I'm visiting my DME for first time because my insurance co referred me to them in order to get mask, hose, filters, etc. I can't afford the deductible coming up starting Jan 1st, so I wanted to get the mask, hose, etc prior while my benefits will pay 80 - 100%%. Any suggestions, I don't trust them, as I've not been impressed when talkiing on the phone with them about coming in to see them. Any suggestions? Stormin
I'm visiting the DME - help!
See if your insurance provider will reimburse you for out-of-pocket expenses.
Purchase everything you want from CPAP.COM (charge to credit card)
Submit an invoice from yourself to your insurance provider as soon as you get the items from CPAP.COM.
They'll send you a check for 80% of your invoice.
Apply it to your credit card balance.
Best wishes,
Den
Hurry.....you're running out of time.
Purchase everything you want from CPAP.COM (charge to credit card)
Submit an invoice from yourself to your insurance provider as soon as you get the items from CPAP.COM.
They'll send you a check for 80% of your invoice.
Apply it to your credit card balance.
Best wishes,
Den
Hurry.....you're running out of time.
(5) REMstar Autos w/C-Flex & (6) REMstar Pro 2 CPAPs w/C-Flex - Pressure Setting = 14 cm.
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
First question is -- did you insurance refer you to them or your doc?
Many times there are multiple DMEs that are acceptable to your insurance but not always. A lot of times the Doc sends your paperwork to the DME of HIS choice, not necessarily the best one for you financially.
Second is make sure to compare what you would pay this DME to what you would pay out of pocket online with no insurance. You might find that there isn't much difference. Depends a lot on your copay and the status of your deducatable. Compare apples to apples on machine costs. Know what the DME intends to provide to you. Machines vary from Mid $300 to $700 or so with some more or less than that range. Use the correct costs in your analysis.
Third. Make sure your insurance doesn't require rent to buy first. If you do, and your insurance year starts Jan 1, you won't be able to avoid the 2007 deductable.
4th, make sure that your insurance won't reimburse for an online purchase.
And know what machine you want going in so you will have the correct cost comparison and can walk if unhappy. Get all the stuff that comes with the machine. Both sets of filters if there are 2, all the sizes of mask cushions if there are more than one.....
Good luck
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CPAPopedia Keywords Contained In This Post (Click For Definition): DME
Many times there are multiple DMEs that are acceptable to your insurance but not always. A lot of times the Doc sends your paperwork to the DME of HIS choice, not necessarily the best one for you financially.
Second is make sure to compare what you would pay this DME to what you would pay out of pocket online with no insurance. You might find that there isn't much difference. Depends a lot on your copay and the status of your deducatable. Compare apples to apples on machine costs. Know what the DME intends to provide to you. Machines vary from Mid $300 to $700 or so with some more or less than that range. Use the correct costs in your analysis.
Third. Make sure your insurance doesn't require rent to buy first. If you do, and your insurance year starts Jan 1, you won't be able to avoid the 2007 deductable.
4th, make sure that your insurance won't reimburse for an online purchase.
And know what machine you want going in so you will have the correct cost comparison and can walk if unhappy. Get all the stuff that comes with the machine. Both sets of filters if there are 2, all the sizes of mask cushions if there are more than one.....
Good luck
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): DME
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Guest
If you have a good idea of which PAP machine you want, or at least a good idea of features you would like in your PAP machine discuss them w/your doctor to make sure your choice(s) fit your needs, the two of you, your doctor and you, come to an agreement on which machine you need and want and then have your sleep doctor write a script for EXACTLY the machine that you want. If he's already FAXed the script to the DME, no problem, just have him re-write it for EXACTLY which machine the two of you agree on. The DME then HAS to supply THAT machine. (Insurance doesn't pay for software or readers).
Be sure to check w/your insurance company for which DME suppliers they have contracted with. You may have some choice and can shop and compare between them.
But be sure your script states EXACTLY which machine you want because they get paid the same whether they supply you w/top of the line or bottom of the line equipment. You can guess which they are going to supply w/o an exact script.
Be sure to check w/your insurance company for which DME suppliers they have contracted with. You may have some choice and can shop and compare between them.
But be sure your script states EXACTLY which machine you want because they get paid the same whether they supply you w/top of the line or bottom of the line equipment. You can guess which they are going to supply w/o an exact script.
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Guest
If it is rent to own, you will be paying the full rental in 2007 (if you insurance year starts there) until you reach your deductable. Unless you have another issue that will make you reach your deductable irregardless of machine purchase, then that money needs to be considered out of pocket for you.
