DME overcharging

Hi all, new user here. Anyone have an issue with the DME company overcharging? Insurance pays 80%. Yet they want me to pay $1000 over 10 months (deductible met already). This for a bipap machine with humidifier. They didn't say which machine, but looking at prices on CPAP.com I feel like I am getting ripped off for money I don't have.

Bilevels are much more expensive than plain cpaps, especially the "good" ones.
Compare like items.
Example:
https://www.cpap.com/productpage/resmed ... chine.html
For your copay, insist on either a Resmed Aircurve 10 model or a Respironics.

You need to find out exactly which bilevel model you are being prescribed.

chunkyfrog wrote:Bilevels are much more expensive than plain cpaps, especially the "good" ones.
Compare like items.
Example:
https://www.cpap.com/productpage/resmed ... chine.html
For your copay, insist on either a Resmed Aircurve 10 model or a Respironics.

I am aware of that, but in that example, that machine is only $1,726. The machine in question they are quoting me for is over $5,000.

Pugsy wrote:You need to find out exactly which bilevel model you are being prescribed.

Just found out, it's the Respironics DS960HS AutoSV ADV System One with the Heated Humidifier

The 960 is the ASV bilevel model and quite pricey. It wouldn't be unheard of to find out that a DME is billing out $5K for that model. Doesn't make it right but they do it.
Most insurance companies pay by HCPCS billing code and not the model or brand.
The HCPCS code for that machine would be E0472
and the humidifier is billed out separately with this code E0562
you need to call up your insurance company and find out the allowable amount for each code and then you are responsible for 20% of that amount.
Bear in mind a new deductible will likely come into play after the first of the year when you figure your out of pocket expenses.
It wouldn't surprise me if the allowable amount was somewhere around $500 for that model. I have seen it before and while it does seem like they are overcharging compared to online pricing...if the insurance company will pay it....it is what it is.

Go to secondwindcpap.com and compare your potential out of pocket expenses to what you can buy that machine for outright.
They are showing a gently used one with humidifier for $1399
and new open box at $1629.

If you want to go private party purchase and save more money for a 960...send me a private message. I might know of one.

You can still used this DME for masks and other supplies even if you don't buy a machine from them. They might not like it because they don't make the big bucks on the machine sell but there is no law that says you have to buy a machine from a DME in order to buy masks or other supplies.

Is your insurance also covering your supplies (fillers, tubing, masks, and the like), if so then for how long? That $5k might also be prepaying for your supplies as well and if your insurance covers supplies in full for as long as you use a machine then it might be worth it to go though the local DME. That said if you have to pay out of pocket for supplies (or don't at least get a deep discount for them) then you might want to look into buying one online.

Do call your insurance company... I got my machine in Feb. 2014, and it was a 13-month deal with first payment in March; I pay 20% of each payment, ins. pays the rest. My share was $31.50/month, I believe, for my apap machine. Come Jan. 2015, it was still the same 20% that I paid. It all depends on your insurance, and there is only so much that your DME can be reimbursed for according to the codes.

Please read my blogposts "What you need to know BEFORE you meet your DME" and "Don't Pay that Upcharge" in my signature below.

The machines listed are outdated, but the facts are still good.

How much the DME charges is a work of fiction. Your Insurance will pay 80% of what it decides a reasonable charge should be--that will be FAR less than the DME wants to charge for the machine. Your responsibility will be to pay ONLY the 20% of the REASONABLE CHARGE set by your insurer--NOT a penny more. Don't pay anything at all until you receive an explanation of benefits on exactly what the insurer paid and what your share is. Don't let the DME tell you what you have to pay, ONLY the insurer can tell you that.

Be sure you understand whether your insurer covers an outright purchase or requires a rental period that can be from 1 to 13 months, typically.

Be sure you understand what your insurer buys (typically the entire mask, the hose, the filter, and the humidifier) and what they may only rent (the blower portion of your machine).

Be sure you understand whether your insurer limits the models you can have under their coverage--most pay by billing codes and do NOT specify make and model.

While you are talking to your ins. co., ask them if you can do an outright purchase instead of a rental. That way you won't straddle a new deductible come Jan. 1st. My ins. approved my 960 as an outright purchase. I then asked the DME to submit the claim as such. I only had to pay 10% of my ins. co. contracted amount, which was much less than the billable amount.