What does your insurance allow/pay for CPAP and gear?

[Janknitz]

I get a kick out of how the DME (all DME's) bill the insurance companies. DME bills the insurance $XXX, the insurance "allows" $YYY. WHY,does the DME bother with the "inflated" bill when they KNOW all they're going to get is $YYY?

It has something to do with how they prove to Medicare and other insurers what their "actual costs" are--information that is somehow calcualted in when Medicare and other insurers compute their allowable amounts. Medicare knows what's going on as far as the bill padding, that's why they eventually set the rates lower than the DME's bill for. It's kind of a shell game. And there are many layers of complexity and jobs that do all the bean counting to figure this all out.

Crazy, crazy, crazy!

[sthnreb]

The problem is that the rental and co-pay barely comes in under the straight out purchase. Naturally most people take the cheaper way out for the same items even though it is minimal. The DME's make-a-de-money. Most of that is on the machine itself. Mine is a M series Auto Bipap that could have been purchased with humidifier for $969 new when I got it last December. It was being discontinued. I will end up paying in rent about $625, probably what the DME paid for the machine or less. However, Medicare will pay them $2415 more for rent. Total machine cost is over $3000. They brought me the cheapest mask they had, which I already had one like and insisted I try and use it. I have since changed provider or DME's for supplies. However I can't change the machine until 5 years and have to continue paying rent for up to 13 months I believe it is at about $47. To change the machine, the new DME would only get the remaining payments or 9 payments. They are legally raping the system and not providing very much service. They even mail the stuff out to you. This new company I use now let me take 3 masks home to try for a week to make a decision. I hope to try 3 more in 3 months. I find the mask is a very importart part of compliance, it has to fit and be comfortable or you won't use it. I've been on the hose now for 9 years. My favorite mask was discontinued and I'm still looking for one as comfortable. I have a 20% Medicare co-pay. Machine rental for me is $310.00 a month, (wow, could buy it is 3 months online), Medicare reduced to $185.78 and I pay 20% of that above Medicare payment. So, the machine rents for $232.22 per month to the DME for 13 months so I am advised. They collect profit of over $2,000 for the machine. So, what are the benefits of a DME?

[lovecpap]

Not sure what DME you are using.....but most AETNA contracts are for $450.00 for the cpap unit.

[sonyat]

I was told I'd have to pay $800 out of pocket to go with a home health company (40%). So I opted to use CPAP.com because 100% out of pocket was less than that (I got a less expensive IntelliPAP). Supposedly, I'm supposed to get 90% of that back in reimbursement (they cover 90% of medical equipment), but they are making me wait for it. I suspect they'll be some issue or another causing them to send me a check for $10 or something nutty like that.

[sonyat]

So it looks like I saved $89.55 by going in network, but insurance paid out an extra $2191.55 for the exact same stuff. Maybe this is why health insurance is so expensive. They seem to have no clue of the real fair market value for what they pay claims on.

Actually, what happens is that the DME charges your insurance company MUCH less than the $2195 -- that's what being "in network" is all about.

Example -- I once had surgery, and the full cost was $30,000 (the poor surgeon only got $5k, but I had to be hospitalized for four days). But thanks to the in-network arrangement, the insurance company only paid the hospital $8000. If I had no insurance, I would have been on the hook for the $30k! I know because I got that bill first -- because I stayed 4 instead of 3 days the insurance company refused to pay the initial bill! Wasn't authorized, you see. Obviously I stayed that 4th night because I was having so much fun...

[sthnreb]

Not sure what DME you are using.....but most AETNA contracts are for $450.00 for the cpap unit.

I don't know who you were asking that to but I will respond with my DME's. I'm in the Atlanta, GA area and I started with In Home Respiratory to begin with because they were recommended to me through a friend who used them. Their accessories must be the least expensive they can purchase since they get paid back the same amount regardless of quality. I have a 6' hose that is new I can't use because of the kinks in it. I've soaked it in warm water and hung it up in hopes it would straighten out. It hasn't. I read a article on here about what can a DME do better to help patients? I noted the writer was with a company near me, however he worked in a different area/office than my region. He told me they were different and would help. I did have some problem to begin with. I was told my prescription was not good that was only 6 months old. I talked with Kevin and he got it straightened out. All seems ok now and this company is Hi Tech Medical Supplies a couple of miles from my house and it is the corporate office for them. My personal insurance ended when I became eligible for Medicare last December. So, now I am on Medicare with a plus plan through Secure Horizons. I pay 20% of Medicare approved pricing for medical supplies. I guess DME's get around that by charging rent on machines instead of 20% of cost? (Runs the price up more than $2,000.00 in my case.) I've contacted my representative with SH and can't seem to get an answer concerning the excessive charges.

