Company A or Company B -- Please help

[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.

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.

Thanks for all of these replies. This is what I don't understand. If my insurance will pay 20% of the price (after deductible), doesn't it make sense that 20% of a more expensive machine would cost me more than 20% of a less expensive machine? To me it makes sense that one machine would cost more than another, it just seems that Company B has set the original price of the machine extremely high, making my 20% a really large amount. I called Resmed and it seems there is not standard list price; each company can set their own price. That doesn't seem right, but it seems to be the way they operate.

I'm sorry if I'm just not getting what y'all are saying. Also -- I didn't see these posts until today. I thought I would get a notice of new posts but I didn't.
Thank you all for your patience with me in these questions!!

[Pugsy]

Your 20% copay should be based on the insurance's contracted allowable amount and NOT what the DME originally charges unless your insurance is atypical.

In most situations the insurance contracted allowable amount is exactly the same for any model E0601 machine and not whether the machine is Escape or Elite or AutoSet because E0601 covers all those models.
It's just the way of billing codes...doesn't matter if it is a bottom line basic cpap or the high end cpap....it's E0601 and that's the way it is.

To charge a patient the excess above the "allowable" amount is not legal in most situations because the DME is supposed to be happy with what the insurance says they should be happy with.

Example....E0601 allowable amount is let's say $600...but DME bills $800....no matter which model (Escape, Elite, AutoSet) and you pay 20% of the allowable amount. It makes no difference at all what the DME wants "charge" for each separate model...the allowable amount is what the final copay is figured on. You pay 20% of 600 and not 800.

99.9 % of all insurance will pay on the E0601 billing code system and not on what the DME charges or the model name or even brand name.
Unless your insurance is not the norm....your 20% copay is based on the allowable amount and what the DME wants to charge for various models is a pie in the sky number.

[HealthyandHopeful]

Your 20% copay should be based on the insurance's contracted allowable amount and NOT what the DME originally charges unless your insurance is atypical.

In most situations the insurance contracted allowable amount is exactly the same for any model E0601 machine and not whether the machine is Escape or Elite or AutoSet because E0601 covers all those models.
It's just the way of billing codes...doesn't matter if it is a bottom line basic cpap or the high end cpap....it's E0601 and that's the way it is.

To charge a patient the excess above the "allowable" amount is not legal in most situations because the DME is supposed to be happy with what the insurance says they should be happy with.

Example....E0601 allowable amount is let's say $600...but DME bills $800....no matter which model (Escape, Elite, AutoSet) and you pay 20% of the allowable amount. It makes no difference at all what the DME wants "charge" for each separate model...the allowable amount is what the final copay is figured on. You pay 20% of 600 and not 800.

99.9 % of all insurance will pay on the E0601 billing code system and not on what the DME charges or the model name or even brand name.
Unless your insurance is not the norm....your 20% copay is based on the allowable amount and what the DME wants to charge for various models is a pie in the sky number.

THANK YOU for spelling that out. I will call my insurance again. I have United Healthcare, so I would think they would be like most other insurance carriers. The lady did say the allowed amount was around $860 but I wasn't clear as to what she meant by that.

Thank you!! Will let y'all know what I find out!

[HealthyandHopeful]

Your 20% copay should be based on the insurance's contracted allowable amount and NOT what the DME originally charges unless your insurance is atypical.

In most situations the insurance contracted allowable amount is exactly the same for any model E0601 machine and not whether the machine is Escape or Elite or AutoSet because E0601 covers all those models.
It's just the way of billing codes...doesn't matter if it is a bottom line basic cpap or the high end cpap....it's E0601 and that's the way it is.

To charge a patient the excess above the "allowable" amount is not legal in most situations because the DME is supposed to be happy with what the insurance says they should be happy with.

Example....E0601 allowable amount is let's say $600...but DME bills $800....no matter which model (Escape, Elite, AutoSet) and you pay 20% of the allowable amount. It makes no difference at all what the DME wants "charge" for each separate model...the allowable amount is what the final copay is figured on. You pay 20% of 600 and not 800.

99.9 % of all insurance will pay on the E0601 billing code system and not on what the DME charges or the model name or even brand name.
Unless your insurance is not the norm....your 20% copay is based on the allowable amount and what the DME wants to charge for various models is a pie in the sky number.

I now understand. Called the insurance, and you are right!! That's why Company A's price was $431!! That's 20% of the allowed amount plus my deductible. The insurance company did say that it depends on the code used as to what the allowed amount is. The E0601 (which is what Company A used) is $861. I called Company B and left a message, asking what code they use. They are supposed to call me anyway today about the price of a used machine (although now I understand what you all have meant about the prices should all be the same). I hope they will call. It's hard to get through to them and get a real person (of course), and so I left the message. If I don't hear by this afternoon I will call again.

