Insurance billing questions

I wish my billl was only $24 a month. One of the ladies I work with asked me today if I had gotten my bill from the DME and I said yes. Her bill was $100 less than mine. I'm going to investigate this Monday. Something's not right here.

I work in the billing department for a DME company and I can tell you guys this, we are obligated to separate the items that we bill for the headgear, mask cushions, water chamber, etc. this is so every item is billed individually and processed by your insurance provider.

The total charges that some of you are seeing on your itemized receipts are typically the charge amounts that are submitted to your insurance company. Most DME companies have a cash pay price for individuals that do not want to go through their insurance if they have a high deductible or poor coverage and benefits. The charge amounts are inflated so that the insurance company will actually pay the cost of the machine.

If your DME provider is in network with your plan, there are contracted amounts that the DME provider and your insurance have in place, for example, lets says I have billed out a CPAP machine to BCBS who we are in network with and our contracted amount that the insurance pays for said equipment is $1,150.00. That means that that is the max amount the patient can be charged if they have not met their deductible or Out of Pocket is $1150.00. If your provider is Out of Network, they can bill the insurance and charge you for the remainder if your insurance so determines that. I always recommend looking over your explanation of benefits that your insurance company send you for that service/claim and paying attention to what your insurance deems is your deductible/copay or what is your coinsurance (they are different patient responsibilities).

As someone had mentioned earlier, there are what are known as "billable time limits" for DME supplies, like 2 cushions per month or one heated tubing per 3 months, etc. These time limits vary from payer to payer, so knowing what your insurance covers and how frequently is important so that your claims don't get denied and you end up stuck with the bill. If you ever call your insurance company with questions regarding your coverage and benefits or claims, ALWAYS get the customer service reps first name and first initial of last name and a call reference number, this protects you if they give you misinformation.

Remember that when choosing a DME provider, it is always advisable to go in network if possible and that you are responsible for the portion that your insurance company deems is your Copay/Deductible or your Coinsurance.

To further clarify these patient responsibilities, your copay/deductible is the set amount you have to meet before your insurance will cover their part, for example your deductible is $1500.00, once you meet that your responsibility is 20% and your insurance covers 80%, the 20% that you are responsible for is your COINSURANCE. There is also the matter of Out of Pocket amounts to be met as well. Most of the time, once you have met you deductible and OOP, your insurance covers items at 100%

I hope this information is helpful!

Also, I forgot to add some more info.

Your insurance provider is the one who determines if your equipment must be billed as a rental or a purchase NOT the DME company. Everyone's plan is different.

For those of you with concerns about the "exceeded amount" the insurance company has whats called an "allowable amount" which is the set amount they will pay for the equipment and they "adjust" off the remainder. Some insurance plans hold the patient responsible for the adjusted amount as well, but this is almost always in an Out of Network scenario.

I will put an example below of what I see on an explanation of benefits:

John Smith Code: E0601 Billed amount: $6000 Allowed amount: $648.00 Adjusted amount: $5352.00 Copay/Deductible: $500 Coinsurance: $29.60 Paid to provider: $118.40

In this example, I have broken it down to show you how the insurance processes the claim according to your coverage and benefits. For John Smith, he had a PPO plan and used an in network provider. His deductible was $500 and his plan paid at 80%/20%. So after his $500 deductible was applied to the $648.00 allowed amount, the remaining $148 was split between the patient 20% responsibility and the insurance paid the remainder tot he provider.

I hope this helps making your explanation off benefits easier to navigate!

For the 1st year I was diagnosed, I got supplies from a local NYC DME. They were nice enough, but they billed my insurance (BC/BS) almost 3X what I could buy on-line. So my co-pay (15%) was pretty high - about $100 for a mask, pillows, hose & filters every 3 months. Some on-line suppliers would bill insurance but would charge you an un-reimbursable insurance billing charge of $99. No advantage there. Then I found easy breathe. I uploaded my prescription and they verified my insurance and now I just go online and chat with their representative about what I need every 3 months. And best of all no upcharges. Now I pay about $35 for the same. A 66% savings on co-pay. I'm getting nothing for this endorsement. I'm just wanting to help those of you who may be new to the CPAP game and wondering about it. You Physician should write your prescription in such a way that the CPAP and Mask are patient preference. If they are decent they will do that. And don't forget to indicate it is a lifelong condition so supplies for 99 years, That should do it. I also would not be afraid of buying a cpap device on line. They are pretty simple devices and most have ample warranty. Hope this helps someone.

Pooh1952 wrote:For the 1st year I was diagnosed, ... Hope this helps someone.

spaaaaaaam.

So, Zoocrew,
I see you started this thread in 2012. How'd it work out for you?

Jay Aitchsee wrote:So, Zoocrew,
I see you started this thread in 2012. How'd it work out for you?

I think I ended up paying about $500 for the initial machine, mask,, hose. I also changed DMEs about 6 weeks in as they lied to me when I tried to order smaller head gear. They were lousy and typical in their overcharging.