BCBS Allowable for CPAP

Does anyone know the approximate "reasonable and customary cost" BCBS allows for CPAP machine to a medical equipment provider? My in-network provider won't share the information and BCBS won't share until I make the purchase and it's released on my benefits explanation statement. My dilema is that my in-network provider is quoting approximately $3000 for the same equipment and supplies I can purchase from CPAP.com for $800. On-line, I read that Medicare "reasonable and customary charges" are a pretty good bench mark, however I cannot seem to locate that information on Medicare.gov.

I had BCBS last year when I bought my equipment
Allowables are as follows from the sheet my provider gave me all the cost estimates on it

Autoset $1010
Heated humidifier $275
Clinateline Hose $120
Nasal pillows frame $73
Headgear $33
actual pillows $22

Ihad a $3300 deductible.

Your job is to understand exactly what your insurance will pay and what your out of pocket costs will be to determine if it's "cheaper" for you to buy online rather than have your insurer pay the DME. Never, never, never, never, never, rely on what a DME says the cost or reimbursement is. YOU need to do your research and call your insurer. DME's can't possibly memorize every plan out there, and sometimes they lie anyway. Remember, whatever contracted price Medicare or your insurer sets, the DME cannot charge you more than your deductible and percentage co-pay of that charge.

If you are a "traditional Medicare" (meaning Medicare Part A and B) recipient, Medicare sets the rates by state. That is published information and I can tell you where to find it if you tell me what state you are in. In that case, BCBS is your Medicare Supplement policy (sometimes called MediGap) and it depends on the plan you have with them how much of the deductible and 20% co-pay they will cover. Plans in different states are different, so asking what "BCBS will pay" may get you a dozen different answers. You need to know your plan in your region. Call them and ASK. Don't ask your DME, they either lie or don't know.

If you are Medicare Part C (also known as Medicare Advantage) that is an entirely different kettle of fish. In that case you MUST call BCBS and ASK what they will cover and how much they will cover.

If you have no Medicare, but only BCBS, it's anybody's guess because BCBS has many plans. Again, you must call BCBS and ask specifically what they pay for under your plan, and what your out of pocket costs will be.

Your DME may charge $3000, but that's really a fictional number. Medicare will pay what it pays every other provider in your state (and doesn't purchase machines, BTW, it is a capped rental with a monthly co-pay for 13 months) and private insurers pay according to contracts with the DME's. Nobody but a poor and unsuspecting uninsured schmuck will pay the full $3000.

I haven't dealt with DMEs choosing instead to go the very low-end route (Craigslist). But don't they charge a higher price in part because they provide additional services such as replacing masks that don't fit, reviewing the data collected by the machine, etc.? Or are those services charges on top of the equipment price?

But don't they charge a higher price in part because they provide additional services such as replacing masks that don't fit, reviewing the data collected by the machine, etc.? Or are those services charges on top of the equipment price?

You are correct, they are SUPPOSED to include those services, and that's why their reimbursement rates are higher. Some good DMEs even actually do what they are supposed to. Others do nothing, beyond collecting the first 30 days compliance data, simply so they can get paid.

I don't begrudge a DME getting a higher reimbursement than an online supplier charges IF they are doing a good job helping a patient find the ideal mask, checking efficacy and helping the patient adjust to the treatment. But the billed amounts (as opposed to the allowable charges) are way out of line.