insurance company mis information

[grumpy]

I have been reading this forum for a couple of days and also doing research on purchases, and insurance coverage. It has been very helpful in so many ways.

I am amazed at what I hear from my insurance co and local DME's. My insurance company told me that they didn't cover APAP, only CPAP. Then, in the next sentence, when prodded, they said if the doctor writes a letter giving reasons I need APAP they would consider it.

They couldn't tell me what the contract price for the unit that I wanted Respironics Auto with C-FLex was but they assured me that I wouldn't pay more going through the insurance company and local DME. How could they know this when they can't even tell me how much get charged for the unit (I can do the 25% copay math).

They also told me that I have to go to a local DME and you just CAN'T go on line and buy from someone there, because those online people don't know what they are doing. I checked with Resprionics (via telephone) and verified that CPAP.com is indeed a certified vendor. If they are certified I have to believe that they have the same training as the local DME people.

No one seems to want to give information without you having your physician send all the info to them. And I don't want to be tied up waiting for a price that I might not be willing to pay, for a machine that I do not want. I can't understand why I can't easily get this information ahead of time to compare to CPAP.com's list price of $725.

I did learn that I can get mask and hose replacement through the local DME (I will see if that is cheaper than footing the bill all by myself since my insurance won't reimburse CPAP.com (at least until I meet my out of network copay which is steep.

Boy this is tough going.

[twillson]

YMMV, but I think most, if not all insurance companies will cover whatever your doctor deems "medically necessary." If your doctor is behind you, there isn't much the insurance company can do, regardless of what they claim.

I really thought I was getting a bad deal from my DME when I saw how much less things cost online. In the end I am not paying much more going through the DME because 1: BS/BC will negotiate a much lower rate for most equipment and procedures than they are billed, and 2) it was pretty easy to reach my deductable in the 1st year of CPAP use.

I'm sure it makes sense for some people to buy online (particularly long-time users and those with limited insurance), but it makes a lot more sense for a new user to go with a DME, especially for your mask(s). A cooperative and accessible DME can make things a lot easier, can help with fitting and sizing, and can let you try stuff out before you buy.

I was able to get a new cushion and then a second mask during my first month with not a peep from my insurance company because the DME believed this was "medically necessary" and the doctor backed their judgement.

[NightHawkeye]

I will see if that is cheaper than footing the bill all by myself since my insurance won't reimburse CPAP.com (at least until I meet my out of network copay which is steep.

Boy this is tough going.

I got a similar story from my BC/BS insurance prior to purchasing. Turns out they handled it as in-network since I made the purchase myself (same as getting a prescription filled, I suppose), and reimbursed me 100%, although they had verbally informed me that I'd only be reimbursed at the out-of-network 60% rate.

Others here have had similar experiences.

Good luck, Grumpy. Sounds like you're on the right track. The more knowledge you have, the better you'll do with xPAP.

Regards,
Bill

[Guest]

If you have BCBS and want an Auto, contact billmyinsurance.com. They are the midpoint between cpap.com and the evil DME.

[Grumpy]

I guess I would agree with the mask fitting is easier at the DME advice excpet I have the mask from my sleep study and I found it to be fine. I tried a couple brands and sizes before I settled on the one I used for the study and still have.

Another responder mentioned getting an additional mask when going through the DME. I had a DME tell me this on the phone too. What I can't figure (and have to call them back (since i had other higher priority questions), is if I don't take the mask, is it a cheaper copay? Or am I (and my insurance company) really paying for the new mask anyway even if I don't need it? Might be nice to try another brand of mask since my sleep study people only had a couple choices. I have to think about that one.

Unfortunately I don't have BC/BS. I have a plan through a large company (work) that is managed by an HMO (but it isn't an HMO plan) and the company actually is the insurer with the HMO company as the manager. So it is really hard to say what they will and won't approve. I do appreciate the advice by the responder who mentioned that surprisingly the insurance paid (worth a try if I buy myself). I did find advice on this forum to keep my original prescription and a copy of my sleep study, makes sense. Seems like good advice.

Thanks for reading and commenting on my post everyone.

[yardbird]

Grumpy-

find out who, at your company, talks to the insurance managing company (hoping that made sense...). Here's why. It sounds like your company is self insured and using a management company. That could work in your favor. They often actually want to SAVE money (which is why they are doing the self insured thing) and if you can show them that the local DME charges a LOT more money for the exact same thing you can get online for a lot less... they may very well go for it.

[investor60]

Grumpy,

have to admit I'm a little grumpy to after dealing with a medical equip. supplier.
see post on page 2. priced my cpap at cpap.com for $766.02, cpap, nose pillow, hose, case--the package. the med. equip. supplier my ins. co. OK'd charges $2600, in 12 installments. far as I'm concerned, it's a "rent to own" scam. currently going around with the ins. co.
you know, I'd almost think there were some kick backs or something going on.
been in business? know anything about wholesale, suggested retail and the possible layers in between? actually, now days they don't use the words kick back, think now it's called "insentives". where does the almost $2000 difference go?
I find that out, I'm going to have some fun, and sleep better.

