Company A or Company B -- Please help

[Janknitz]

My choices are:
1-A used S9 Autoset that they do have there at the office with only 300 hours used. They need to check on price, if insurance would cover a used machine, and if it would come with a warranty.
2-A new S9 Autoset -- will check on price.
3-A new S9 Elite -- will check on price.
They will let me know the price of each on Monday and I will decide by Tuesday.

You will accept ONLY choice #2, the new S9 Autoset. The price does NOT matter because your insurance company will set the price, even if you still have to pay your deductible. An E0601 machine is an E0601 machine. So whether you get the used machine or the new machine YOUR OUT OF POCKET COSTS WILL BE THE SAME. Why accept a used machine??

Be sure you call your insurance company and understand exactly:
1. How much they set as the reimbursement amount for an E0601 machine. And what will they pay toward the purchase of the humidifier--what is your share. THESE ARE SET BY THE INSURER, NOT THE DME.
2. What your share would be, once the deductible is met.
3. Whether they will purchase outright or require a rental period. If rentals are required, for how long until you can own the machine? Will you have to pay a balance of the purchase price when that time is up?

If your prescription calls for an APAP, that's what they MUST provide. So no Elite will be acceptable (and, it will cost you the SAME out of pocket as the Autoset, anyway).

Company B sounds like they are trying to set you up for "balance billing" which is most likely illegal in your state, and most certainly against the contract with your insurer. So beware. Your out of pocket costs should be exactly the same, no matter which E0601 machine you get. If not, something smells. I have a blog post on balance billing to help you understand what it's all about. Before you talk to this DME again, call your insurance company and ask if the DME is permitted to balance bill. Don't talk to the DME about prices without understanding this.

If you keep working with this company and get the kinks worked out on pricing/billing, then you should still be very wary. Don't accept any machine without checking first to be certain it's an AutoSET not Auto Escape. And check the run hours before you sign ANYTHING accepting the machine.

Be careful they don't kill you with kindness. Never, never, never, never, never, never EVER trust a DME.

[HealthyandHopeful]

My choices are:
1-A used S9 Autoset that they do have there at the office with only 300 hours used. They need to check on price, if insurance would cover a used machine, and if it would come with a warranty.
2-A new S9 Autoset -- will check on price.
3-A new S9 Elite -- will check on price.
They will let me know the price of each on Monday and I will decide by Tuesday.

You will accept ONLY choice #2, the new S9 Autoset. The price does NOT matter because your insurance company will set the price, even if you still have to pay your deductible. An E0601 machine is an E0601 machine. So whether you get the used machine or the new machine YOUR OUT OF POCKET COSTS WILL BE THE SAME. Why accept a used machine??

Be sure you call your insurance company and understand exactly:
1. How much they set as the reimbursement amount for an E0601 machine. And what will they pay toward the purchase of the humidifier--what is your share. THESE ARE SET BY THE INSURER, NOT THE DME.
2. What your share would be, once the deductible is met.
3. Whether they will purchase outright or require a rental period. If rentals are required, for how long until you can own the machine? Will you have to pay a balance of the purchase price when that time is up?

If your prescription calls for an APAP, that's what they MUST provide. So no Elite will be acceptable (and, it will cost you the SAME out of pocket as the Autoset, anyway).

Company B sounds like they are trying to set you up for "balance billing" which is most likely illegal in your state, and most certainly against the contract with your insurer. So beware. Your out of pocket costs should be exactly the same, no matter which E0601 machine you get. If not, something smells. I have a blog post on balance billing to help you understand what it's all about. Before you talk to this DME again, call your insurance company and ask if the DME is permitted to balance bill. Don't talk to the DME about prices without understanding this.

If you keep working with this company and get the kinks worked out on pricing/billing, then you should still be very wary. Don't accept any machine without checking first to be certain it's an AutoSET not Auto Escape. And check the run hours before you sign ANYTHING accepting the machine.

Be careful they don't kill you with kindness. Never, never, never, never, never, never EVER trust a DME.

I called my insurance and they confirmed that after my $325 deductible I will pay 20% of the cost of the machine. So, the machines will be at different costs depending on their price. I don't understand how giving me a choice and letting me know what the costs will be of each means they are trying to set me up for balanced billing, or that something suspicious is going on. But I will look for your post on that and read about balanced billing and ask the insurance about it they mention it. I should find out everything on Monday, so that will give me time to contact my insurance before going in on Tuesday and making a decision. I felt good about my appointment today and the outcome. I'll know more on Monday.

