CPAPtalk.com

jdm2857 wrote:About the headgear issue: DME bill the mask and the headgear separately, even if they buy
them as one unit. So the mask charge plus the headgear charge should be compared to
cpap.com's single price for the whole shebang.

Thanks for that information. That puts cpap.com in the "clearly cheaper" category.

John

pbriggs wrote:okay, so here is another question along this line...

Can we just purchase from cpap.com and send a copy of the paid bill to the insurance company to be counted towards our deductible? With my high deductible plan typically I don't reach my deductible, but some years I do. So I am thinking to purchase supplies from cpap.com and then send a copy to the insurance company to keep track of to meet my deductible. Assuming of course that the cost at cpap.com is less than the cost from the DME based on the "reasonable" insurance contract price.
Paul

With my insurance, that's exactly what I do.
After the annual deductible is met, they send me a check.
Ask your insurance company what they need in terms of identification of the CPAP supplier. They will have specific needs such as tax number, billing code, address, etc.

As for counting the online price against your deductible; I tried that.
After BCBS "lost" my claim paperwork for about 3 months, they finally applied the expense
--toward my out of network deductible (double the in-network deductible)
Yes, the insurance company promotes the price gouging! Either way, they come out ahead.
Out of network--they are unlikely to pay at all, and in network, there is little doubt the "gravy" is shared.
Hmm, kickbacks, anyone? Oh, excuse me, "commissions", "finders fees", whatever they call their dirty money.

chunkyfrog wrote:As for counting the online price against your deductible; I tried that.
After BCBS "lost" my claim paperwork for about 3 months, they finally applied the expense
--toward my out of network deductible (double the in-network deductible)
Yes, the insurance company promotes the price gouging! Either way, they come out ahead.
Out of network--they are unlikely to pay at all, and in network, there is little doubt the "gravy" is shared.
Hmm, kickbacks, anyone? Oh, excuse me, "commissions", "finders fees", whatever they call their dirty money.

No there is no kickbacks or 'dirty money'. That's just rhetorical nonsense even I wouldn't go to.

It's just a small example of our overall disjointed, poor healthcare system. Some insurers have special contracts with certain vendors -- in exchange for markedly reduced prices on things, they funnel all their business to them. If you are outside the circle, the discounts don't apply, or may go to people with other insurance carriers. And as Americans, we have let this system go on forever.

Too cheap to buy insurance or cant afford it? Well you either pay the full rack rate or ask the vendor for a similar discount, or buy on the secondary market. However in practicality, almost no one pays the full rate. They either don't deal with brick and mortar DMEs or they buy online or from craigslist, etc.

I know for me with my BCBS PPO discounts, one I meet the annual deductible, my preferred provider DME is the cheapest way to go. The discount BCBS shaves off is pretty severe. The DME bills an otherwise shocking amount, but BCBS cuts a large percentage off. I then pay 20% of the discounted rate. So a few months ago I got a bill for a new ResMed cushion, and I think, two filters. (Hard to tell from the bill but I know I got a cushion at minimum). The DME billed $60 and the BCBS discount was -$26.23. My ultimate share was only $6.75. When I first bought my CPAP I asked if I could buy the blower and mask online for less than what the preferred provider DME would charge, and then get my cost reimbursed, but they said no, I would have to use the PPOs DME for the best out of pocket cost to me. My Preferred Provider deductible is somehow lower than if I use non-preferred providers. It all is seemingly backwards, but that's the deal some insurers take -- they get discounts, but they have to refer business to the preferred providers even if slightly more costly up front in some cases. Medicare and the VA are really the only ones that have it right. They are the closest thing we have to a proper single payor system, where, because of such huge volume, the best values are obtained for purchased DME equipment (and everything else). The relatively small private insurers just cant command that kind of buying power.

And its great how frankly confusing and opaque the whole current system is. I cant tell you how many weeks it took me to compare the costs for sleep studies in my area!.....

This depends on your plan. If it is an HMO (which can be part of a high deductible plan), then no. If it is a PPO, you likely can count it but maybe at a different rate. Your best bet is to call the # on the back of your insurance card and ask. Your question would be: if I use and out-of-network provider for my DME, does it count toward my deductible, and at what rate?

