CPAP&Insurance?

[investor60]

Hi,

turned 60, was diagnosed with sleep apnea, a common condition, treated with a piece of medical equipment, called a CPAP machine. I have health insurance, so I went ahead and got the machine. before I go any further with the story, the thing to remember is that the insured parties copay is based on the price of the equipment.
if you googled for the machine I got(Resmed S8 Elite, w/humidifier and "nosepillow" face mask) you'll get a number of hits from online medical equip. suppliers that would sell you the bundled package for under $800.
that would, to the ins. co. be "out of network" with a larger copay.
with my ins. co., staying "in network" means going thru their approved medical equip. provider, who charges $2613 for the exact same equipment. also, going this way means that it isn't a one time buy with one time billng, the ins. co. and the equip. provider enter into a "rent to own" deal with payments spread over 12 months. my copay percentage would be smaller.
now, what I'd like to know is---does the ins. co. really pay the equip. provider the grossly inflated price or is this just a billing scam to get larger copays?
I have heard that some ins. co.'s buy equip. like this from the manufacturer and ship to the customer from their warehouse, cutting out third party providers. once again I would ask, is the customers copay based on what the ins. co. paid for the equip.("wholesale") or some very inflated price("retail plus")?

thanks.

[Wulfman]

Sounds to me like you're getting it pretty well figured out.....

This whole insurance thing is complicated.....depending on which company, coverage, deductibles, etc., etc. And, what they will and won't allow.

What I recommend to those who can do it this way, is to get their prescription and purchase from CPAP.COM and then submit an invoice (from themself) to their insurance provider for reimbursement (the insured person SHOULD be considered "in network" and should get the higher reimbursement percentage). Next option is to talk to BILLMYINSURANCE.COM and see if they can work with their insurance provider. Third option is to just purchase out-of-pocket because what the "system" is going to charge the person will almost equal what their out-of-pocket amount will be anyway.

I don't think that the insurance providers can purchase and distribute the equipment.....that is usually done through DMEs (Durable Medical Equipment providers).

In many cases, insurance providers have a fixed amount that they will reimburse the DMEs and that's why the DMEs want to push the cheapest equipment.....it maximizes their profit.

Best wishes,

Den

[Brent Hutto]

When I received my CPAP and mask a couple weeks ago, there was indeed a sort of "list price" on the paperwork along with a "writedown" to the lower amount that was my insurance company's negociated price. My copay was figured on the price that the insurance company had negociated (i.e. after the writedown) as was the remaining amount that was filed. That was on the mask and humidifier. On the CPAP machine itself there was no writedown, just a certain monthly payment ($111) for a certain term (10 months) and I'll be paying 20% of that monthly amount as a copay.

Not sure why any of this matters to OP. All you really need to know is what your cost will be under each alternative (and any potential implications for yearly deductables and out-of-pocket maximums).