It's so nice to finally understand. Sorry I have been slow about this. I know many of you have tried to explain!! The light has come on!

[palerider]

I called Resmed and it seems there is not standard list price; each company can set their own price. That doesn't seem right, but it seems to be the way they operate.

it's called "competition" generally manufactuers aren't allowed to dictate what their product sells for, though they may "suggest" a price. you might see things about lawsuits and such about "price fixing" most *everything* works this way, that's why you shop around for things, otherwise, every seller would sell the same model of refrigerator at the same price. (having just bought a new freezer, I can tell you the prices are similar, but not exact, and shopping around saved me money, for example).

[Janknitz]

H&H, I'm glad the has finally come on for you!

So you see, NOBODY should charge you more than $431. And Company B must bill the same code as everyone else, E0601 for a CPAP or APAP machine, no matter what model. It's FRAUD to use a different code for those machines.

Now you just have to figure out how to deal with Company B, assuming you even still want to use them now that you get what a slimeball they are, trying to upcharge you or pawn a used machine on you.

Here is how someone on another forum handled the issue with her DME, the insurer was Tricare:

Late this afternoon, I have been informed that my DME's "billing department will work with my insurance" (uh, they have to they are contracted providers). I was further advised that I am NOT responsible for the $300.00 upgrade fee. Yeah, I wonder how many other clients they have swindled?? My prescription has been changed as I had requested (APAP 6-10 cm) and my new machine will be in tomorrow. My only responsibility is 20% of the "amount allowable" by my insurance company per my benefits.

Their song changed after I sent a nice, but extremely firm email quoting from Tricare's provider section that APAP is coded as CPAP. I firmly reminded my DME that "balance billing" (charging a beneficiary over the allowed amount) is in violation of their contract with Tricare and if they continued to discuss a $300.00 "upgrade fee" that I would have no other choice but to file a grievance against their company with Tricare and any other relevant state agency. I ended the email nicely by saying that I really hoped we could come to a reasonable solution because I would like to give Sleep Med my business and to recommend them to others (not going to happen).

[Janknitz]

ONE more thing:

Be aware that the $431 is for the blower unit only. They will also you 20% of the contracted price for the outright purchase of the humidifier and also the hose, filters, and mask. So expect your out of pocket costs to be a little higher. And don't be surprised if they give you a new mask in a sealed bag, but charge by the part--headgear, mask, and cushion. It's common practice, and it costs you MORE.

[HealthyandHopeful]

ONE more thing:

Be aware that the $431 is for the blower unit only. They will also you 20% of the contracted price for the outright purchase of the humidifier and also the hose, filters, and mask. So expect your out of pocket costs to be a little higher. And don't be surprised if they give you a new mask in a sealed bag, but charge by the part--headgear, mask, and cushion. It's common practice, and it costs you MORE.

I forgot about the humifier. Is it also covered with the E0601 code? So, I SHOULD pay $431 for the Autoset, and then 20% (I pay 20% in network) of the allowed amount for the humidifier. Is this right? I will need to find out the humidifier code to find out the allowed amount for it. Is this correct?

Ah -- but still (I just realized) I should have been given the same price for both machines. It is still sinking in. I was given a price of about $240 more if I got the Autoset over the Elite. I'm getting it!!

Thanks!

PS I looked for that light bulb icon!!

[bwexler]

NO!
Insurance seldom makes sense.
The insurance allows only one price for ANY CPAP or APAP machine. It does not matter what brand or model or what the list price is. The insurance sets that one price by contract. DMEs than try to talk you into a cheaper machine (more profit for them) or convince you to pay extra money you should not owe (more profit for them).
On rare occasion you will run into someone like Jenni. If you do treasure that experience. If not arm yourself here with the knowledge you need to fight and win your battles.

As several have already said, call your insurance company and have them tell you what their contract price is and what your payment will be. It will be the same at any honest in network provider for any machine, CPAP or APAP.

[HealthyandHopeful]

NO!
Insurance seldom makes sense.
The insurance allows only one price for ANY CPAP or APAP machine. It does not matter what brand or model or what the list price is. The insurance sets that one price by contract. DMEs than try to talk you into a cheaper machine (more profit for them) or convince you to pay extra money you should not owe (more profit for them).
On rare occasion you will run into someone like Jenni. If you do treasure that experience. If not arm yourself here with the knowledge you need to fight and win your battles.

As several have already said, call your insurance company and have them tell you what their contract price is and what your payment will be. It will be the same at any honest in network provider for any machine, CPAP or APAP.

I finally found out the reason for the extra cost. Y'all are not going to like this and I don't either. Before I explain, I will say that I called my insurance company (again) and they do not understand either and don't agree that Company B should charge the extra cost. My insurance agent still has an open ticket on this and is going to be contacting Company B to ask them to explain. The insurance guy did try to call but left a voice message to call back. He included this extra piece of information in the open ticket so that whoever speaks to Company B will have the information.

