More DME Games

Reading through Sal's stories - it kept passing though my mind how each time you interact with a physician and DME and sleep lab - the cost of treatment gets more and more expensive. These idiots you end up talking to get paid well and it all adds up in the end.

I was surprised to see on my Rx for CPAP that it said that and AHI>15 was essential for medical necessity for insurance coverage unless you had other co-morbid conditions (like heart problems, etc.). They all make such a big production out of getting a machine - and an S9 Autoset costs $850! I bet it ends up costing insurers 3 times that because they throw up all these roadblocks.

Now a heart attack or stroke can cost them hundreds of thousands - so you think they'd want to be a bit into prevention. So what's the real cost of an S9 autoset? No one knows, but my guess is around $500 - or the DME is not going to make any money. So everyone makes money but only a fraction get proper treatment.

My mother was diagnosed years ago with sleep apena - she has it really badly. But they couldn't give her a machine because the sleep lab couldn't record her sleeping long enough - I think for the past 40 years she sleeps in 5 minute increments. She was going to go for another sleep study, but finally gave up - even though she has US Military insurance that will cover anything that Medicare does not. If they create enough red tape and roadblocks they can avoid treatment altogether. It deters a lot of people. So much for medical progress.

Sorry I digress, but congrats Sal for kicking some serious butt! We need more people like you in this country and perhaps we can get these clowns into shape!

jonquiljo wrote:Reading through Sal's stories - it kept passing though my mind how each time you interact with a physician and DME and sleep lab - the cost of treatment gets more and more expensive. These idiots you end up talking to get paid well and it all adds up in the end.

I was surprised to see on my Rx for CPAP that it said that and AHI>15 was essential for medical necessity for insurance coverage unless you had other co-morbid conditions (like heart problems, etc.). They all make such a big production out of getting a machine - and an S9 Autoset costs $850! I bet it ends up costing insurers 3 times that because they throw up all these roadblocks.

Now a heart attack or stroke can cost them hundreds of thousands - so you think they'd want to be a bit into prevention. So what's the real cost of an S9 autoset? No one knows, but my guess is around $500 - or the DME is not going to make any money. So everyone makes money but only a fraction get proper treatment.

My mother was diagnosed years ago with sleep apena - she has it really badly. But they couldn't give her a machine because the sleep lab couldn't record her sleeping long enough - I think for the past 40 years she sleeps in 5 minute increments. She was going to go for another sleep study, but finally gave up - even though she has US Military insurance that will cover anything that Medicare does not. If they create enough red tape and roadblocks they can avoid treatment altogether. It deters a lot of people. So much for medical progress.

Sorry I digress, but congrats Sal for kicking some serious butt! We need more people like you in this country and perhaps we can get these clowns into shape!

Re: Costs. That was one of the things I set out to track down today. I looked into the billing the sleep center sent to my insurance company, and what was actually paid. It went like this (as best I can tell - since the sleep center never sent me a billing, I am reconstructing based on the insurance EOB's):

Sleep Study:

Billed $6000
Insurance Paid: $3000 based on 50% reimbursement due to the center being out-of-network

DME:

Billed $7216.59
Network Discount: $3300.00
Disallowed: $1019.77
Balance: $2896.82

Now here it gets a bit tricky. The sleep center has a policy that they do not charge a patient more than what the insurance pays. In my case, there was a remaining deductible of $1291.59 that insurance expected to be paid by me - but the sleep center did not charge me - so the amount they actually received for the DME was $1605.23.

So the sleep center was paid $1605.23 from my insurance to purchase an obsolete (but new) Respironics REMstar Plus M-Series - along with quarterly masks, hoses and filters.

I would bet I could have purchased that same machine and supplies online for under $1000. The sleep center, purchasing wholesale, should be able to purchase those same products for (my guess) approximately half of the price I might pay - so estimate $500. An approximation of their sales margin is a factor of 3 times their direct costs (or 300% mark-up, if you prefer to look at it that way).

Not a shabby mark-up for most businesses - and I would imagine they enjoy higher margins with most other patients who are processing claims in-network.

Much of the above is merely my conjecture - so take it for whatever it may be worth.

A new PR system one REMstar plus (with online discount) is about $400 with about another $100 for the humidifier and probably another $125 for the mask. I believe that's the model that is now sold in place of yours. This is what you could buy it for. I think lots of people are making lots of money.

Now with all the sleep studies and titration studies and Dr visits costs:

How much did all this (including sleep study) cost you out of pocket?

jonquiljo wrote:A new PR system one REMstar plus (with online discount) is about $400 with about another $100 for the humidifier and probably another $125 for the mask. I believe that's the model that is now sold in place of yours. This is what you could buy it for. I think lots of people are making lots of money.

Now with all the sleep studies and titration studies and Dr visits costs:

How much did all this (including sleep study) cost you out of pocket?

In my case, the cost out of pocket was $0 (zero).

I seriously doubt this is the norm, however.

FWIW

Boy DHC - are you lucky! I would have paid the full $3000 remainder for the sleep study (if I had met my deductible) and about $1450 for the DME (again, if I met my $2000 deductible). I guess that's why (since I knew I had apnea anyway) I chose the take home study machine at $200 and bought my equipment out of pocket online.

And I pay about $5000 a month in insurance premiums for the privilege of paying that much! Reform, what reform?