Insurance billing questions

[zoocrewphoto]

I am in for a fight with the dme for billing issues. I'm hoping you can help me know what is normal. I know they are overcharging for the machine and rent for 2 months. My insurance is refusing to pay.

My questions. Are all items normally billed seperately? when you get a new mask that comes with headgear is it normal for them to bill for headgear seperately? Does the humidifier come with a chamber or seperately billing?

When the insurance rents for two months and then converts to a sale, does the rent count toward the sale price? My s9 auto was charged at $1642.5o in addition to 2 months of rent at 175.20 each. My insurance paid one month rent and $317.70 and refused the rest. I am not paying over $1200 for something that costs $853 without insurance.

[123.Shawn T.W.]

My insurance policy says that I pay a percentage (20%) and BCBS pays 80% of the contracted price, and that's it!

For instance my first sleep study billed BCBS $3200.00 However BCBS had a contract with them and it was reduced down to on $640.10, that is what we paid (actually I paid the whole amount because I had not met my deductible yet {only $10 left now})

You need to find out if your insurance policy has the same thing, there is an official name for it, but I can't remember what it is ...

Call you ins co, and ask them if the above is how they work? Then ask them what the total is, and what your portion should be?

[greatunclebill]

with tricare prime i have no deductibles. on durable supplies and equipment they pay 80% and i pay 20% of the allowable amount. for a cpap that is somewhere around 1500 of which we pay around 350 total price. this would be divided by 13 for 13 monthly payments. hose, mask, humidifier are all seperate and billed at the same 80 - 20 split. the sleep study allowable charge is around 600 of which we pay zero because it is a diagnostic procedure just like lab, x-ray or mri.

[brucifer]

My insurance company does not rent CPAP equipment. They only purchase. The DME providers are allowed to charge high prices for the equipment they sell. To control costs, insurance companies often have contracts with in-network DMEs that limit what the insurer will pay and what the insured (you) will pay. For example, a DME provider may charge $1,500 for a CPAP machine, but if XYZ insurance company has an agreement to only pay $700, then @ 20% co-pay, the most you will pay is $140, and the DME provider cannot bill you for the the residual amount.

BTW, my insurance company was charged $995 for the S9 Autoset, $309.95 for the humidifier, and $69.95 for the heated hose. Since my DME provider was in-network, my insurance company (CIGNA) didn't pay near that amount.

[dragon672]

I have to pay the rental fee for 13 months then the machine is mine. My part is 67.64 a month until I meet my deductible of $2000; which I won't. None of my co-pays for doctor's visits and medicine count toward my deductible. So I'll end up paying about $1061.26 for my machine. My BCBS coverage isn't the best apparently.

[brucifer]

I have to pay the rental fee for 13 months then the machine is mine. My part is 67.64 a month until I meet my deductible of $2000; which I won't. None of my co-pays for doctor's visits and medicine count toward my deductible. So I'll end up paying about $1061.26 for my machine. My BCBS coverage isn't the best apparently.

I should have been more clear. You're absolutely right. You do have to meet your deductible first. In my example above, you would have to pay the $700 contracted price IF you had not yet met your deductible.

[zoocrewphoto]

I am actually looking at the statements from my insurance. They pay 85%, but they are refusing to pay for most of the s9 because the price exceeds the allowable amount. I have not received the official bill yet from the dme. Just the statement from insurance that says what I am responsible for.

I will be sending a letter to the insurance but Im not sure what is normal. The dme said I was covered for 85% and the insurance told me the same before I went to the dme. So I was shocked to see the payments denied.

The dme has already lied to me claiming the small headgear for the Quattro fx did not exist. Then refused to order it when I gave them the number. They have also refused to tell me what I am allowed to get how often. I have fired them but they don't know it yet. I want to get this settled before I tell them I am going elsewhere.

[brucifer]

I am actually looking at the statements from my insurance. They pay 85%, but they are refusing to pay for most of the s9 because the price exceeds the allowable amount. I have not received the official bill yet from the dme. Just the statement from insurance that says what I am responsible for.

