dme provider prices?

mattman wrote:Check out some of my other posts for an explanation of how this breaks down. Basically, the insurance companies dicatate exactly how, what and how much the DME company will bill. They have little to no control over the process.

Also check and see exactly what was paid. What you see billed is usually (but not always) going to be what's called a 'Submitted' amount. The ins company will then reimburse usually between 40% and 60% of that amount.

It is still and will always be far, far more than what you can pay cash online though. It's often not quite as big a difference when you look at the actual allowed amount though.

Thanks, mattman. I will read some of your other posts. Many years ago I did billing for doctors, so I do have some basic knowledge of how things work. I realize that there are individual billing codes for each item (CPAP, humidifier, mask, headgear, filters, hose, etc.) and that the amount "allowed" is not always the same as the amount "billed".

I haven't received a copy of the statement from my insurance company showing what they paid the DME yet, as I just got the equipment last week. That'll be interesting. I am paying 20% of the submitted amount, and if there IS a big difference between the submitted amount and what the insurance actually "allows" the DME then I may decide to have a little talk with them.

I do feel very fortunate that, so far anyway, I am happy with my DME/sleep doctor/lab (one and the same). You DO have to educate yourself beforehand, however. If I hadn't known better, then for sure I would've ended up with a ResMed Escape and H3i humidifier. Not that those are bad machines therapy-wise, but I definitely want to keep track of my own treatment so I insisted on a machine with full data capability. I told them what I wanted and got the S8 Elite II without any problem. It works well for me. I'm happy, and the doctor will be pleased that I'm 100% compliant -- win/win.

~ DreamOn

Mattman wrote

Also check and see exactly what was paid. What you see billed is usually (but not always) going to be what's called a 'Submitted' amount. The ins company will then reimburse usually between 40% and 60% of that amount.

Please note that your copay (the amount you pay with real dollars) is based on the "Submitted" amount. The insurance company, per its contract with the DME, gets a break - Mattman says it is typically 40% - 60% in savings to the Insurance Company - and you get stuck with paying your full copay amount.

Consider the following example (a real example since I was the stuckee). My Insurance/DME acquired APAP (I bought an equivalent backup machine online the same week for $526) had a submitted cost of $1180 (# on my copay invoice) of which my 20% copay was $236 (in real $$$s out of my pocket). I estimated (after some research and a phone call to a person-in-the-know) that my DME ("A") was getting about $280 less my copay amount from the Insurance Company ($900 savings or > 75%) .

The math for my example produces the following $$$ amounts:

DME Submitted: $1180
DME Received (My Copay + Insurance): $280
I paid (20% copay): $236
Amount the Insurance Company really paid: $280 - $236 or $44 (Note that the stuckee, me, paid $236 since my 20% copay was calculated from the "submitted amount").

YMMV re the actual amounts / percentages based on your DME's contract with your Insurance Company. However, please note that you will be paying the lion's share of the final "adjusted" cost for your Insurance/DME provided machine.

cinco777 wrote:Mattman wrote

Also check and see exactly what was paid. What you see billed is usually (but not always) going to be what's called a 'Submitted' amount. The ins company will then reimburse usually between 40% and 60% of that amount.

Please note that your copay (the amount you pay with real dollars) is based on the "Submitted" amount. The insurance company, per its contract with the DME, gets a break - Mattman says it is typically 40% - 60% in savings to the Insurance Company - and you get stuck with paying your full copay amount.

Consider the following example (a real example since I was the stuckee). My Insurance/DME acquired APAP (I bought an equivalent backup machine online the same week for $526) had a submitted cost of $1180 (# on my copay invoice) of which my 20% copay was $236 (in real $$$s out of my pocket). I estimated (after some research and a phone call to a person-in-the-know) that my DME ("A") was getting about $280 less my copay amount from the Insurance Company ($900 savings or > 75%) .

The math for my example produces the following $$$ amounts:

DME Submitted: $1180
DME Received (My Copay + Insurance): $280
I paid (20% copay): $236
Amount the Insurance Company really paid: $280 - $236 or $44 (Note that the stuckee, me, paid $236 since my 20% copay was calculated from the "submitted amount").

YMMV re the actual amounts / percentages based on your DME's contract with your Insurance Company. However, please note that you will be paying the lion's share of the final "adjusted" cost for your Insurance/DME provided machine.

Sucks doesn't it? What's even worse is that the insurance companies won't allow the DME company to charge cash sale patients a lower amount either. It's insane.

I always hated that whole "submitted/allowed" amounts business. I fully agree that a company that submits bills to insurance companies should get paid more than what's charged to someone paying cash simply because the hurdles and barriers insurance companies install in the process are amazingly obnoxious. I think it's horrible though that they have the power to dictate not only how a provider bills them but then also how a provider handles a customer who pays cash and doesn't involve insurance at all.