According to Company B: The price including deductible and then my 20% would be $432 (or so -- I think it was more, but should be $432..... Ah, probably will be more with the humidifier!) on a basic machine (the Escape). But since the Autoset is a more expensive machine that does more than the basic machine, they charge a $292 upgrade fee for this one. I would have to sign a paper saying that I agree to this upgrade fee and that I know that insurance will not cover it. (If I had chosen the Elite, that one would have only a $50 upgrade fee). That's it. Also ... I cannot buy this machine unless I sign that paper and pay the upgrade fee. SO, I will wait and let my insurance talk to them and see what happens from here. Will definitely let you all know!

[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 for taking the time to respond to me on this forum. I posted this separately but wanted to post in answer to yours as well. This is what I found out about the charges:

Company B told me that the price including deductible plus my 20% would be around $480 on a basic machine (the Escape). But since the Autoset is a more expensive machine that does more than the basic machine, they charge a $292 upgrade fee for this one. In order to get this machine, I would have to sign a paper saying that I agree to this upgrade fee and that I know that insurance will not cover it. (If I had chosen the Elite, that one would have only a $50 upgrade fee). I cannot buy the machine from them without signing this form and agreeing to pay the upgrade fee. In the meantime, my insurance agent is supposed to contact them and find out why they are charging like this. I hope to know something soon. I'm ready to get started on my treatment!

Thank you again!

[Nick Danger]

Sorry, but this is BS. Might be time for Company C if your insurance company can't talk sense into their heads.

If you check CPAP.COM, you'll see they sell the Escape for $599, the Elite for $649, and the Autoset for $724 (none of these prices include humidifier).

So, first of all, IF Company B are permitted to charge an "upgrade" fee and stay in compliance with their insurance company contract (this would be a very unusual contract in the US), the fees should be at most $50 to go to elite and $125 to go to Autoset. If the purpose of the fee is to just make sure the DME doesn't lose money, then the actual fee should be lower than the difference in CPAP.COM's prices - because ResMed is charging the vendor less than the numbers shown above (otherwise CPAP.COM couldn't make a profit and sponsor this forum!).

It sounds to me as though Company B is violating their contract with your insurance company (assuming the contract is the one everyone else in the US uses that doesn't permit balance billing).

[HealthyandHopeful]

Sorry, but this is BS. Might be time for Company C if your insurance company can't talk sense into their heads.

If you check CPAP.COM, you'll see they sell the Escape for $599, the Elite for $649, and the Autoset for $724 (none of these prices include humidifier).

So, first of all, IF Company B are permitted to charge an "upgrade" fee and stay in compliance with their insurance company contract (this would be a very unusual contract in the US), the fees should be at most $50 to go to elite and $125 to go to Autoset. If the purpose of the fee is to just make sure the DME doesn't lose money, then the actual fee should be lower than the difference in CPAP.COM's prices - because ResMed is charging the vendor less than the numbers shown above (otherwise CPAP.COM couldn't make a profit and sponsor this forum!).

It sounds to me as though Company B is violating their contract with your insurance company (assuming the contract is the one everyone else in the US uses that doesn't permit balance billing).

I'm wondering what choices Company B has. I am in network and this is what they have agreed to in order to be an in network provider. Are they not going to be obligated to sell the machine to me without the upgrade fee? I suppose I should start looking for Company C. I really don't want to do this. But you may be right. All of this and I just want to feel better. What a shame a person (so many people) have to go through this.

[Pugsy]

What a bunch of weasels.

Your insurance company says $861 is what the DME should be happy with for the E0601 machine and believe me...they make a profit at $861 on the S9 Autoset. They just want a bigger profit hence the "upgrade fee of $292".

yes, the humidifier is a separate HCPCS code and a separate charge but they shouldn't be able to screw you around with it.
E0562 Humidifier, heated, used with positive airway pressure (CPAP/BiPAP/APAP) device

If it were me I wouldn't pay them one thin dime of an upgrade fee...I would find DME #C if they refused to waive the "upgrade" fee crap.
Your choice but at least you now understand the screwing they are trying to do to you and if you want to let them get away with it...do what you want. I know you are ready right now to get your machine and they are counting on that to put pressure on you.

There are DMEs out there who don't try to pull the crap that A & B tried to pull. Finding one takes a bit of work and time though. Get a list from UHC who are in network providers in your area and start making phone calls and now you know what to ask for specifically.

[Nick Danger]

Good question about Company B's choices. Their contract for being "in network" probably forbids them from balance billing. But what if they ignore this part of the contract and the insurance company decides not to do anything about it? In any event, this doesn't seem honest. As many of us have found, there are a lot of shady operators out there in the DME world. There are also good ones - unfortunately, it is hard to sort them out without going through the process... sigh...