Conversations with an Insurance Company

Snoredog wrote:then after you have rented for 20 months, paying all those copays and rental fees your job gets outsourced to India and you lose health insurance and are then really screwed (is that the same as being penalized?). At that point with Apria, you'll be stuck with paying those ridiculous rental payments each month on your own in addition to paying $380-$760 for COBRA (read the fine print of the agreement you signed when you got the machine).

Rent-to-own is the most expensive way to purchase anything. Apria knows this and makes a killing in profit off it, it is why they rent.

From my experience none of that is accurate. The insurance company paid for a rental for only 15 months and from most of the discussions here that seems to be standard. Some reported renting for only like 10 or 11 months but most seem to be 15. I can't say I like Apria but it certainly isn't fair to say they are charging people 760 dollars a month because someone changed insurance. I'd be very supprised if someone can show any proof of that. From what I've learned speaking with my insurance and with my dme company it is the insurance companies that determine the rental rate and decide if the unit is a rental or purchase. Apria or anyone else aren't the ones deciding that.
Let me be clear - I'm no fan of Apria. I think the customer service there stinks. It just isn't fair to attribute things to them that aren't accurate.

CG and Iggy1 -- wow! What fun reads.

Funny but sad when we think about what a mess the whole medical equipment/insurance/DME thing is.

[quote="ignorant1"]The irony of a unit purchased “out of network”:

I have a 70/30 individual PPO policy with Blue Cross. They are willing to pay 70% of a highly inflated price to a DME (say 70% of $1,800 = $1,260). That means my co-pay of 30%, is $540 for a machine that I can buy for less than $500.

It gets even better. After working my way up the food chain to a supervisor:

BC: …well sir, if you purchase it out-of-network, we will only pay up to 50% of the “negotiated fee”, not 70%.
ME: How much is the negotiated fee?
BC: The negotiated fee is the amount that Blue Cross negotiates with each provider of medical….
ME: (interrupting) what I want to know is the dollar amount of the negotiated fee for a CPAP machine.
BC: We don’t have that information available, it depends on the supplier.
ME: If a supplier is out-of-network, doesn’t that inherently mean that BC doesn’t have a negotiated fee with that supplier?
BC: That is correct.
ME: Then how much is BC willing to pay for a CPAP machine purchased out-of-netowrk?
BC: We don’t have that information.
ME: What is the minimum/maximum range of pricing that BC authorizes?
BC: We don’t have that information available.
ME: Who does?
BC: It wouldn’t be available to you sir, it is confidential.
ME: It’s confidential? Why?
BC: The fees are negotiated with each company, and it wouldn’t be fair for the information to be known to other companies.
ME: I wasn’t planning to open a DME supply business anytime soon. I am the customer, not the supplier.
BC: Silence.
ME: So let me understand this correctly: I am required to pay my 70% co-pay of the purchase price for something that I am not allowed to know the price of?
BC: Umm… You could call different suppliers to see how much it is.
ME: I already did. It is more than triple the price than if purchased out-of-network.
BC: The price is determined by each DME supplier.
ME: Does BC have a list of preferred providers, and by preferred I mean suppliers that have lower prices than others?
BC: No sir, we don’t have a list like that. I can provide you a list of all providers however.
ME: So if someone calls in, looking to save themselves some money, as well as save BC some money, BC cannot help them determine which supplier to go to?
BC: No sir.
ME: Does that sound logical to you?
BC: It is BC policy not to direct the patient to any particular provider of service.
ME: When BC buys its company cars, do they go to the dealer and order a car without knowing the price, & just leave it up to the dealer to charge whatever they felt like?
BC: Sir?
ME: I know a car dealer that would gladly let BC pay only 70% of $100,000 for a Ford Taurus. BC’s paid amount would equal only slightly more than double the normal price – a bargain versus triple the normal price.
BC: Silence
ME: If I could PLEASE explain this to you once again, I can purchase a machine for less than $500. It is the same machine that BC is willing to pay 70% of $1,800 for, so BC is willing to pay $1,260 for the same machine that I can get for $500.
BC: I didn’t say that BC would pay that amount. BC will pay 70% of the negotiated rate.
ME: That IS the agreed upon negotiated amount per the DME; BC pays that amount to them as a matter of course.
BC: Yes sir, then that is the amount that they charge BC.
ME: I understand this. So BC is willing to force me to use a supplier that charges more than triple the price, so that BC policy is such that it assures that not only am I getting screwed, but BC is too.
BC: We don’t force anyone to go to any DME supplier
ME: BC encourages the use of a DME supplier that is in-network, correct?
BC: Yes.
ME: If I don’t use an in-network supplier, I am penalized by the BC policy of paying only 50% of a fee that they will not even disclose to me, is that correct?
BC: I wouldn’t say penalized, sir. You are free to use the services of an in-network provider.
ME: Yes, I understand. This seems to be a circular discussion, doesn’t it?
BC: Sir?
ME: How about if I call several in-network providers to find the one that will charge the most money?
BC: Silence.
ME: Then, BC would be paying SOOO much more money than they would pay even IF they would pay 100% of my purchase price for the same machine purchased out of network.
BC: No sir, BC will not pay 100%.
ME: Thank you for clarifying that for me, as I truly am not that bright & obviously cannot make any sense out of an irrational system. Could you please send me written documentation supporting the information discussed today?
BC: It is all in your policy, sir.
ME: No, actually it isn’t. I need the written documentation about the negotiated fees being confidential, and that BC will not provide assistance to either it’s members or itself to help determine the lowest cost provider of same-kind equipment, therefore wasting huge amounts of money.
BC: We don’t have any documents like that.
ME: I imagine not. I guess that when I bring this entire line of reasoning to the attention of the California Medical Board and the State Insurance Commissioner, they may be able to get to the bottom of this.
BC: BC policy complies with all regulations.
ME: I’m sure it does.
BC: Silence.
ME: Can I get information on how to open up a DME supply business? I hear they make an absolute fortune by ripping off insurance companies that don’t make any efforts in cost containment.
BC: BC makes every effort to save its members money by negotiating the best possible fees available.
ME: It seems to me that BC could use some better negotiators. I don’t really see much point in wasting more time on this conversation, wouldn’t you agree?
BC: Is there anything else that I can help you with today sir?
ME: Not right now. But when I find the in-network DME with the highest pricing on the planet, I’ll be sure to get back to you.
BC: Thank you sir, have a nice day.