I will be sending a letter to the insurance but Im not sure what is normal. The dme said I was covered for 85% and the insurance told me the same before I went to the dme. So I was shocked to see the payments denied.

The dme has already lied to me claiming the small headgear for the Quattro fx did not exist. Then refused to order it when I gave them the number. They have also refused to tell me what I am allowed to get how often. I have fired them but they don't know it yet. I want to get this settled before I tell them I am going elsewhere.

Hmmmm....did your insurance company set you up with your DME provider? Also, is your DME provider in-network? If the answer is "yes" to both of those questions, then you should insist that your insurance company handle the issue with the DME provider for you. Your DME provider CANNOT charge you more that the contracted price for your S9 if there is such an agreement with your insurance company. Most major insurance companies do have such agreements in place with in-network doctors, hospitals, labs, and DME providers. Also, your insurance company is the party who should inform you of the particulars of your plan. For example, I know that I am allowed a new mask every three months and new nasal pillows every month. Find out from your insurance company what you are entitled to receive and the timetable.

If you chose your DME provider on your own, and if it is out-of-network, then you will probably have to work with your DME provider and reach some kind of an agreement in order for you to keep your machine. Also, see if you signed and agreement with your DME provider which states that you are responsible for any costs that your insurance company refuses to pay. They have you over a barrel if you signed such an agreement.

I suggest that you insist that your insurance company handle this for you. That is one of the reasons why you pay your insurance premium each month. If they refuse, then you may need to write them a respectful but firm letter stating that if they do not do what they had promised that you intend to write a letter to your state Insurance Commissioner. Then, follow through if you need to do so. I hope it doesn't come to that. Please keep us posted. Best of luck.

[cherylgrrl]

Are all items normally billed seperately? when you get a new mask that comes with headgear is it normal for them to bill for headgear seperately? Does the humidifier come with a chamber or seperately billing?

I am a newbie and haven't actually gotten a billing yet from the DME. But I can tell you that I signed an itemized statement that had separate line items for mask, headgear, humidifier, CPAP machine, pollen filters, tubing, etc.

With my insurance, I have to deal with a "preferred provider" or they won't pay anything at all. I live in Nevada, and there is only one preferred provider so there isn't much choice. I am actually afraid to see my bill because on my statement they charged my Quattro full face mask at $435 when you can buy it online for $160. My copay comes to $130 for that mask, so that's not much of a discount. I'd hate to tell you what my monthly premium is for that insurance.

Oh yeah, they also tacked on $600 for "Monitoring Feature". Another forum has advised me that if my machine doesn't have a 3G antenna on the back (it doesn't) I'm not getting that monitoring service.

Be prepared to talk to your insurance company to find out exactly what they cover and how, and to fight with the DME about their charges. It seems that's just the way this works.

[zoocrewphoto]

Hmmmm....did your insurance company set you up with your DME provider? Also, is your DME provider in-network? If the answer is "yes" to both of those questions, then you should insist that your insurance company handle the issue with the DME provider for you. Your DME provider CANNOT charge you more that the contracted price for your S9 if there is such an agreement with your insurance company. Most major insurance companies do have such agreements in place with in-network doctors, hospitals, labs, and DME providers. Also, your insurance company is the party who should inform you of the particulars of your plan. For example, I know that I am allowed a new mask every three months and new nasal pillows every month. Find out from your insurance company what you are entitled to receive and the timetable.

If you chose your DME provider on your own, and if it is out-of-network, then you will probably have to work with your DME provider and reach some kind of an agreement in order for you to keep your machine. Also, see if you signed and agreement with your DME provider which states that you are responsible for any costs that your insurance company refuses to pay. They have you over a barrel if you signed such an agreement.

I suggest that you insist that your insurance company handle this for you. That is one of the reasons why you pay your insurance premium each month. If they refuse, then you may need to write them a respectful but firm letter stating that if they do not do what they had promised that you intend to write a letter to your state Insurance Commissioner. Then, follow through if you need to do so. I hope it doesn't come to that. Please keep us posted. Best of luck.