I think you get the idea of the DME vs. Online cash prices.
Do the math and decide if it is worth it.
May well be if the 80 - 100% coverage is 100% and the deductable is not too high.
I think you get the idea of the DME vs. Online cash prices.
Do the math and decide if it is worth it.
May well be if the 80 - 100% coverage is 100% and the deductable is not too high.
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Guest
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ColoradoDreamer
- Posts: 126
- Joined: Thu Oct 19, 2006 6:31 pm
When I got my mask, hose and filters from the DME they were out right purchases. They are not rentals. So, if you are looking for equipment other than the machine and humidifier you may want to consider going ahead with the purchase of these now.
Another item to consider is that the Insurance company most likely will not pay what the DME is asking. The DME wanted $206 for my mask and the ins. company allowance was $94. I paid 10% which is $9.40! I estimate that the ins. company will pay half of what the DME is asking for the machine and humidifier and I will pay 10% of that half.
So, if the DME says that the machine and humidifier is $1600, your insurance may have a plan allowance less than that. Even if you do have to pay next year to meet the deductable, it won't be what the DME is asking for but the Ins company's plan allowance. As you say, you will have to do the math. I have been doing the same.
Another item to consider is that the Insurance company most likely will not pay what the DME is asking. The DME wanted $206 for my mask and the ins. company allowance was $94. I paid 10% which is $9.40! I estimate that the ins. company will pay half of what the DME is asking for the machine and humidifier and I will pay 10% of that half.
So, if the DME says that the machine and humidifier is $1600, your insurance may have a plan allowance less than that. Even if you do have to pay next year to meet the deductable, it won't be what the DME is asking for but the Ins company's plan allowance. As you say, you will have to do the math. I have been doing the same.
Really good point Colorado on the mask and hose. May be able to include the humidifier in that since that is usually purchased too, but you have to see if you can get the insurance to buy that without the machine, and the humidifier is cheaper in a bundle. But with good coverage and the year coming to an end, it may well be prudent to get the humidifier at the local DME quickly too.
My experience (though I understand the billed vs. contracted price deal) is the $1600 is most likely the latter. That seems to be the number the DME accepts as payment (in my own experience and in other posts on this forum), not what they bill, that could be higher. Of course the patient should check to be sure, but I would expect that the $1600 is the one that the copay will be computed with.
My experience (though I understand the billed vs. contracted price deal) is the $1600 is most likely the latter. That seems to be the number the DME accepts as payment (in my own experience and in other posts on this forum), not what they bill, that could be higher. Of course the patient should check to be sure, but I would expect that the $1600 is the one that the copay will be computed with.
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ColoradoDreamer
- Posts: 126
- Joined: Thu Oct 19, 2006 6:31 pm
SG, my statement from my ins. Co. shows that the humidifier, for me, is a rental. The DME charged it as such. I understand that there may be some DMEs and Ins Cos that see it as you mentioned, that it is a purchase and not a rental. Agree that now would be the time to purchase the humidifier, if one had to buy not rent.
The reason why I question what my DME tells me the items will cost is based on what I see on my insurance company statement. They are clearly paying less than half of what the DME is charging them for the cpap and humidifier rental. Of course, if the DME continues to bill the ins co. for two years for the rental, then they will get their $1600 (or whatever it is for me) and I will be left paying the annual deductibles! I would then be better off purchasing it out right. I will call the ins co. to see what I can expect to be paying and for how long. I may also call the DME to see what they say.
I am still trying to find my way through this all. I still don't have a clear picture on this rental with the DME and ins co. (maybe this is the way they want it to be). I am one that needs to know what I can expect to be paying (and how long) early in the game. This reduces the stress level and allows me to budget and consider my options.
The reason why I question what my DME tells me the items will cost is based on what I see on my insurance company statement. They are clearly paying less than half of what the DME is charging them for the cpap and humidifier rental. Of course, if the DME continues to bill the ins co. for two years for the rental, then they will get their $1600 (or whatever it is for me) and I will be left paying the annual deductibles! I would then be better off purchasing it out right. I will call the ins co. to see what I can expect to be paying and for how long. I may also call the DME to see what they say.
I am still trying to find my way through this all. I still don't have a clear picture on this rental with the DME and ins co. (maybe this is the way they want it to be). I am one that needs to know what I can expect to be paying (and how long) early in the game. This reduces the stress level and allows me to budget and consider my options.