The prescription that I have is from my PCP. The doctor I saw today is a sleep specialist and will write the prescription for my machine. If he had refused to write one for the one I hoped to get, I would have had the option to use the prescription that I have from my PCP at another DME. I'm glad this will be my last stop and I don't have to do that!

[Nick Danger]

I'm glad you found a doctor who appears to care about his patients!

[HealthyandHopeful]

I'm glad you found a doctor who appears to care about his patients!

Thank you! What a relief!! I am anxious to get on with my treatment. Hopefully next week will go smoothly!

[Janknitz]

Double check with your insurer whether different models are really different prices or if they pay ONE PRICE for ALL E0601 machines--that's what most insurers do. If it's one price fits all E0601 machines, then the DME cannot make you pay the difference between an Elite vs an Autoset, though they may try to convince you otherwise.

[Sir NoddinOff]

I'm a little worried by all this talk about Company A. I suspect I know who they are but can't be sure. Maybe
HealthyandHopeful will PM me and lift this burden of worry from my shoulders. I'm in a position where I have to make some decisions about my own 'Company A'

[Cpappmomma]

Call your insurance company and ask what their allowable for e0601, e0562, a4604, a7030 thru a7039 and a7046 are.


These are the contracted in-network prices that your insurance company has stated that they will pay for any of the above items. E0601 is the only billing code, regardless of the model, escape, autoset, new or used the dme provides you. This is where your knowledge and a great dme come into play! Don't let the dme railroad you, go in to this more informed than you are.

[HealthyandHopeful]

Call your insurance company and ask what their allowable for e0601, e0562, a4604, a7030 thru a7039 and a7046 are.


These are the contracted in-network prices that your insurance company has stated that they will pay for any of the above items. E0601 is the only billing code, regardless of the model, escape, autoset, new or used the dme provides you. This is where your knowledge and a great dme come into play! Don't let the dme railroad you, go in to this more informed than you are.

I talked to the Sleep place and they will have the S9 Autoset (not Escape) for me tomorrow morning at my appointment. They have an S9 Elite there as well. The cost for me (including my $325 deductible which I have not met) will be $775.36 for the Autoset or $535 for the Elite. (This includes the H5i humidifier -- I believe that is the model #). I understand that one costs more than the other and with my responsibility being 20% after the deductible, I understand that my cost will be different depending on which I choose.

I called my insurance and the agent is going to contact the sleep office and ask what codes they are using, what the prices and costs are and then let me know by Thursday the result of that conversation. If they overcharge me, I would assume they will reimburse if needed after talking with my insurance. Should I assume that and go ahead and get my machine tomorrow? Or should I wait until after Thursday to get the machine? I am so ready to get started!

ASSUMING that all is correct, my next question is: Is it worth me paying an extra $250 for the Autoset over the Elite? All of my decision have been based on what I have learned here. I don't know much yet and am taking a leap of faith.

Thank you for all the help I have been given. I'll surely be glad when this part is behind me. Then I'll be back asking questions about other aspects of OSA beside the purchase of my machine!

[palerider]

I talked to the Sleep place and they will have the S9 Autoset (not Escape) for me tomorrow morning at my appointment. They have an S9 Elite there as well. The cost for me (including my $325 deductible which I have not met) will be $775.36 for the Autoset or $535 for the Elite. (This includes the H5i humidifier -- I believe that is the model #). I understand that one costs more than the other and with my responsibility being 20% after the deductible, I understand that my cost will be different depending on which I choose.

I called my insurance and the agent is going to contact the sleep office and ask what codes they are using, what the prices and costs are and then let me know by Thursday the result of that conversation. If they overcharge me, I would assume they will reimburse if needed after talking with my insurance. Should I assume that and go ahead and get my machine tomorrow? Or should I wait until after Thursday to get the machine? I am so ready to get started!

ASSUMING that all is correct, my next question is: Is it worth me paying an extra $250 for the Autoset over the Elite?