A more reliable way to check this with no phone call is to send one receipt (a copy. Keep the original), in to an address you'll find on their website (with a claim form that will require info you can get from cpap.com), and see what you get back. Covered or not, they have to process it. You will get back an EOB-an Explanation of Benefits-that will give you your answer.

Hope that's not confusing. The phone call gets you to Customer Service who reads an interpretation of your benefit. The receipt submission gets you the answer from Claims, which is where the financial transaction actually happens. Jean

Jeannh wrote:This depends on your plan. If it is an HMO (which can be part of a high deductible plan), then no. If it is a PPO, you likely can count it but maybe at a different rate. Your best bet is to call the # on the back of your insurance card and ask. Your question would be: if I use and out-of-network provider for my DME, does it count toward my deductible, and at what rate?

A more reliable way to check this with no phone call is to send one receipt (a copy. Keep the original), in to an address you'll find on their website (with a claim form that will require info you can get from cpap.com), and see what you get back. Covered or not, they have to process it. You will get back an EOB-an Explanation of Benefits-that will give you your answer.

Hope that's not confusing. The phone call gets you to Customer Service who reads an interpretation of your benefit. The receipt submission gets you the answer from Claims, which is where the financial transaction actually happens. Jean

HMOs generally have no deductibles. Are you referring to whether if you buy in cash, online, the insurer will later reimburse you for the item purchased in that way?

HMOs generally have no deductibles. Are you referring to whether if you buy in cash, online, the insurer will later reimburse you for the item purchased in that way?

Here in CA, Kaiser has high deductible and copay plan that are HMOs after the deductible and/or copay is met...

Jeannh wrote:

HMOs generally have no deductibles. Are you referring to whether if you buy in cash, online, the insurer will later reimburse you for the item purchased in that way?

Here in CA, Kaiser has high deductible and copay plan that are HMOs after the deductible and/or copay is met...

That's almost the worst of both worlds -- a highly restrictive HMO network plus a high deductible on top. I hope at least the plan is super super cheap for having to put up with such things. There better be some plus for the consumer. Unless is it a group plan through an employer?

I agree, it almost seems like no insurance at all, or insurance in name only.
It seems like some of the high deductible plans are a bit like the old "major medical" plans they used to offer.
My folks had insurance in the 50's and 60's, that paid for nothing unless you went to the hospital.
Then insurance companies discovered preventive care could save them money.
Lately, regulations have pushed for better preventive care, but cpap lags far, far behind.

JohnO wrote:Wow. I think that'll be the last set of supplies I get from the local DME. Granted, the filters at CPAP.COM are not genuine Philips Respironics, but I've used them, and can't tell them apart. The DME has good and helpful people, but once you've been in this rodeo for a year, the service is unneeded for the price you pay. I don't know what that extra Headgear line item was for. The cynic in me says, "it was for extra DME profit." I imagine some folks have a higher percentage of the item cost covered by insurance, but for me, I think CPAP.COM is the way to go.

John

Code: Select all

Item	             Price (DME)	Ins. Covers	My Share		CPAP.COM
TrueBlue Mask	          $163.00 	 $67.83 	 $95.17 		 $99.00 
Headgear?	               $55.00 	 $22.85 	 $32.15 		 $-   
Tubing	                  $50.00 	 $16.82 	 $33.18 		 $15.99 
Disposable Filters	      $33.00 	 $10.74 	 $22.26 		 $11.95 
Non-Disposable Filters	  $18.00 	  $5.99 	 $12.01 		 $11.95 
Totals	                 $319.00 	$124.23 	$194.77 		$138.89 

Another good reason to ditch the whole prescription thing - it all just plays into the hands of those who bleed the poor OSA sufferers at the bottom of the food chain.

Can we just purchase from cpap.com and send a copy of the paid bill to the insurance company to be counted towards our deductible? With my high deductible plan typically I don't reach my deductible, but some years I do. So I am thinking to purchase supplies from cpap.com and then send a copy to the insurance company to keep track of to meet my deductible. Assuming of course that the cost at cpap.com is less than the cost from the DME based on the "reasonable" insurance contract price.

It depends on the insurer. You'll have to ask.