[Brent Hutto]

The insurance company has two options in dealing with a typical CPAP patient:

Option 1. Hire a rep, send the rep to the patient's house, have the rep order equipment from cpap.com for on behalf of the patient for $800, show the patient how to use it, answer questions whenever the patient has a problem and swap masks a couple times until they get one that works. Oh, and replace stuff when it's worn out keeping in mind that the patient may or may not know when stuff wears out or is working properly. Finally, this rep the insurance company hires has to be licensed by the local government as a health care provider.

Option 2. Pay a DME $2,000, billed out over 12 months (so it's effectively more like $1,800) and let the DME handle everything else.

Not surprisingly, the insurance company figures it comes out ahead on average by pickig Option 2. On some patients maybe they could save a few bucks with Option 1 but they need one system that fits everyone, from internet forum hounds/mail-order shoppers to little old ladies who can't leave the house without help.

I think what most people around here want is Option 2 except for they'd like the DME to do it for about 75 bucks over what cpap.com charges for the hardware instead of grossing $1,000 for the service. I'll clue you in...there is no business in the world that can afford to hire licensed technicians to hand-hold little old ladies for a couple hundred bucks a pop.

Now here's the problem. Any time you have an offer on the table to sell something at a $1,000 markup in return for an open-ended "Do whatever it takes to meet the customer's needs" you're going to attract some shoddy operators who want to collect the thousand bucks and then stiff the end user on the "whatever it takes". An outfit like that is ripping off the patient and indirectly the insurance company. They should be outed and if they're not going to get real about providing the care they're getting paid to deliver they need to be cut off from that line of business. However, the ripoff isn't the fact that they charge $1,000 but the fact that they don't deliver the service they contracted to deliver.

[investor60]

Brent,
thanks for the reply and explanation.

apparently the ins. co.'s are geared to making their worst nightmare customers happy at the expense of the more awake/hands on types. I can understand that there are those customers out there that need to be walked thru everything(repeatedly) and probably couldn't deal with ordering online and then solving a problem via email to tech. support.
this has been my first involvement/go around with the healthcare industry, equip. suppliers, etc. guess I learned some valuable lessons.
(actually, I'm just embarrased that I didn't do a better job of shopping and allowed myself to take the easy path and follow doctors recommendations, advice from the ins. co. customer service rep.-----valuable lessons....).

[Brent Hutto]

I've been fortunate in two ways. First, my insurance only has a 20% copay so I was able to get the stuff I wanted from a local DME and it will still be cheaper than buying it out-of-pocket. Second, the DME that my doctor recommended offers very good service. Prompt, straightforward to deal with and very accomodating to my trying and swapping various masks to get one that fits well.

I'd probably have a different attitude if I had gotten ripped off the way some people apparently have. I know the sleep doc said that out of 30 places in town to get CPAP equipment only six to eight of them were worth dealing with. So in his opinion, the odds don't seem to be much better than what you would gather from reading here. Like I said, there's a lot of money on the table for somebody who wants to grab it and run.

[HP]

Very little of my APAP & mask purchase from cpap.com was reimbursed by my ins. co., because my plan has a separate deductible for "in network" and a separate deductible for "out of network." That's a nasty feature.

I had a ton of in network charges for medical testing before it was concluded I had sleep apnea, but no out of network charges so my "out of network" deductible had not been met.

But the ins. co. didn't question my purchase of an APAP when the prescription said "cpap." The ins. co. did botch up the processing, delaying the reimbursement for a couple months, because the insurance code numbers needed to be entered "by hand." lol

On the bright side, warnings noted about DME's on this site convinced me to shop the internet to avoid the insanity, politics, and inconvenience of the DME.

If things get worse, I could be cannibalizing my wife's spare vaccuum cleaner!.....lol

But the pricing and service at cpap.com is super!

[NightHawkeye]

Very little of my APAP & mask purchase from cpap.com was reimbursed by my ins. co., because my plan has a separate deductible for "in network" and a separate deductible for "out of network." That's a nasty feature.

HP, did you challenge this at all? If the purchase was recent, it may not be too late to do so. I believe it was Wader who determined that when you purchase equipment yourself and submit the bill to insurance, you become the de-facto in-network provider. I didn't even have to argue with my insurance company about it. They just recognized it as such.

Regards,
Bill

[ozij]

Wulfman...

O.

[Wulfman]

Wulfman...

O.

You called???

Hi Ozij.

Actually, I thought they were progressing pretty well. I liked Bill's answer and agree with what he said.

If they want to read more, they can read my response (at the end of this thread) to someone else who asked me last night about how I dealt with my insurance provider ("the system") and got reimbursed. It's really pretty easy to get your money back out of them.....because the user (insured) SHOULD be considered "in-network" as far as reimbursement. AND, the user/insured/purchaser needs to submit a bill to their insurance provider from THEMSELVES.....not try to have the provider reimburse CPAP.COM....because that WILL be out-of-network.

viewtopic.php?t=8153&start=15

Best wishes and sleep well y'all.

Den