There's not a small amount of jealousy over online providers such as this one being able to have one inventory but multiple business (One for cash sale, one [or more] for private insurance, one for Medicare, etc) setup to sidestep those hurdles where traditional brick and mortar providers aren't allowed to do so. It definately makes for an uneven playing field but that is the nature of the internet.

What puzzles me (putting it mildly) from reading the posts on the forum is that apparently neither the insurance provider or the DME will tell the patient (beforehand) what is going to be charged or paid.......like it's some big friggin' secret.

On the other hand, when I was shopping around with a couple of the local DMEs back in 2005, they DID tell me what the prices of things were going to be. One of the locals told me that I could have ANY CPAP I wanted for somewhere between $1300 - $1400. That was just the machine and didn't include anything else and I have no idea if that's what they would have submitted to my insurance or what my insurance would have paid, had I gone that route.......but at least they told me. One told me that a UMFF mask would be $255......PLUS they wanted another $60 for the headgear......and $60 for a hose. The UMFF at that time was about $139 from CPAP.COM......and that included the headgear.
It didn't take me long to figure out where I was gonna buy MY stuff.


Den

Wulfman wrote:What puzzles me (putting it mildly) from reading the posts on the forum is that apparently neither the insurance provider or the DME will tell the patient (beforehand) what is going to be charged or paid.......like it's some big friggin' secret.

On the other hand, when I was shopping around with a couple of the local DMEs back in 2005, they DID tell me what the prices of things were going to be. One of the locals told me that I could have ANY CPAP I wanted for somewhere between $1300 - $1400. That was just the machine and didn't include anything else and I have no idea if that's what they would have submitted to my insurance or what my insurance would have paid, had I gone that route.......but at least they told me. One told me that a UMFF mask would be $255......PLUS they wanted another $60 for the headgear......and $60 for a hose. The UMFF at that time was about $139 from CPAP.COM......and that included the headgear.
It didn't take me long to figure out where I was gonna buy MY stuff.


Den

Of course, it's hard for me sitting here to say for sure so all I can really do is relate my own experience.

What I can tell you is that if I were to get a phone call from someone who said "I have BCBS of Maryland and I have a prescription for a CPAP. What's my cost" I wouldn't be able to answer. There are far too many variables. What specific plan of BCBS? Do you have DME coverage (Not all do). Have you met your deductible? Do you even have one? What's your diagnosis (Not just sleep apnea, what does it specifically say on your prescription) What's your out-of-pocket expense? What exactly is your prescription for? (Patients will often call an item one thing when the prescription is actually for something entirely different - ie say they have an order for a CPAP when it's really for a BiPap). Do you qualify for insurance to even pay for it? There area a million questions that insurance makes a provider answer before they will even tell you what their plan pays.

Then you toss in the problem of if I quote a number and their actual amount comes in higher for ANY reason I get utterly blasted and threatened with legal action and calls to any number of local, state and federal agencies. Trust me when I say I'm speaking from experience. I distinctly remember a specific case where someone would not let me off the phone until I gave them an average cost for a nebulizer for a Medicare patient. I begged this guy to let me speak with his doctor before giving him any price estimates. Well come to find out when he got to our store what their doctor was actually ordering a tracheostomy humidifier - a totally different type of machine with hugely different costs. When I tried to explain that this was not what he asked about over the phone he got very irate, started telling me I was a thief and a con artist who was trying to take advantage of Medicare. He then managed to get in touch with the regions Ombudsman and even better - called the paper in the area and we actually had to go through all kinds of crap to deal with it.

Granted that was about the worst case but there were many other similar though less hairy situations. So yeah, I know I was very leery about quoting prices simply due to the amount of variables when dealing with insurance companies and doctors who all have different ideas about who should get what and how.

Which again I just come back to - it sucks doesn't it?

mattman wrote

What I can tell you is that if I were to get a phone call from someone who said "I have BCBS of Maryland and I have a prescription for a CPAP. What's my cost" I wouldn't be able to answer. There are far too many variables. What specific plan of BCBS? Do you have DME coverage (Not all do). Have you met your deductible? Do you even have one? What's your diagnosis (Not just sleep apnea, what does it specifically say on your prescription) What's your out-of-pocket expense? What exactly is your prescription for? (Patients will often call an item one thing when the prescription is actually for something entirely different - ie say they have an order for a CPAP when it's really for a BiPap). Do you qualify for insurance to even pay for it? There area a million questions that insurance makes a provider answer before they will even tell you what their plan pays.

Thanks for sharing your experiences as a DME employee. When you honestly express your DME related experiences as you did in your recent posting, I can put myself in your shoes for a moment and feel your frustration and understand your "damned if I do and damned if I don't" predicament. I hope your new days are less stressful than your old days.