Anonymous wrote:

Snoredog wrote:then after you have rented for 20 months, paying all those copays and rental fees your job gets outsourced to India and you lose health insurance and are then really screwed (is that the same as being penalized?). At that point with Apria, you'll be stuck with paying those ridiculous rental payments each month on your own in addition to paying $380-$760 for COBRA (read the fine print of the agreement you signed when you got the machine).

Rent-to-own is the most expensive way to purchase anything. Apria knows this and makes a killing in profit off it, it is why they rent.

From my experience none of that is accurate. The insurance company paid for a rental for only 15 months and from most of the discussions here that seems to be standard. Some reported renting for only like 10 or 11 months but most seem to be 15. I can't say I like Apria but it certainly isn't fair to say they are charging people 760 dollars a month because someone changed insurance. I'd be very supprised if someone can show any proof of that. From what I've learned speaking with my insurance and with my dme company it is the insurance companies that determine the rental rate and decide if the unit is a rental or purchase. Apria or anyone else aren't the ones deciding that.
Let me be clear - I'm no fan of Apria. I think the customer service there stinks. It just isn't fair to attribute things to them that aren't accurate.

first of all I did't say they charged $760 a month YOU did, get your facts straight. As for your experience you either don't any or are living under a rock. As for your accuracy statements? you should take your own advice or learn to read.

she already said she rented the machine for 1.5 yrs. At latest count that is 18months and they are still charging her a monthly rental and copay. so if you want to talk about accuracy you are not even close in your account.

So I can understand why you like to throw pot shots as a guest (no balls).

Wow, What a hassle you guys have been through and are going through. I guess I'm lucking insurance is Cigna, they use Apria. cigna picked up 100% of the cost, nothing out of pocket for me. I got a brand spanking new Remstar Auto with Cflex and Heated Humidifier and Comfortlite2 mask. Apria charged Cigna a grand total of 836 and change. I guess i should consider myself lucking.

Back to the original topic for College Girl:
Like some other posters advised, I suggest calling Apria billing. When I got the machine, Apria told me my insurance would rent it for 2 or 3 months and then the insurance would buy it. Of course they didn't remind me, but after 3 months I phoned Apria customer service and the branch, who referred me to billing. Billing sent me a statement saying I needed to pay nothing, and a sticker to put on the machine saying I owned it, in case it ever needs repair. The surprise is that Apria's price for the APAP wasn't that much higher than cpap.com's price, at least on the statement they sent me.

Good luck. I fully agree with those who have had problems with Apria and major stress. Been there, done that and got the stress symptoms to show it.

