HealthNet HMO & cpap.com

[Tigerlily]

Hi,
Just wondering if anyone else has health insurance through Health Net HMO and bought dme from cpap.com and tried to get re-imbursed?

I bought my cpap machine on cpap.com in March and sent a claim into them for re-imbursment and they denied it completely.

Is this standard for insurance companies or do I just have a crappy one?

Am I always just going to have to pay for my apnea supplies out of pocket?

[Wulfman...]

Hi,
Just wondering if anyone else has health insurance through Health Net HMO and bought dme from cpap . com and tried to get re-imbursed?

I bought my cpap machine on cpap . com in March and sent a claim into them for re-imbursment and they denied it completely.

Is this standard for insurance companies or do I just have a crappy one?

Am I always just going to have to pay for my apnea supplies out of pocket?

There are lots of "depends" with these circumstances.
From reading on this forum for over eight years, HMOs are typically resistant to reimbursing their members for DME purchases.......PPOs are somewhat better but it "depends" on their own policies.
It "depends" on how you went about it.
It "depends" on if you asked them beforehand if they would do that.
It "depends" on whether the insurance provider considers the member (YOU) to be "in-network".
It "depends" on whether you just sent the invoice to them and asked to be reimbursed or whether you actually made out an invoice with you as the billing party and your HMO as the party being billed.

Eight-plus years ago, I was in a PPO when I went through this. I asked them beforehand (they said "yes"), I bought the items from CPAP(dot)COM and then made out my own invoice with me as the billing party and my insurance provider as the party being billed. I also included a copy of the invoice from CPAP(dot)COM as proof that I wasn't inflating the costs of the items I was billing them for. I also included the insurance codes on my invoice to them......which I copied off the invoice from CPAP(dot)COM. They then sent me a check for 80% of it.


Den

.

[Wulfman...]

In fairness, I should add that beyond that initial purchase, I have purchased all of my additional supplies and equipment out-of-pocket. Mainly because I never met my deductible, which was $750 when I was working and then $2000 after I retired (and before going on Medicare). For that kind of money, I could buy lots of supplies and extra machines. I'm stocked up now.


Den

.

[ughwhatname]

Hi,
Just wondering if anyone else has health insurance through Health Net HMO and bought dme from cpap.com and tried to get re-imbursed?

I bought my cpap machine on cpap.com in March and sent a claim into them for re-imbursment and they denied it completely.

Is this standard for insurance companies or do I just have a crappy one?

Am I always just going to have to pay for my apnea supplies out of pocket?

I have HealthNet and asked them specifically about out-of-network reimbursement and they said no. I'm required to go through Apria for everything. Due to the surgery I just had I asked whether my out-of-network costs would count toward my out of pocket maximum, and they said no to that as well.

[hobbs]

Health Net paid 50% of my S8 Auto five years ago. Coverage was 80% in network and 50% out of network.

[Tigerlily]

It "depends" on if you asked them beforehand if they would do that.

Hi Den,
I did not ask ahead of time. I didn't know that my DME would rip me off by trying to rent me a very basic model that I would end up paying $1,300 for. I didn't have the knowledge of all this ahead of time.

It "depends" on whether you just sent the invoice to them and asked to be reimbursed or whether you actually made out an invoice with you as the billing party and your HMO as the party being billed.

I got the form from cpap.com as well as one from Health Net and sent them both asking for re-reimbursement, not sure if I did the latter. I did put the proper billing codes.

[Tigerlily]

I have HealthNet and asked them specifically about out-of-network reimbursement and they said no. I'm required to go through Apria for everything. Due to the surgery I just had I asked whether my out-of-network costs would count toward my out of pocket maximum, and they said no to that as well.

Ok, so they consider cpap.com out-of-network. Hmmmmm

[Tigerlily]

Health Net paid 50% of my S8 Auto five years ago. Coverage was 80% in network and 50% out of network.

From purchasing it online? If so, they must have changed coverage.