If the item is a rental, then the $1600.00 figure is most likely closer to the actual price since the costs go up exponentially with a rental plan.
If the item is a purchase I would lean to the $1600.00 figure as the submitted amount and not the allowed. The majority of purchase prices tend to fall in the $800-$1200 range depending on the plan (Though there are obviously exceptions of course).
Aside from that - as everyone else has said: Do the math. Figure out which will work best for you.
DO factor in several things though. If this is your first go around with PAP therapy you MAY do better dealing with a local company who can provide more hands-on service if you need (Ability to use different machines if needed, ability to play with different masks if needed, ability to help with any of the random issues that can arise in the first 3 months).
Yes I work for a DME company. No I don't stand to profit a dime no matter where you go. That's why I always agree with people here. Do the math - figure out which is best for you - online or Brick-n-mortar. Just remember that in many cases there are intangibles that should be factored into that equation as well and not just straight dollars!
Most of all though - Good Luck and stick with it!
mattman
If the item is a purchase I would lean to the $1600.00 figure as the submitted amount and not the allowed. The majority of purchase prices tend to fall in the $800-$1200 range depending on the plan (Though there are obviously exceptions of course).
Aside from that - as everyone else has said: Do the math. Figure out which will work best for you.
DO factor in several things though. If this is your first go around with PAP therapy you MAY do better dealing with a local company who can provide more hands-on service if you need (Ability to use different machines if needed, ability to play with different masks if needed, ability to help with any of the random issues that can arise in the first 3 months).
Yes I work for a DME company. No I don't stand to profit a dime no matter where you go. That's why I always agree with people here. Do the math - figure out which is best for you - online or Brick-n-mortar. Just remember that in many cases there are intangibles that should be factored into that equation as well and not just straight dollars!
Most of all though - Good Luck and stick with it!
mattman
Here is the rental and the cost breakdown.
Insurance Companies determine beforehand if items will be a rental or a purchase. That choice is made strictly by your insurance company and will vary from plan to plan and insurance to insurance. For example - with us BCBS Health Options is a rental for 3 months then converts to a purchase. However, BCBS Federal is an outright purchase. There was an older BCBS plan that dissolved a couple years ago that was a 15 month rental. Nice consistency there huh?
The insurance company also sets the price for each item. They tell a provider 'We will pay x dollars for this item.'.
HOWEVER, they also tack on an extra qualification - they will also only pay a percentage of each claim submitted to them.
So, again using our BCBS example - they have set our price at $815 for a complete CPAP setup.
However, they also only pay 40% of whatever claim we submit to them. So in order for us to hit thier price of $815 we actually have to submit a claim for $2037.
That's what is referred to as the 'Submitted' (2037) and 'Allowed' (815) amounts.
MOST of the time, the rentals are for 3 months then they convert to a purchase. Sometimes they are rentals for 12 or 15 months then convert to a purchase (What's referred to a 'Capped Rental'). VERY VERY rarely you will run into an insurance company that requires an indefinate rental. This almost NEVER happens anymore. Medicare used to do this with BiPAP ST units and that was one of the last open-ended rentals and this just recently went away as well.
For the 3 month rentals there is a charge each of the first 3 months then a lump sum amount to complete the purchase during the 4th month.
For the capped rentals there is a charge each month for either 15 months then the item converts to a purchase with no lump sum amount - the monthly rental payments are expected to be the full purchase price. (There are a few cases where it might stay as a rental with no more monthly charges. For CPAPs this usually only occurs with straight Medicare).
For the indefinate rentals there is a charge each month forever. As I said though I'm not aware of any plans that still do this.
Hope that helps!
mattman
Insurance Companies determine beforehand if items will be a rental or a purchase. That choice is made strictly by your insurance company and will vary from plan to plan and insurance to insurance. For example - with us BCBS Health Options is a rental for 3 months then converts to a purchase. However, BCBS Federal is an outright purchase. There was an older BCBS plan that dissolved a couple years ago that was a 15 month rental. Nice consistency there huh?
The insurance company also sets the price for each item. They tell a provider 'We will pay x dollars for this item.'.
HOWEVER, they also tack on an extra qualification - they will also only pay a percentage of each claim submitted to them.
So, again using our BCBS example - they have set our price at $815 for a complete CPAP setup.
However, they also only pay 40% of whatever claim we submit to them. So in order for us to hit thier price of $815 we actually have to submit a claim for $2037.
That's what is referred to as the 'Submitted' (2037) and 'Allowed' (815) amounts.