Wow, I thought I was the only one having these issues

My DME company (Pacific Pulmonary) insisted that my Insurance Carrier (United Healthcare) would only allow me to rent the equipment for 10 months, at which time it would be converted to a purchase.

Well, 10 months would mean it would extend into next year and I would have to meet all my deductibles all over again before the insurance would kick in. This would make my total out of pocket expenses well exceed just buying the machine outright off of the Internet.

What I did is call my insurance company for a Pre-Certification approval for purchase. They said it was very unusual for a patient to request Pre-Cert and that the DME usually does that.

So, I requested the DME to resubmit the claim as a purchase, they said they did and it was rejected. I called the Insurance company back and they said they had no record of a purchase request being made!!

Can you believe it? The DME flat out lied to me...

So, I call the insurance company back and insisted that they open a Pre-Cert record on my behalf and got the reference number for the claim.

I then called the DME back and said that the insurance company had no record of the purchase request and was greeted with hems and haws. Excuses and more lies..

I finally told them I had filed a Pre-Cert request and gave them the record number.

Boy did their tune change.. Once they knew I was on to them and that I knew how the system worked, they became very helpful.

Needless to say, I am the proud owner of my very own CPAP machine and since my deductibles have already been met for this year, it cost me next to nothing out of my pocket...

One thing clued me in to this method. The "rental agreement" that I was asked to sign by the DME stated that I was aware of my Insurance Carriers policies and procedures.. Well I made sure to educate myself on them and it paid off..

So, the fact they negotiate price the reason why I can buy the mask and equipment for under half the price my hospital is charging my insurance? Since I also have to bleed 30% of the cost (and then some because outpatient is only covered up to $2,500 on my policy), I'm in the same boat. There are some people negotiating a price without my ability to have a say in the process and then I get a bill. I've been asking those questions too: how much does this cost? Everyone, including the financial person, says they don't have that information. I have the attitude that I simply have to wait until I get the bill to assess the damages.

Thanks for reminding me-my original "rental" period was 10 months-starting Feb 2 2006. I switched to Medicare as the primary insurance starting May 1. So time for me to get out all my EOB's and Summaries to check out how much has been paid, get an account statement from Apria, and make sure we are all on the same page.

My machine is the only item rented. The humidifier, mask, hoses, filters are outright purchases with a 10% copay. (Now-Medicare pays their allowable & insurance pays the difference up to their allowable and since Apria is in network there have been no furthur charges to me.

kwjw3 wrote:Can you believe it? The DME flat out lied to me...

I've dealt with Pacific Pulmonary before and they are really topnotch folks. I'd be willing to wager that they did actually file a purchase claim and it was denied and what you heard from the CSR from United didn't have access to all the information. That's really very common especially for an out of the ordinary request like that. Getting United to Pre-Auth a purchase is a process akin to passing legislation through Congress. Most likely she didn't look in the correct places to see if a Pre-Auth was made. To be honest I'm not even sure how they would be able to go about checking that unless you actually spoke to the Case Manager. Especially if it was done anytime within the first 6 months. It usually takes an insurance company about 6 months or so to update records for something like that.

justdan wrote:There are some people negotiating a price without my ability to have a say in the process and then I get a bill.

Well, the way the price negotiations work with Insurance Companies is Insurance Company X will decide to either come into a new area or start a new plan in an existing area. They will then contact providers saying "We are doing (whatever) in your area. We will pay $x.xx for yyy services. Do you want be a provider?" An example of a common contract for something that hits home for us here is United PPO agrees to pay 40% of an allowable of $1945.00 for an E0161 CPAP claim. We can either agree to accept that or turn down the United PPO contract.
There isn't any real negotiation in the true sense of the word. You either accept what they pay or you don't. That's it end of story. It's extremely rare to the point of almost never happening) that you get to specify any conditions back to them (Such as I want all clean claims paid within 12 months) etc. You either take what they give you or you walk.
Kinda sucks huh?
Plus you get to have conversations like those posted here when you call to check on a claim!

Mattman

I too had the darndest time figuring out what the total cost for my machine would be before I agreed to take it.

Multiple calls to multiple "in network" DME's.

Called insurance and also got the same answer to my questions about what the contract price was. I also asked, "How do you know that you are paying the DME the correct amount if you don't know what that is?". Silence.....

I kept at it until I pinned them down (the DME and the Insurance company on both price and number of months rent to buy, as well as rental getting applied to purchase...). Luckily while I was doing this I had a used Cpap I had purchased from an auction so I could continue this until I was satisfied that I knew how much I was in for.