Post
by Guest » Sat Aug 11, 2007 7:00 am
Here is what I learned when I started using xPAP a couple years back.
My Sleep Doc and Lab did a good job, no complaints against either. Doc was willing to give me a Rx for APAP even though he didn't think I needed it.
Doc was going to supply me with a "loaner" (read "rental") machine at first to make sure I was able to tolerate treatment, then if that went well he would supply the basic Remstar "tank" machine, mask, case, hose, etc. and bill my insurance directly, I just had to pay my 20%. All sounded very reasonable and convenient. The assitant spent about 15 minutes with me figuing out mask size and showing me how to use the machine.
After 1 week, all was good and I wanted my own machine. Here is what it was going to cost me:
A)1 Week cpap rental- $200, insurance allowed $150, $50 write-off, my share $30
B)Mask- $150, insurance allow $125, $25 w/o, my share $25
C)Headgear- $75, insurance allow $50, $25 w/o, my share $10
D)Swivel connector- $50, insurance allow $35, $15 w/o, my share $7
E)Hose- $50, insurance allow $25, $25 w/o, my share $5
F)Respironcs Remstar CPAP machine- $1040, insurance allow $900, $140 w/o, my share $180
G)Carry case for CPAP-$50, insurance allow $50, my share $10
H)Heated humidifier-$365, insurance allow $365, my share $73
So for mask and machine, I was looking at $310 out of pocket, plus another $30 for the rental week. Insurance was contributing $1360, for a total to the Dr. of $1700.
What a bargain, huh!
Before commiting, I did a little research on the internet and made several calls to a not terribly helpful insurance person. It was like pulling teeth, but I learned a little bit about the way insurance works for DME.
First thing first, everything has a "billing code" and for every "billing code" there is an "allowable amount" that varies with your geographic location (or the providers location actually).
Coincidentally, there are billing codes for:
CPAP Rental
CPAP Mask
CPAP Mask headgear
CPAP Mask Swivel connection
CPAP Tubing
CPAP Machine
CPAP Heated Humidifier
CPAP Machine carry case
Now, make/model makes NO differnence for billing code or allowable amount. Whether you get a Blows-at-night model 1 el'cheapo, or a Super-deluxe twilight dream-maker supreme, the billing code is E0601 and it has a maximum allowable amount that has nothing to do with the actual unit purchased.
So the Dr, who knows exactly what insurance allows, bills the max (or more) regardless of what his cost was for the machine.
Next, guess what ... EVERY xPAP machine sold in this country (or at least everyone sold by cpap.com) comes from the manufacturer sealed in a box with a hose and a carry case included. The one your Dr buys came with hose and case to, he/she is just billing those items seperately because there are billing codes for them and it is a way to get more money.
Same with the mask. Most masks come complete with mask, swivel, and headgear. Dr. splits it out though. So after spending considerable effort to learn the "system" I decided to do this...
Buy a Remstar Auto w/C-Flex and Heated Humidifier from cpap.com - $760
Buy a Mask with swivel and headgear from cpap.com - $100
Buy Encore Pro Software and reader from cpap.com - $125
My out of pocket cost was $985 since cpap.com doesn't bill insurance. After getting my goodies, I went through a fast and painless re-imbursement process with my insurance (Aetna) and got a check for $788, bottom line my cost was $197, a savings of $113 to me and a savings of $572 for my insurance (they didn't even thank me!).
On top of that, I got the top end (at the time) APAP machine with data recording instead of the basic CPAP with compliance info. I also got the Software to monitor and provide feedback on my therapy.
It has been quite an education. Was my Dr. going to "Rip me off", no. He is in busines to make money. He has overhead, and everything he was doing was legitimate and legal. Taking advantage of a system isn't necessarily "wrong" or "unethical". That said, the Dr. was going to collect $1700 for equipment he probably was paying no more than $700 for, about $1000 profit. I know, his time etc was spent and he should be compensated. He was- I and my insurance paid for the office visits, the sleep tests, the follow up. I personally think $1000 is a little much for the service of having equipment drop shipped to his office. As far as "24 hour service and support" that was never offered and I doubt few hoseheads can call their RT in the middle of the night if the box stops blowing. Was it the best thing for me? no.
Knowledge is power. Take control of your therapy, look at your options, listen to the advice of the professionals, but make your own decisions and then take responsibility for them.