I want our Congress to ignore the lobbyists' lies and payoffs and pass a meaningful Health Insurance reform bill (I support a Public Option) so we can start to fix our broken and frustrating health care system.

cinco777 wrote:Thanks for sharing your experiences as a DME employee. When you honestly express your DME related experiences as you did in your recent posting, I can put myself in your shoes for a moment and feel your frustration and understand your "damned if I do and damned if I don't" predicament. I hope your new days are less stressful than your old days.

I've always thought Matt's a "good'un."
Back in 2007...

I wrote:And would that everyone could have the support of a caring DME employee like some of the ones we see here -- BrianRT, KansasRT, matt, fidget; and several who posted in the past like -- IllinoisRRT and MelMel / MelMel1, and JeffroDoe.

viewtopic.php?p=154606#p154606

(akcpapguy, you're definitely a good'un, too!)

I'd say Matt's extremely good in his DME job. He's patient, seems good with people, likes interacting respectfully with other cpap "users" here, likes to learn, good sense of humor.

mattman wrote: There's not a small amount of jealousy over online providers such as this one being able to have one inventory but multiple business (One for cash sale, one [or more] for private insurance, one for Medicare, etc) setup to sidestep those hurdles where traditional brick and mortar providers aren't allowed to do so. It definately makes for an uneven playing field but that is the nature of the internet.

Is that the real reason you come here to start troubles? Jealousy? Really??

mattman wrote:Check out some of my other posts for an explanation of how this breaks down. Basically, the insurance companies dicatate exactly how, what and how much the DME company will bill. They have little to no control over the process.

I find this hard to believe. Really!! Charge us more than it could ever be worth?

I love it when the DME blames the insurance companies for their low level of reimbursement, and the insurance companies blame the DME for over-billing. KInd of shows the state of our healthcare situation. Too much control by non-medical individuals, who are in a profit-making capacity. I am willing to grant that there may be some "good guy" DME out there, who really cares about his/her patients. However, the financial motivation is far too great for most of them to provide consistent, caring service to patients (which should be their first responsibility). As regards insurance companies, the figure 438% in a decade is the rule of law.

mattman wrote:
Check out some of my other posts for an explanation of how this breaks down. Basically, the insurance companies dicatate exactly how, what and how much the DME company will bill. They have little to no control over the process.

Really wrote
I find this hard to believe. Really!! Charge us more than it could ever be worth?

Check out one of my earlier postings to this thread where I showed the math for my Insurance/DME purchased APAP unit.

The Insurance Company does receive a $$$ benefit from the DME charging outrageous/insane prices in that our real $$$ copays are based on the DME "submitted price" not on the Insurance "allowed" price. As a result, we, the insured, pay the lion's share of the "allowed" price as the Insurance Company only pays the DME the "allowed" price minus our copay $$$.

cinco777 wrote:

mattman wrote:
Check out some of my other posts for an explanation of how this breaks down. Basically, the insurance companies dicatate exactly how, what and how much the DME company will bill. They have little to no control over the process.

Really wrote
I find this hard to believe. Really!! Charge us more than it could ever be worth?

Check out one of my earlier postings to this thread where I showed the math for my Insurance/DME purchased APAP unit.

The Insurance Company does receive a $$$ benefit from the DME charging outrageous/insane prices in that our real $$$ copays are based on the DME "submitted price" not on the Insurance "allowed" price. As a result, we, the insured, pay the lion's share of the "allowed" price as the Insurance Company only pays the DME the "allowed" price minus our copay $$$.

Which is why I've said the insurance companies have completely screwed up the system

Which is why I've said the insurance companies have completely screwed up the system

So, if that is the case, are you out there fighting for a public option in national heath care, or are you believing the negatives?

mattman wrote

Which is why I've said the insurance companies have completely screwed up the system

Based on my own experiences and research, I believe that the DMEs, Insurance Companies, XPAP manufacturers, and all their paid lobbyists have corrupted the system (and in the order listed). I support the Public Option. I am on Medicare and would love to have my wife, children (adults), and friends have access to a Public Option. Without a Public Option, we are all screwed.

Well gang I hope to get a great nights sleep tonight. I picked up my new machine today and a new mask. This DME which I found through the FP salesman, these people are the best DME people I have ever meet at one of these providers. They were fabulous to me when I was with them today. The salesman called them yesterday and it was not 5 minutes they were on the phone calling me. Talk about service. I went to there location today and got mcahine and supplies. did not have to order anything, got the machine i wanted no questions asked, it was like they were bending over backwards to get my business. I was told that what ever my insurance pays is what they will except, they will not bill me for one penny more that insurance pays. This is a small co only been around for 2 years and they are trying to build the business. If they provide service to everyone like they did me today. They should have a good reputation going for themselfs. I just hope they do not get to big.