I called the inusrance company before going to the DME to ask how cpap equipment is paid for. They told me it was just like a doctor appointment. The DME bills for it, and they pay 85%. I was never told anything about in or out of network. I have a PPO plan that has always been pretty good. I can pick my own doctors, etc. And I have never been told it was out of network. I know that my coverage is 85% even if I am out of town.

When the doctor faxed my info to the DME, they called and said they would verify my insurance and then make the appointment. They confirmed my insurance, and the paper I signed says" Estimated insurance coverage is 85% of contracted amount. Deductible may apply. I made the deductible with the sleep study.

Down in the fine print, it says "I will be fully responsible for all deductibles, co-insurance, and items that are disallowed. All costs of the device and/or supplies not paid for by insurance will become my responsibility.

So, I am not sure where that leaves with me the insurance not paying for the overly high price that the DME is billing for. I will be working on my letter to the insurance company and my list of questions for them. I have not received a bill yet for the S9. They have sent a bill for a couple of the smaller items, and one of the rent payments. I will not pay it until I know what the full payment for the machine will be. They did not tell me the price of the machine when I got it. The invoice only shows the first month rent.

I also do not understand how they can bill seperately for the headgear when the mask only comes with one size headgear standard. You can't buy it without headgear. And both my different masks have been charged at the same price, even though they are different styles. I know that local DMEs will charge more than online stores, but their markup is extreme. $310 for the mask, and another $50 for "generic headgear".

[brucifer]

Down in the fine print, it says "I will be fully responsible for all deductibles, co-insurance, and items that are disallowed. All costs of the device and/or supplies not paid for by insurance will become my responsibility."

So, I am not sure where that leaves with me the insurance not paying for the overly high price that the DME is billing for. I will be working on my letter to the insurance company and my list of questions for them. I have not received a bill yet for the S9. They have sent a bill for a couple of the smaller items, and one of the rent payments. I will not pay it until I know what the full payment for the machine will be. They did not tell me the price of the machine when I got it. The invoice only shows the first month rent.

I also do not understand how they can bill seperately for the headgear when the mask only comes with one size headgear standard. You can't buy it without headgear. And both my different masks have been charged at the same price, even though they are different styles. I know that local DMEs will charge more than online stores, but their markup is extreme. $310 for the mask, and another $50 for "generic headgear".

I'm not surprised about the fine print. Doctors and hospitals use that same fine print as well. That way they make you put pressure on your insurance company to pay.

I have CIGNA PPO which sounds very similar to your plan. It's an 85/15 plan, and I get to choose my doctors and specialists; however, I get the best deal if I choose CIGNA's in-network providers, but since most doctors and specialists in my area are in-network, that hasn't been much of an issue for me. When I was diagnosed with OSA, my sleep doctor made sure that my DME provider was in-network, and I called CIGNA to make sure as well. That being said, it would have been nice if your insurance company had watched your back and prevented you from having to deal with your crappy DME provider. It would have also been nice if your insurance company had stuck to their word instead of leaving you in the lurch.

As for your DME provider's bill for rental of your s9, I wouldn't pay that bill either, not yet anyway. You need to have everything settled with your insurance company first.

My DME provider had me sign a delivery ticket with the prices for each equipment item before I took possession of the items. I guess since your DME provider was renting you your S9, only the monthly rental price was listed. I know that you're not obligated to purchase an item that you're renting.

It really seems almost criminal what these DME providers charge and how they are allowed to charge for parts on a packaged item. They all do it, but the amount that your DME provider is charging seems even more greedy than most. Anyway, you're doing the right thing to write a letter to your insurance company. Hopefully they will step up an take care of you.

[Uncle_Bob]

Anyone diagnosed with a condition that required ongoing medical insurance claims would do well to obtain the insurance companys medical policy documentation for the condition.

