New CPAP - Being ripped off on my machine?

Hi All,

So 2 months ago I was diagnosed with mild sleep apnea. I then did a one month trial with a machine, which has been absolute hell. I'm still not even convinced it is helping any, and if it is, its only minor.

Now today I got the letter from my insurance company, detailing the estimate submitted by the sleep doc. I was floored. They submitted an estimate for roughly $2,700 for a machine that I can order online for $1,000.

I called them on the phone and they claim the difference in price is because the price submitted to the insurance company includes their cost for ongoing service and care. $1,700 sounds like a crap load of ongoing service and care, but even worse than that is my insurance company says the "standards" are for a maximum of $2,00 for a machine, and that is all they cover. Which means I will be out of pocket a lot of money if I go through with this.

Anyway the reason i'm posting this is to get some advice from others who have been through this.

1) If i'm not even sure the machine helps, or if it does its only minor, is it worth doing? I still wake up a half dozen times a night, and falling asleep initially with the mask on is near impossible.
2) Is this "normal" to be charged so much more than the cost of the machine itself, or am I being scammed?

Prices vary immensely, which you already know.
What they don't tell you is the insurance company negotiates a price below the asking price.
Talk to insurance, and find out what your deductible and copay are.
Also, who is in network for your insurance.
---There are ways . . .

I'm not sure what you mean by the Insurance company negotiates a price below asking price?

I've already spoken with my insurance, and they will reimburse me for 80% of the expense, with a somewhat unclear note that says "Payment will be limited to the reasonable and customary amount of $2000 for cpap unit, supplies approved @80% coinsurance". I originally read that to mean they will reimburse me for 80% on up to $2,0000 of a machine, but I guess it could mean they will reimburse me up to $2,000. Its a bit unclear I guess, but i'm fairly certain it is the former; they will reimburse me 80% on a machine that costs less than $2,000 and anything above that would be on me.

Prices vary is an understatement lol. That said, they've treated me well during the last month of trial, so I don't want to just walk away from them if what they are offering is reasonable, but it just seems like it is not.

Call your Ins. Co and/or go on their website and get a list of approved DME(Durable Medical Equipment) providers from them.

Then call around and have them all quote you on the same equipment. Make sure that they still accept your insurance.

Pick the one with the best deal, or even talk them into a $2,000 quote to earn your business.

No one says you have to use the first DME (Durable Medical Equipment) provider that quoted you $2,700.

I never heard of a charge upfront for ongoing care. That's BS. Dump that doctor/DME and take your prescription to someone else.

Agathorn wrote:I'm not sure what you mean by the Insurance company negotiates a price below asking price?

I've already spoken with my insurance, and they will reimburse me for 80% of the expense, with a somewhat unclear note that says "Payment will be limited to the reasonable and customary amount of $2000 for cpap unit, supplies approved @80% coinsurance". I originally read that to mean they will reimburse me for 80% on up to $2,0000 of a machine, but I guess it could mean they will reimburse me up to $2,000. Its a bit unclear I guess, but i'm fairly certain it is the former; they will reimburse me 80% on a machine that costs less than $2,000 and anything above that would be on me.

Prices vary is an understatement lol. That said, they've treated me well during the last month of trial, so I don't want to just walk away from them if what they are offering is reasonable, but it just seems like it is not.

Forget the 80%. The important thing to you is you will have to pay 20% of the price the insurance company negotiated with the DME (plus any deductibles). Have another discussion with the insurance company with this in mind. Find out their negotiated price and your deductibles.

1) If i'm not even sure the machine helps, or if it does its only minor, is it worth doing? I still wake up a half dozen times a night, and falling asleep initially with the mask on is near impossible.

You need some help to get the CPAP process working correctly. Register, fill out your equipment profile and start a new post dealing with this and do not include your insurance issues in the new post.

LSAT wrote:I never heard of a charge upfront for ongoing care. That's BS. Dump that doctor/DME and take your prescription to someone else.

Keep calm LSAT.

It is unlikely that there is a "charge upfront for ongoing care". They probably just told him they have to charge more than an internet supplier because they have a B&M operation including staff to assist in person with customers. Most B&M suppliers will tell you that. And it is true that their operating costs are higher.

This racket, and I use the term racket not to disparage the efficacy of treatment but rather the business end of things with manufacturers and DMEs, must just be an unholy dollar producing process. Throw insurance companies and medicare into the mix, and I'm sure the DMEs just slobber over the gravy. My DME (which I consider to be better than most by far) charges me and my insurance company $72.00 for a replacement seal for my Quattro Air. It costs $54.00 total on a straight purchase from our kind hosts.