1) it seems like "the sleep place" is ripping you off, cpap.com and directhomemedical both list the autoset itself at 725. 883 at cpap.com for the stylish pink "for her" model with the humidifier included. ask your insurance company if you can buy it online and save you and them money.

2) I'd say it's worth the extra, you might not need it right away, but it's better to have it and not need it than need it and not have it and have to go through the hassle of changing machines later.

[Janknitz]

I would wait the few days to be certain how your insurer reimburses for CPAP machines. A few days will not make a difference in a condition that has likely been going on for YEARS. I promise that you will feel that you have been ripped off by Company B if you go ahead and give them extra money they weren't entitled to. And as far as getting a refund, that will take a lot of work and effort on your behalf--they will fight you tooth and nail.

The retail price of an Autoset ($724) vs. an Elite on our hosts, cpap.com is $649, a difference of $75 RETAIL. That means that the wholesale difference between the two is no more than about $35 to $40. So a difference of around $240 seems pretty out of line.

Now, be aware that the CPAP.com prices are for the blower only. Presumably your out of pocket costs for the machines from Company B includes the humidifier purchase ($159 from our hosts), hose, mask, and filters. AND, you probably cannot pay against your deductible using CPAP.com. So it still may be worth waiting to confirm whether or not Company B may balance bill, my guess is that they may NOT and you aren't going to be very happy if you learn this after you gave them your money.

[HealthyandHopeful]

I would wait the few days to be certain how your insurer reimburses for CPAP machines. A few days will not make a difference in a condition that has likely been going on for YEARS. I promise that you will feel that you have been ripped off by Company B if you go ahead and give them extra money they weren't entitled to. And as far as getting a refund, that will take a lot of work and effort on your behalf--they will fight you tooth and nail.

The retail price of an Autoset ($724) vs. an Elite on our hosts, cpap.com is $649, a difference of $75 RETAIL. That means that the wholesale difference between the two is no more than about $35 to $40. So a difference of around $240 seems pretty out of line.

Now, be aware that the CPAP.com prices are for the blower only. Presumably your out of pocket costs for the machines from Company B includes the humidifier purchase ($159 from our hosts), hose, mask, and filters. AND, you probably cannot pay against your deductible using CPAP.com. So it still may be worth waiting to confirm whether or not Company B may balance bill, my guess is that they may NOT and you aren't going to be very happy if you learn this after you gave them your money.

I am so confused as to what to do! I called CPAP.com and their price for both the Autoset and H5i humidifier would be $883. But they are out of network, and my out of network deductible is $1000 and then I pay 30%. I figured out that the total price of the one from Company B must be over $2500 for my cost to come to $775. I called Resmed and they do not set the prices that companies charge.

I did go ahead and call Company B and left a message saying I would come later in the week, that I want to be sure of the cost, that my insurance company is going to call them to verify and let me know by Thursday.

A lady from Company B is supposed to call me in the morning anyway with the price of the used S9 Autoset (I forgot to give this info in my other post). I will talk to her about it when she calls.

Company A, the company that I was not comfortable dealing with, had told me that my cost for the S9 Autoset would be $431.

I'm anxious to get started but it seems wise to take a few more days to be sure! I am glad the lady from insurance will be contacting Company B and getting back with me.

[palerider]

I am so confused as to what to do! I called CPAP.com and their price for both the Autoset and H5i humidifier would be $883. But they are out of network, and my out of network deductible is $1000 and then I pay 30%. I figured out that the total price of the one from Company B must be over $2500 for my cost to come to $775. I called Resmed and they do not set the prices that companies charge.

I did go ahead and call Company B and left a message saying I would come later in the week, that I want to be sure of the cost, that my insurance company is going to call them to verify and let me know by Thursday.

A lady from Company B is supposed to call me in the morning anyway with the price of the used S9 Autoset (I forgot to give this info in my other post). I will talk to her about it when she calls.

secondwindcpap.com lists a number of "gently used" autosets with humidifier at 529$ so that's the cheapest price so far.

