No deals with the local DME

greenham · Post by **greenham** » Wed Jan 03, 2007 2:42 pm

Thank you all for providing sound advice on the ins - n - outs of dealing with my OSA.

My sleep study showed SEVERE OSA. My Dr office signed the script and referred it to the Ins co. They approved and referred me to the DME.

I have done my research and know what I want. (the M series Auto w/ Cfex) heated humidity and data card.

DME says no the Resmed s8 CPAP is all they will authorize. I ask how much are you charging the Ins co. $1,200 (CPAP.com wants $600.) I say it's the 3rd day of the year. I Haven't met the deductible yet ($2,500) They say, talk w/ your ins company. I said what other charges would I be responsible for to use this? $100 deposit, and $800 for humidifier and supplies. So for a mear $2,000, which they so kindly pointed out would or could be put against my deductible. I can have the basic CPAP machine. Or using CPAP.com and $850 I can get the machine that I think will be the bet for me.

Had the deductible already been met, and I will willing to use just a CPAP without any features, it would have been 30/mo (my portion of the 80/20%) plus the $100 deposit, and full ownership in 12 months.
Roughly I would have owned the machine for about $400. Not really a bad deal if all you want is CPAP and have already met the deductible.

rested gal · Post by **rested gal** » Wed Jan 03, 2007 2:57 pm

greenham wrote:I have done my research and know what I want. (the M series Auto w/ Cfex) heated humidity and data card.

Good for you, greenham! Interesting story about what the DME told you they would and wouldn't do.

Please send me a PM with your email address (the "PM Me" button at bottom of my post here.)

Wulfman · Post by **Wulfman** » Wed Jan 03, 2007 3:13 pm

And......another WISER CPAPer is born (to take charge of their own therapy).

Way to go!

Best wishes.

Den

Sleepless_in_LM · Post by **Sleepless_in_LM** » Wed Jan 03, 2007 4:20 pm

Be sure to check with your insurance company. I was recently surprised to find out that I could buy from cpap.com AND get reimbursed by my insurance. The best of both worlds!!!

snorestats · Post by **snorestats** » Wed Jan 03, 2007 4:24 pm

Greenham,

Welcome aboard.

Get the machine you want. Wow... $2500 deductible sure is high.

So, you planning to purches the M Series with CPAP.com? If it's cheaper out of pocket for you, then that's the way to go.

I decided on the Resmed Auto w/CFLEX (the older non-M series). I'm a newbie as well.

dataq1 · Post by **dataq1** » Wed Jan 03, 2007 4:45 pm

Congradulations Greenham,
I just wish that I'd been as alert as you when I started 2+ yeras ago. I'm still totally befuddled by the Insurance allowances, and why they vary so much.
Bottom line is that you, the consumer, have to look out for yourself. And if your "insurance" is self-insured by your employer... you've got to look out for their best interests.
Welcome aboard

Snoredog · Post by **Snoredog** » Wed Jan 03, 2007 4:46 pm

if you are smart you will:

1. Obtain a copy of your PSG (needed to bill insurance).
2. Letter of Medical Necessity from your doctor (req. to bill insurance).
3. Copy of the cpap Prescription (needed to bill insurance).

4. Buy the machine you want on-line, get everything, the heated humidifier, mask, complete package. The cpap prescription will get you any machine or mask you want.

Search around, think you will find cpap.com the cheapest around, they also have the freshest inventory. If you find a better price from an online supplier such as a package that includes a free mask, include the URL in the comments box when you place the order and they will match it.

5. Make copies of items 1-3 and copy of your invoice from cpap.com, then bill your insurance company just like a drug prescription reimbursement. At worst they can only dispute the charge as out-of-network of which they will still have to pay whatever that coverage is. It may take you 6 months to get your reimbursement back but still better than using a DME and paying the deductible for those trumped up charges.

Note: Items 1-3 are required to bill insurance.

greenham · Post by **greenham** » Wed Jan 03, 2007 4:50 pm

Thanks Snoredog for the advice.

After talking with the DME, I spoke to the Ins co. (BCBS) which Cpap.com is a participating member. BCBS said send them everything, as you described and they would apply it towards my deductible.

Man you have to watch these guys every step of the way!!!

Linda3032 · Post by **Linda3032** » Wed Jan 03, 2007 5:15 pm

If you get a "package deal" from cpap.com, you might have them break it down to individual codes instead of one lump code. My insurance required a separate code for the heated humidifier, etc.

dataq1 · Post by **dataq1** » Wed Jan 03, 2007 5:19 pm

I spoke with my BCBS on the 28th of Dec and was told that cpap.com was out-of-network so my coinsurance would be 30% as compared with 10% for in-network.
If your BCBS includes Cpap.com then another congradulations is due you!