Pardon the crudity, but you can't tell me someone isn't using dollar bills for toilet paper here.

Agathorn,

The amount the insurance company bills is pure fantasy on their part. The key is here

Payment will be limited to the reasonable and customary amount of $2000 for cpap unit, supplies approved @80% coinsurance

Your insurance company decides what is "reasonable and customary" and it's usually far below the fantasy price the DME bills for. Then, once the insurance company decides how much reasonable and customary is, the insurance will pay 80% and you owe ONLY the remaining 20% on whatever is "reasonable and customary". Do NOT let the DME dog you into paying one cent more than your insurance company says you owe out of pocket on your 20% of the "reasonable and customary" amount.

To avoid getting ripped off, refuse to pay the DME UNLESS and UNTIL you have received an "Explanation of Benefits" from the insurer outlining exactly what the insurance company will pay and what your share of that is.

Furthermore, don't let the DME stick you with a brick. REQUIRED READING: see my blog below for "What you need to know BEFORE you meet your DME". Also read my blogpost on "Don't pay that upcharge!". Understand your insurer's "reasonable and customary" should cover ANY CPAP or APAP machine-- even the top of the line--for the same price, but the DME will want to sell you a brick (one that totally lacks EFFICACY data) so their profit margin is higher.

You are having trouble, and with EFFICACY data (AHI and leak data) we can help you, but if you don't have that data you're SOL. More than likely, the DME has already taken advantage of your ignorance and given you the bottom of the line machine.

The important things are to see if you're in a PPO (Preferred Provider Option) plan and then be sure the DME is "in network."

With those things, the DME is required to bill you only the negotiated price for the CPAP. If those aren't true, the DME may be able to rip you off above and beyond the "insurance" price and you may have to pay the difference.

There may be some slight variations on the above.

old dude wrote:This racket, and I use the term racket not to disparage the efficacy of treatment but rather the business end of things with manufacturers and DMEs, must just be an unholy dollar producing process. Throw insurance companies and medicare into the mix, and I'm sure the DMEs just slobber over the gravy. My DME (which I consider to be better than most by far) charges me and my insurance company $72.00 for a replacement seal for my Quattro Air. It costs $54.00 total on a straight purchase from our kind hosts.

Pardon the crudity, but you can't tell me someone isn't using dollar bills for toilet paper here.

DMEs and insurance companies have some funny ways of doing business (because the industry is heavily regulated). But the CPAP part of B&M DMEs is not at all highly profitable.

If you can generate a good volume supply supplemental oxygen, you can make some money. But if you were to only supply CPAP, you probably would not survive - the margins are not there.

ChicagoGranny wrote:

LSAT wrote:I never heard of a charge upfront for ongoing care. That's BS. Dump that doctor/DME and take your prescription to someone else.

Keep calm LSAT.

It is unlikely that there is a "charge upfront for ongoing care". They probably just told him they have to charge more than an internet supplier because they have a B&M operation including staff to assist in person with customers. Most B&M suppliers will tell you that. And it is true that their operating costs are higher.

Granny...This is what they told him.....
"I called them on the phone and they claim the difference in price is because the price submitted to the insurance company includes their cost for ongoing service and care."

Some of the prices seem outrageous, but I put them in perspective.
My hearing aid cost more than a full cpap setup; as does a really good mattress.
A cushion costs more than a bra, but the bra is not saving my life.

chunkyfrog wrote:Some of the prices seem outrageous, but I put them in perspective.
My hearing aid cost more than a full cpap setup; as does a really good mattress.
A cushion costs more than a bra, but the bra is not saving my life.

first teeth, and now bras?? there seems to be a lot about frogs I was unaware of.

What some DMEs attempt to do, is collect your deductible (say $1000) from you plus 20% of there inflated price ($2700X20%=$540) so $1540 from you, then the $800 negotiated price from the insurance company less your 20% copay.

So they try to collect a total of $2150 in my hypothetical example instead of the $800 they are entitled to.

It is imperative that YOU educate yourself on which machine you want/need and what your insurance company will actually pay after your deductible and your copay.

You also need the list of in network DMEs your insurance allows you to use. And where you stand on meeting your deductible.
If you had an in lab sleep study, you may have already met your deductible.