I live in Arizona but my insurance is with BCBS of Alabama. I am able to login to myBlueCross on there web site and there is a link to medical policys, there are hundreds of policys including one for Management of Obstructive Sleep Apeana. It deatils how often I am entitled to supplies and the insurance billing codes for these supplies, so you can see what your DME is up to.
My policy also allows me to purchase on line and class all on line purchases as in network. The only information that I find hard to get is the maximum allowable amount that the insurance will allow for each item, the BCBS rep said she could not get this information and that it does change frequently.

Full face mask, each
A7030
1 in 180 days
Chinstrap
A7036
1 in 180 days
Combination Oral/Nasal Mask, each
A7027
1 in 180 days
Face Mask Interface, replacement for full face mask
A7031
1 in 180 days
Filter, disposable
A7038
1 in 90 days
Fuses (Pkg of 2), (billed on unlisted DME code)
E1399
Headgear/Softcap
A7035
1 in 180 days
Nasal interface (mask or cannula type)
A7034
1 in 180 days
Nose Pillows (Pair)
A7033
1 in 180 days
Oral Interface Used With Positive Airway Pressure Device, Each
A7044
1 in 180 days
Replacement Cushion for nasal mask interface
A7032
1 in 180 days
Replacement Nasal Pillows for Combination Oral/Nasal Mask
A7029
1 in 180 days
Replacement Oral Cushion for Combination Oral/Nasal Mask
A7028
1 in 180 days
Reusable Filter, non-disposable
A7039
1 in 180 days
Shell, (billed on unlisted DME code)
E1399
Tubing/Hose
A7037
1 in 365 days
Heated tubing
A4604
1 in 365 days
Non-heated humidifier
E0561
1 every 3 years
Heated humidifier
E0562
1 every 3 years
CPAP machine
E0601
1 every 3 years

[leejgbt]

Whether a DME company is in network or not, there are certain guidelines that govern their behavior. First, almost all follow Medicare guidelines when billing for CPAP and supplies. This means that if Medicare wants each part of the mask billed separately then that is what most DME's will do regardless of insurance. Also, DME companies have to establish a "usual and customary" charge that has a 3 to 5 year look back with insurance companies. Although this feature is slowly dying, most DME companies still bill this way. So, how it works is you charge today what you want to be paid five years from now. That is why you will see a charge of $250 for a mask and the insurance allowed amount is $175. The good news is that unless you are out of network the allowed amount is the maximum amount that can be collected. If the DME is out of network it gets ugly. You insurnace will still only pay based on the allowed amount but will usually have a co-pay amount that is even higher. For example if the in-netwark amount is 80%-20% the out of network will usually be 70%-30% or worse. Your DME will demand the full amount billed when they are out of network but this can usually be negotiated to the out of network co-pay amount. Another bad thing about going out of network is most insurance companies have an in-network deductible and an out of network deductible. So even if you met you in-network deductible you will have all your charges applied to a different, often higher, out of network deductible.
I am hoping for your sake that you are just reading the Explanation fo Benefits wrong. Be sure you are looking at the final amount you owe not what they billed. Good Luck!

[justpam]

I'm dealing with some of the same problems with my DME and BCBS. I appreciate being able to read through this forum and have so many questions answered. In a perfect world, the prescription my doctor gave me for all this equipment would/should fall under the "prescription co-pay". Anyway, thanks to all of you for all the great and encouraging info I'm reading on here.

[SleepDepraved2]

I am sitting here with a bill from Lincare which is how I found out they are not considered in network for my new BCBS coverage. They were under my old BCBS coverage, so now I have to switch providers to get someone who IS. It makes for interesting reading:

Rent BiPAP S
Amount billed - $632.43.
Insurance allowed amount - $104.83
Insurance amount due - $83.86
Customer Amount due - $20.97

Rent CPAP Humidifer, Heated
Amount billed - $81.75
Insurance allowed amount - $16.22
Insurance amount due - $12.98
Customer amount due - $3.24

Then down at the bottom it says "Total Insurance Pending - $466.36"

I know it's only $24 per month for me, but over a year that adds up, so I will be switching to a DME in the SUPPORT network. I already called and they do carry my machine.