BTW, for those that find themselves with cpap.com being out-of-network, be sure to try cpap.com sister organization billmyinsurance.com. Rumour has it that they share the same inventory, but will do all the insurance billing for you. (and they happen to be in my network). They will also provide verification and give you a price of what you actually will pay...before you purchase.

(Also, I don't work for either organizations)

Good Luck, and stay connected with the board... GREAT INFORMATION !!!

Wulfman · Post by **Wulfman** » Wed Jan 03, 2007 5:27 pm

dataq1 wrote:I spoke with my BCBS on the 28th of Dec and was told that cpap.com was out-of-network so my coinsurance would be 30% as compared with 10% for in-network.
If your BCBS includes Cpap.com then another congradulations is due you!

BTW, for those that find themselves with cpap.com being out-of-network, be sure to try cpap.com sister organization billmyinsurance.com. Rumour has it that they share the same inventory, but will do all the insurance billing for you. (and they happen to be in my network). They will also provide verification and give you a price of what you actually will pay...before you purchase.

(Also, I don't work for either organizations)

Good Luck, and stay connected with the board... GREAT INFORMATION !!!

Yes, CPAP.COM would be out-of-network.....but YOU shouldn't be......as a policy holder/group member (by default, you should be considered in-network). What you need to do is ask your insurance provider is if they will reimburse YOU for out-of pocket medical and DME expenses. If they will, then you purchase your equipment and then make out an invoice TO your insurance provider from YOU (as the billing party)......they should then send you a check (assuming your deductible has been met) for the percentage that they will pay for Durable Medical Equipment. If your deductible has not been met, this will apply toward the deductible.

Den

mattman · Post by **mattman** » Wed Jan 03, 2007 6:07 pm

Just remember that when you use billmyinsurance or any other provider to bill to the insurance, the price would jump back up to the $1200 just like a DME.

It's the INSURANCE company that sets those prices, NOT the DME.

Aside from that, it sounds like you have things nicely under control.

mattman

dataq1 · Post by **dataq1** » Wed Jan 03, 2007 7:35 pm

Wulfman wrote: What you need to do is ask your insurance provider is if they will reimburse YOU for out-of pocket medical and DME expenses.

I did ask and the answer was: 'Yes we will reimburse you for out-of-pocket medical and DME expenses. Just provide a sales slip from a network provider and we will process it and your coinsurance will be 10% of the allowance. If the sales slip is from a non-network provider then we will process it and your coinsurance will be 30% of the allowance.' They also pointed out that any DME expenses MUST come from a licensed provider.

I guess that's the way my insurance (Highmark BCBS - in Pennsylvania) deals with it. I don't see any other way to talk them into it, short of getting my employer to take up the cause.

Best to you,

Wulfman · Post by **Wulfman** » Wed Jan 03, 2007 10:40 pm

dataq1 wrote:
Wulfman wrote: What you need to do is ask your insurance provider is if they will reimburse YOU for out-of pocket medical and DME expenses.
I did ask and the answer was: 'Yes we will reimburse you for out-of-pocket medical and DME expenses. Just provide a sales slip from a network provider and we will process it and your coinsurance will be 10% of the allowance. If the sales slip is from a non-network provider then we will process it and your coinsurance will be 30% of the allowance.' They also pointed out that any DME expenses MUST come from a licensed provider.

I guess that's the way my insurance (Highmark BCBS - in Pennsylvania) deals with it. I don't see any other way to talk them into it, short of getting my employer to take up the cause.

Best to you,

That sounds like a bunch of gobbledegook to me. 10%.....30% of the "allowance"? What does THAT mean?

What's their definition of a "licensed provider"? CPAP.COM is actually considered a DME provider.....and they also sell to small "mom & pop" B&M shops.

I would think that if your invoice to them was within the "allowance", they wouldn't have any problem paying you for a significantly less amount then what they're gonna get dinged for, from an "in-network" provider from THEIR list.

Ask them just why in the H*LL they're so intent on wasting your insurance premiums when you are trying to save them many hundreds of dollars. (I'm presuming that you are in a group plan and they deduct premiums from your paycheck)
Keep going up the chain of command in the organization.....? (yours and theirs)

I dunno.......some of those outfits are nuts!

Den

greenham · Post by **greenham** » Thu Jan 04, 2007 7:08 am

Wulfman,

I have been trying to figure out why in my case BCBS is so HELL BENT on overspending vs what I can get the stuff for and ask for a far more reasonable reimbursement.

The machines of insurance are so overcomplicated that none of them have thought through. "What if we actually have an honest and thrifty policy holder" We could save them thousands, and then should be able to enjoy lower premiums and more efficient reimbursement.

Damn, Sorry, let me jump off my soapbox

No deals with the local DME

No deals with the local DME

Re: No deals with the local DME

Wulfman is right

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