Insurance vs self pay

Hello all. Curious how to figure out when it’s better to go the cash route or the insurance route when getting a new machine. The hubby has a DreamStation 1 from 5 years ago, and this recall replacement is awful random. When I called our insurance and asked about doing self-pay with reimbursement, I was told “no chance” (even though that’s what we did back then). Instead, I was told we must get a prior authorization and then rent for so many months from an approved dme provider, with a monthly payment. Well…this sounds like a lot of hoops and I’m not sure how much we’d save. Our obstacles are that we don’t have a regular Cpap doctor and not very patient to wait for the 40-60 day delay from the approved provider list.

Consider you might be able to find a gently used machine (they are out there because so many people fail) and one of our members sells on Craigslist for very decent prices. Or even buying a new machine on Cpap.com--what will all this cost?

Do the math first--actual out of pocket expenses. Don't forget to include:
Co-pay to see the doctor to get the script
Sleep study if required (deductibles and co-payments?)
Deductible for DME (if you have 13 months of "rent to own" you will have TWO deductibles)
Co-payments for rentals.

Add in the aggravation factor. Then decide.

You can STILL get supplies from your DME even if you buy your own machine, if it's worth it for the insurance hassle. When I had DME coverage it cost me $8 and a bunch of headaches for 6 filters. On Amazon I bought 54 for about that price and NO hassle.

If all you need is the machine I can't for me imagine going the insurance route again. I did buy a new machine for my recall replacement because I could and it was on sale (day one of the recall, they had not elevated the prices yet). Had I less disposable income I would have seriously considered a very lightly used Resmed at a bargain price. Totally worth it IMO if for no other reason than not having to deal with insurance bureaucracy, and the gotcha bills that may follow when you miss a hoop. And the the dollar for dollar difference does not factor in the hassle of time and effort to get all the ducks on a row for eventual *potential* reimbursement.

1sleepyhubby wrote: ↑

Tue Oct 05, 2021 1:50 pm

Hello all.

if you decide to go out of pocket, forum member lsat often has gently used machines for sale. you may want to send him a private message to see if he has anything currently.

eta: speaking of, here he is with some machines for sale-

https://www.cpaptalk.com/viewtopic/t183 ... ead#unread

you're not likely to do better than that.

Talk to the approved DME. I believe most of the hoop jumping will be at their end, and they've had practice doing it.

stevenal wrote: ↑

Wed Oct 06, 2021 12:07 pm

Talk to the approved DME. I believe most of the hoop jumping will be at their end, and they've had practice doing it.

Unfortunately the dme company insurance recommended won’t give me any idea of what a monthly rental runs, or what the price they’ll charge to the insurance company so I could at least do back of the envelope math.

1sleepyhubby wrote: ↑

Wed Oct 06, 2021 6:01 pm

stevenal wrote: ↑

Wed Oct 06, 2021 12:07 pm

Talk to the approved DME. I believe most of the hoop jumping will be at their end, and they've had practice doing it.

Unfortunately the dme company insurance recommended won’t give me any idea of what a monthly rental runs, or what the price they’ll charge to the insurance company so I could at least do back of the envelope math.

Start with your insurance. They will know exactly how much is allowed no matter what the DME bills.

While you are at it find out if any other DME's are in network for you.

Ask here for experience with the DMEs esp. the one you are now dealing with.

If you are anywhere near Medicare age, and expect to use it,
DIY is not likely to be any help when you hop over that line.
Medicare is extremely anal.

I have no problem w/Medicare.

IMO its the Medicare *Advantage* plans where you run into trouble. They are HMOs, only certain docs have conceded to accept their lower rates and you need approval for almost everything.

IMO you are much better off with good 'ol Medicare and then picking up a Medicare co-pay - this way you will know what your medical expenses are for the entire year. The co-pay will automatically pickup any co-pays that Medicare has paid for.

The only hospital in America that I know does NOT accept Medicare is the VA Hospital - too bad, soo sad.

I recently decided to go the self-pay route, after being frustrated by the compliance hassles for even basic supplies, and realizing out-of-pocket costs were comparable.

I had previously bought very lightly used main machine and backup.