[WilsonVilleUSA]

So it looks like I saved $89.55 by going in network, but insurance paid out an extra $2191.55 for the exact same stuff. Maybe this is why health insurance is so expensive. They seem to have no clue of the real fair market value for what they pay claims on.

Actually, what happens is that the DME charges your insurance company MUCH less than the $2195 -- that's what being "in network" is all about.

Example -- I once had surgery, and the full cost was $30,000 (the poor surgeon only got $5k, but I had to be hospitalized for four days). But thanks to the in-network arrangement, the insurance company only paid the hospital $8000. If I had no insurance, I would have been on the hook for the $30k! I know because I got that bill first -- because I stayed 4 instead of 3 days the insurance company refused to pay the initial bill! Wasn't authorized, you see. Obviously I stayed that 4th night because I was having so much fun...

No, I hav e copy of the bill from the provider and the EOB from insurance. Those were the charged, allowed and paid amounts. I was savvy enough to get the machine I wanted, otherwise provider would have given me the el cheapo model and numbers would have been the same.

[kempo]

Just talked to my insurance. My cost after insurance for the S9 autoSet with humidifier will be $380. Insurance will pay 90% for mask, hose, etc.

[sthnreb]

Just talked to my insurance. My cost after insurance for the S9 autoSet with humidifier will be $380. Insurance will pay 90% for mask, hose, etc.

So there is a savings of $473? on the machine from an outright purchase from cpap.com? 90% of accessories is good. Especially if they have in network purchases that reduce the price.

I show $244 for humidifier and $853 for the S9 Auto, a total of $1097 at Cpap.com.

[WilsonVilleUSA]

Just talked to my insurance. My cost after insurance for the S9 autoSet with humidifier will be $380. Insurance will pay 90% for mask, hose, etc.

What percentage of the S9 are they paying for? 90% as well or something less? If your $380 cost is the same 10% that tou pay for consumables, that tells you they are allowing $3800 for the machine They would be paying $3420, over 300% of what it costs at cpap.com ($1072 w/H5i) that DME is making some serious coin.

If cpap.com can sell it for $1072 as a ResMed mandated minimum, I am guessing dealer cost is in the $500-$600 range.


I am new to the S9, does anyone know what the prices were on them before ResMed MAP rule went into effect?

[kempo]

According to my insurance our in network DMEs can not charge more than $1500 for a cpap machine to our insurance company. Now this is weird. My insurance will pay for a humidifier but not a heated humidifier which according to them cost twice as much. So the humidifier will cost me more than the cpap.
They will only pay half the cost of the heated humidifier. $150 for cpap $230 for humidifier.

They must have hired a bunch of lawyers and used car salesmen to come up with that program.

All I know is my cost for the S9 AutoSet with humidifier will be $380. Now having said that. I have a yearly deductable to meet first ($500) which has already been meet this year. I usually have my deduct meet by June of every year. So I guess you could look at it two ways. I paid either $880 or $380.

[sthnreb]

I guess it's like water and electricity, a person take the route of least resistance or lowest cost. Even though the DME makes mucho dollars on patients and Insurance companies. It's easy to see why Healthcare is so expensive. It's not really the patients that are getting the real benefits of insurance but the providers. On Cpap/Bipap machines the DME makes the big bucks on the machine itself and not as much on the accessories. Mine will make about $2500 profit off of my machine. All they do is deliver them and spend 30 minutes at most going over how to turn it on and off. Must be lots of overhead? With my Medicare Advantage Plan I don't think I have an in network and out of network. All the same.

[RN Ricky]

I think most of the problem is all about contracts. Once a provider gets the bid they can charge what they want to and the Insurance companys (the high ups) put on blinders even when the contracts end. Some of my home care patients get zip from their companies while others get so much stuff that I scavenge to give to the less fortunate ones. (Don't worry everything is sealed.) Granted the policies premimum and services differ but where is the common sense? Besides my momma always taught me to never waste anything...which brings back to the subject why do these companies wast money? Can't they shop around?? The buyers for dept. stores as well as customers do!

[Captain_Midnight]

All insurances are different, and some excel in some respects over others.

That said, mine seems quite good re OSA as it covers 100 percent of everything. I get a new machine every four years, and a new mask every six months. It all goes through one DME (the much-maligned Apria) however I have had no issues with them in 4.5 years.

I do think that smarter insurance companies will cover much or all of OSA therapy equipment, as it is cheaper in the long run versus some of the truly nasty, and expensive health consequences of untreated OSA.

.

[scbeaver]

The cost of S9, H5i, Heated Hose, four filters and a Swift FX mask was $856.85 before ResMed's price fixing went into effect.


Sleep Well

Steve