[jenni7535]

I work for a DME company and have for 15 years. As mentioned before every single machine mentioned is coded under E0601. Some companies will try to charge more for a Autoset because it is only reimbursed as a CPAP. However when a company enters into a contract with a insurance company they agree to take what is allowed from that carrier, meaning they can not bill you anything additional. So with that being said your out of pocket should be the exact same on ANY cpap machine or auto cpap machine. Some companies will try to upcharge you on a auto. If they are telling you there would be different pricing for each machine then something is not right at all. I would check into that. We have about 4 machines and no matter what we pay for them we get what the insurance contracts allow. We choose to provide auto to every patient and we choose to carry Resmed. These are the most expensive machines available, but we know that they are going to last. Be very careful because as nice as some companies may seem there are a lot of companies who dont have the patient's best interest at heart. Good luck.

Also if a company can bill out of network they get paid more money since they are not subject to the in network contracts. If we were to bill out of network we would match the in network pricing and we wouldnt charge more than what in network would, but we would also make sure that the out of network deductible applies to the in network deductible. Dont let them bill out of network and bill for more and charge you more. Sometimes with the deductible being high it is cheaper to buy online but remember you dont have a company backing you for supplies and repairs online. And the insurance is not too hip on paying for supplies on something that they did not purchase. Just be very careful. You can contact me with any questions. jenni7535 at yahoo is my email address.

[Janknitz]

I work for a DME company and have for 15 years. As mentioned before every single machine mentioned is coded under E0601. Some companies will try to charge more for a Autoset because it is only reimbursed as a CPAP. However when a company enters into a contract with a insurance company they agree to take what is allowed from that carrier, meaning they can not bill you anything additional. So with that being said your out of pocket should be the exact same on ANY cpap machine or auto cpap machine. Some companies will try to upcharge you on a auto. If they are telling you there would be different pricing for each machine then something is not right at all. I would check into that. We have about 4 machines and no matter what we pay for them we get what the insurance contracts allow. We choose to provide auto to every patient and we choose to carry Resmed. These are the most expensive machines available, but we know that they are going to last. Be very careful because as nice as some companies may seem there are a lot of companies who dont have the patient's best interest at heart. Good luck.

At last, refreshing honesty from a DME !!! Jenni, I'd love to know the name and location of your company, as you deserve some business! In all the years I've been on this forum I've NEVER seen a DME admit this was true.

Healthy and Hopeful, I hope Jenni's post explained what I've been trying to tell you. That the DME is not allowed to charge you more than the contracted price with your DME regardless of which machine you get. One price for ANY machine. You don't need the insurer to call company B, you need the insurer to call YOU and explain to YOU how much a contracted DME is allowed for any E0601 machine and exactly how much of that YOU are expected to pay out of your pocket, including the deductible. If it's $XXX, it should be the same price for the Autoset as for the elite as for a used model.

You are better off buying from the DME if it's a purchase rather than a rental, so you can use your deductible and get hands on assistance. But that doesn't mean you have to get ripped off by a company perfectly willing to be nice while taking advantage of you.

[HealthyandHopeful]

I work for a DME company and have for 15 years. As mentioned before every single machine mentioned is coded under E0601. Some companies will try to charge more for a Autoset because it is only reimbursed as a CPAP. However when a company enters into a contract with a insurance company they agree to take what is allowed from that carrier, meaning they can not bill you anything additional. So with that being said your out of pocket should be the exact same on ANY cpap machine or auto cpap machine. Some companies will try to upcharge you on a auto. If they are telling you there would be different pricing for each machine then something is not right at all. I would check into that. We have about 4 machines and no matter what we pay for them we get what the insurance contracts allow. We choose to provide auto to every patient and we choose to carry Resmed. These are the most expensive machines available, but we know that they are going to last. Be very careful because as nice as some companies may seem there are a lot of companies who dont have the patient's best interest at heart. Good luck.

Also if a company can bill out of network they get paid more money since they are not subject to the in network contracts. If we were to bill out of network we would match the in network pricing and we wouldnt charge more than what in network would, but we would also make sure that the out of network deductible applies to the in network deductible. Dont let them bill out of network and bill for more and charge you more. Sometimes with the deductible being high it is cheaper to buy online but remember you dont have a company backing you for supplies and repairs online. And the insurance is not too hip on paying for supplies on something that they did not purchase. Just be very careful. You can contact me with any questions. jenni7535 at yahoo is my email address.

Thank you so much. The part that I don't understand is that with my insurance, my cost is (after the deductible) 20% of the price of the machine. Doesn't it make sense that one machine would cost more than another if that is how my insurance works?