When it comes to insurance and DMEs there are billed amounts for services/products and there are approved amounts that the insurance company says the DME has to be happy with getting and those amounts can be widely apart but the only amount you have to worry about is the approved amount.
The billed amount (or what I call the pie in the sky amount) is often quite high...no real restrictions on billed amount but the approved amount will usually get greatly reduced. DMEs have to write off the difference between billed amounts and actual allowable amounts when they are an in network provider for any insurance company.

Everything you might owe as part of your responsibility is based off the approved amount and your insurance plan.

What insurance will pay is known to both the DME and insurance companies but not always to the person you might be talking to or maybe the person simply doesn't want to do the work to figure it out.

Insurance companies pay by HCPCS billing codes for a particular product. They DON'T pay by brand or model of anything.
If you call up your insurance company and ask what it allows for a cpap/apap machine of so and so brand or model they won't have that in the fee schedule but ask about E0601 HCPCS billing code (which is cpap/apap machine) they will have that amount available to someone....probably not the someone in customer service you first get when you call them.
Same thing with the DME....someone there in the billing department knows what they normally bill out and will expect to be "allowed" and what your portion might be. The RT doing the fitting or the person working the desk is unlikely to know these amounts...not part of their job description to know.

I would run..not walk...away from any DME who couldn't/wouldn't give me clear cut numbers as to what I would be expected to pay. Those numbers are available. They ask you to sign a legal document accepting the machine and financial responsibility for it and it's open ended with no amounts????? Come on now...would you buy anything not knowing how much you are going to be writing a check for????

Your insurance company knows these allowed amounts as well and they know your portion depending on your plan but you likely will need to go higher up the pay chain to find someone with access to those numbers than the lowly customer service rep you get first when you call.

Like I have said before, insurance phone operators are like nesting dolls.
Only the last one is solid--the rest are hollow.

I respectuflly beg to differ with Pugsy on one point. DME's usually know what the Medicare allowable amount is on any particular HCPCs code because a large portion of their CPAP customers are on Medicare. But there can be literally hundreds of insurers out there, and each insurer may have many levels of plans, each with their own deductibles and copays. Not all insurers have a contracted rate with a particular DME and if not contracted with that DME the insurers have their own reimbursement schedules for DME. DME providers, even their billing departments, may truly not know what your insurer is going to pay and what portion is your responsibility, until they have submitted a bill.

It is the insurer's responsibility to tell you about the costs, and beginning next year, it will be the LAW: https://www.kff.org/private-insurance/f ... t-in-2022/

Health plans must provide an advanced explanation of benefits. Also beginning in 2022, consumers can request advance information about how services will be covered before they are provided. For scheduled services, consumers can submit requests and, generally within three business days, the health plan must provide written information including about whether the provider/facility participates in-network, and a good faith estimate of what the plan will pay and what patient cost liability may be.

Janknitz wrote: ↑

Thu Oct 07, 2021 6:52 pm

Not all insurers have a contracted rate with a particular DME

True but one would think that if the insurance company recommended a particular DME then they would have a working contract with that DME....usually they recommend DMEs that are in network.

And even if they didn't...all it takes is a simple phone call which apparently the DME (that the insurance company recommended) was unwilling to do.

1sleepyhubby wrote: ↑

Wed Oct 06, 2021 6:01 pm

Unfortunately the dme company insurance recommended won’t give me any idea of what a monthly rental runs,

Pugsy wrote: ↑

Thu Oct 07, 2021 7:56 pm

Janknitz wrote: ↑

Thu Oct 07, 2021 6:52 pm

Not all insurers have a contracted rate with a particular DME

True but one would think that if the insurance company recommended a particular DME then they would have a working contract with that DME....usually they recommend DMEs that are in network.

And even if they didn't...all it takes is a simple phone call which apparently the DME (that the insurance company recommended) was unwilling to do.

1sleepyhubby wrote: ↑

Wed Oct 06, 2021 6:01 pm

Unfortunately the dme company insurance recommended won’t give me any idea of what a monthly rental runs,

I still think it may depend on what plan you are on with a particular insurer. For example, on Covered California plans there are three levels with each insurer--Gold, Silver, and Bronze. The DME won't necessarily know if you have a deductible, what the deductible is, how much of the deductible you have met, and what level you are on a particular plan which dictates what the reimbursement is (which can be all, some or none). And, DME's lie like snakes anyway. So I would never, EVER, trust a DME who tells me what the out of pocket cost is going to be, if they ever would. ALWAYS check with your insurer.