money by purchasing the equipment you want from CPAP.COM and then send your insurance provider an invoice from YOU for reimbursement. The second option is to check with BILLMYINSURANCE.COM and see if they can work with your insurance provider. A third option is to pay for it out-of-pocket. The LAST option is to deal with the insurance provider and local DME and desperately try to get the equipment YOU want....and then bend over and grab your ankles. One of the important things is to get your prescription in hand (and don't let go of it) so you can deal with whomever you wish.
Try to get a machine that will record your nightly statistics (in the case of Respironics that would be the REMstar Auto w/C-Flex and the REMstar Pro 2 w/C-Flex) and then eventually (if not sooner) get the card reader and software to monitor your therapy.

It's YOUR life, YOUR health, and YOUR therapy. You're going to be the one using this stuff......not the doctor, DME or insurance provider.....YOU! By any or all means, get what YOU want!

<end of sermon>

Best wishes,

Den

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, cpap.com, DME, Prescription, auto

Guest · Post by **Guest** » Tue Jan 17, 2006 1:21 pm

Call your original provider and ask if the equipment was paid for and if it is yours to keep.
Skeptic Soul

wading thru the muck! · Post by **wading thru the muck!** » Tue Jan 17, 2006 1:33 pm

ScottGA,

You should have gotten an EOB (Explaination Of Benefits) from you insurance company detailing exactly what they have paid. If you don't have that, I would call your insurance company and have them fax you another copy. If they did pay for the whole machine, fax the EOB to the DME and tell them you are keeping the machine. If they did not pay for the whole machine, you may be able to use the amount they did pay as compared to the online price to negotiate with the DME. I'm sure they would much rather get their money and let you keep the machine.

NightHawkeye · Post by **NightHawkeye** » Tue Jan 17, 2006 1:36 pm

I called my insurance company and was first told the same info you were (i.e., rent to own) but when I asked specifically about purchasing it online I was told that was acceptable, but that it would be reimbursed at the out-of-network rate (i.e., 60%). I kinda figured my out-of-pocket might be less if I bought online so that's what I did.

Still waiting for the check. (It's only been a couple of weeks since I submitted the claim.)

Regards,
Bill

Wulfman · Post by **Wulfman** » Tue Jan 17, 2006 1:52 pm

My insurance provider was originally going to reimburse me as out-of-network (60%), but when I brought it to their attention that I should be considered IN-NETWORK, they "discovered" their error (they had already issued one check) and sent me the difference which made it 80%. This is no different than buying medications or paying for other doctor visits out-of-pocket, so they should reimburse you at the in-network rate. Some (maybe most) insurance providers require you get "pre-approval" for some of these services and equipment (which I had, in my case).

Den

NightHawkeye · Post by **NightHawkeye** » Tue Jan 17, 2006 2:04 pm

This is no different than buying medications or paying for other doctor visits out-of-pocket, so they should reimburse you at the in-network rate.

Den, I'm not sure I fully understand the logic here. For that matter I'm not sure I understood my insurance representative's logic either. With my high deductible policy, they have been paying 100% of everything since I met the deductible. I'm hoping they'll pay 100% of the BiPAPAuto as well.

Regards,
Bill

Wulfman · Post by **Wulfman** » Tue Jan 17, 2006 2:20 pm

Bill,

For your sake, I hope they do, too.
This whole thing depends on what each policy provides for.
According to whatever your coverage stipulates, after you've reached/met your deductible it can be 80, 90 or 100 percent. But my point was that YOU as the policyholder SHOULD be reimbursed at whatever the in-network rate is.
If my insurance provider would have issued a check to CPAP.COM, they would have considered them as out-of-network and would have only paid 60%. But whereas I paid for my equipment out-of-pocket and then billed my insurance provider, I was considered in-network and got the higher rate.

Hope that clarifies it.

Den

NightHawkeye · Post by **NightHawkeye** » Tue Jan 17, 2006 2:33 pm

But whereas I paid for my equipment out-of-pocket and then billed my insurance provider, I was considered in-network and got the higher rate.

OK, I understand now. That's the part that wasn't sinking in for me.

Thanks,
Bill