MOST of the time, the rentals are for 3 months then they convert to a purchase. Sometimes they are rentals for 12 or 15 months then convert to a purchase (What's referred to a 'Capped Rental'). VERY VERY rarely you will run into an insurance company that requires an indefinate rental. This almost NEVER happens anymore. Medicare used to do this with BiPAP ST units and that was one of the last open-ended rentals and this just recently went away as well.
For the 3 month rentals there is a charge each of the first 3 months then a lump sum amount to complete the purchase during the 4th month.
For the capped rentals there is a charge each month for either 15 months then the item converts to a purchase with no lump sum amount - the monthly rental payments are expected to be the full purchase price. (There are a few cases where it might stay as a rental with no more monthly charges. For CPAPs this usually only occurs with straight Medicare).
For the indefinate rentals there is a charge each month forever. As I said though I'm not aware of any plans that still do this.
Hope that helps!
mattman
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ColoradoDreamer
- Posts: 126
- Joined: Thu Oct 19, 2006 6:31 pm
mattman,
The info you provided does help me. This Insurance,apnea, sleep study, DME, CPAP, software, masks, etc stuff was all neatly contained in a black box to me a few months ago. I'm trying to learn but more black box stuff keeps oozing out of the box. Right now it is pretty messy. The only thing I know for sure is that there is a lot more in there waiting for me.
I do have BCBS-federal and I am going the rental route. So, I guess the out right purchase is optional even on the federal plan. It is nice to hear that after 3 months it will convert to a purchase. Calling BCBS in on today's list of things to do to confirm this.
Now, I noticed that the DME billing date to the ins. company is at the beginning of the rental month. That being the case, the DME should bill for the 3rd, and hopefully final, month in the middle of Dec. A question is if the ins company will pay all for the Dec billing or if they will break it out between the calendar year. Yes, this is the Scot in me wanting avoid additional costs, but the rest of me will be happy if they split up Dec and Jan.
The info you provided does help me. This Insurance,apnea, sleep study, DME, CPAP, software, masks, etc stuff was all neatly contained in a black box to me a few months ago. I'm trying to learn but more black box stuff keeps oozing out of the box. Right now it is pretty messy. The only thing I know for sure is that there is a lot more in there waiting for me.
I do have BCBS-federal and I am going the rental route. So, I guess the out right purchase is optional even on the federal plan. It is nice to hear that after 3 months it will convert to a purchase. Calling BCBS in on today's list of things to do to confirm this.
Now, I noticed that the DME billing date to the ins. company is at the beginning of the rental month. That being the case, the DME should bill for the 3rd, and hopefully final, month in the middle of Dec. A question is if the ins company will pay all for the Dec billing or if they will break it out between the calendar year. Yes, this is the Scot in me wanting avoid additional costs, but the rest of me will be happy if they split up Dec and Jan.
While all insurance plans are different, I also had a rent to buy. It was supposed to be 3 months. They called for my card (compliance) at 2.5 months and then processed the purchase. My opinion based on my own experince, with a different insurance of course, is if your 3rd payment is mid Dec, it is questionable whether you will get the purchase in this year. I certainly hope so. A little pushing might not be a bad thing.
Back to the machine costs. I really don't think most DMEs want you to know. I called 3 before accepting stuff from one and all three I had to pull teeth to get a straight answer as to the total cost of the machine. They REALLY wanted to just tell me my monthly rental. But I wasn't interested in that, I wanted the whole picture to make my cash vs. Insurance decision.
I was considering the machine and humidifier in the $1600 comment. I believe mine was in the $1500 plus range -- about $1200 for the machine which falls into Mattman's range and $300 for the humidifier. I don't know what he was quoting for his aprox $800 to $1200 range, but I suspect he was talking machine, which again is misleading since you need the humidifier too and they aren't giving that away free.
Back to the machine costs. I really don't think most DMEs want you to know. I called 3 before accepting stuff from one and all three I had to pull teeth to get a straight answer as to the total cost of the machine. They REALLY wanted to just tell me my monthly rental. But I wasn't interested in that, I wanted the whole picture to make my cash vs. Insurance decision.
I was considering the machine and humidifier in the $1600 comment. I believe mine was in the $1500 plus range -- about $1200 for the machine which falls into Mattman's range and $300 for the humidifier. I don't know what he was quoting for his aprox $800 to $1200 range, but I suspect he was talking machine, which again is misleading since you need the humidifier too and they aren't giving that away free.