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

[WilsonVilleUSA]

Just an informal survey. I was shocked and amazed yet again when I recently upgraded to a new machine. My employer is self insured and uses Aetna to manage the plan. DME coverage using an in-network provider is a 90%/10% split. Using an out of network provider it is a 65%/35% split. They REALLY try to press you into going to an in-network provider and tout how much higher the coverage is.

Here is what the in-network provider's charges, insurance allowed charges, and my cost (10%) are for my new equipment:
..............................Charged....Allowed.....10%
ResMed S9 AutoSet........$2350.......$2350.....$235
H5i Heated Humidifier.....$600.........$600......$60
H5i Water chamber.........$100..........$24.....$2.40
Filter...........................$50..........$19.....$1.90
SlimLine Hose................$80..........$51.....$5.10
Swift FX Mask...............$225.........$171....$17.10
Headgear....................$100...........$50........$5
Nasal Pillow...................$75...........$36.....$3.60

TOTAL.......................$3580........$3301...$330.10 Insurance Pays $2970.90


Here is what the EXACT same stuff would cost from https://www.cpap.com, and my costs at the %35 reimbursement:

...........................cpap.com.......35%
ResMed S9 AutoSet.......$853........$298.55
H5i Heated Humidifier...$219..........$76.65
H5i Water chamber.......INCLUDED
Filter........................INCLUDED
SlimLine Hose.............INCLUDED
Swift FX Mask.............$127.......... $44.45
Headgear..................INCLUDED
Nasal Pillow................INCLUDED

TOTAL......................$1199.......$419.65 Insurance would pay $779.35


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.

[elena88]

I got an explanation of benefits from my insurance company today for my s nine, humidifier and filters..
it was 2600.oo
The bills come shortly there after, and are the same amount as the EOB.. so I was freaking out thinking I owed the DME
that much.. and I knew my insurance would not pay for it..
I about had a heart attack.
I THOUGHT I had an even trade for the system one I paid for..
Turns out I did, and I dont owe them squat.. If I did, I was going to return the machine.

Did you know that you need a prescription from your doctor TO RETURN a machine?
That is what the DME told me!
I said, hey, well, youre going to be out this new s9, Im not paying twenty six hundred bucks for it, so you better take it back..
Then they mentioned I could sign a medical waiver...
In the meantime they found out what happened.. somebody screwed up and billed me for the new machine.

[GTOJim]

Due to a job change our insurance just changed from Blue Shield to Health Net. Both companies will only allow a certain amount to be charged. I just ordered a FF mask, tubing, and filter. Apria billed my insurance $1,100, insurance allowed just over $200 of the charges. My new insurance covers 50% so out of pocket was just over $100.
On-line pricing is very close to the $200 the insurance allows to be charged.

5 weeks ago my wife had a knee replacement, hospital bill was over $135,000, amount allowed by insurance was $38,000, our responsibility to pay is zero. I'm sure if we did not have insurance the hospital would insist we pay the full $135,000.

I can give a lot more examples such as these. It's been a pet peeve of mine, these highly inflated prices.

[Patrick A]

The truth is as little as they can get away with.

[GTOJim]

Seems it should be as much as they can get away with. They sure try.

[Jaylee]

The truth is as little as they can get away with.

Yep. I have been making payments on mine for a year. My insurance is super bad though.

[Janknitz]

Brick and mortar stores do have higher costs. They not only have to pay the "Brick and mortar costs" (rent, insurance, utilities, employee costs, inventory, etc) but they also must have RT's on staff, and the documentation and billing load for reimbursement and compliance (insruance compliance, Medicare and Medical, and state law compliance) is absolutely staggering. Plus, they wait--anywhere from a few weeks to a few YEARS for reimbursement from various pay sources (How would you like to do business like that--oh wait, I do ). Some insurances don't even cover the cost of doing business, so they make it up with other insurance companies and private payors. To some degree, the DME's deserve the higher rates they get.

I wouldn't begrudge a penny to them if they really did what they are supposed to do, but too many, particularly those larger companies, cut corners wherever they can, and wherever they can is patient care and customer service. When they start treating me like dirt and have an attitude with me because they consider my insurance company, and not me personally, is their "customer" then they don't deserve MY money. They may discount my actual contribution to the money they collect from my insurance company, but ultimately those dollars come from ME--money I paid into the insurance, sweat from my brow that my husband or I paid to an employer or or my state, federal and Social Security Taxes.

An online store may be able to offer great prices because they don't have the burdens of a brick and mortar store, but if the online company gives me a fair price AND treats me right, then they deserve my business if the brick and mortar does not.

[Patrick A]

The insurance's Primary and Secondary pay for every thing. Haven't had to pay anything since I got stuck on Medicare. I got put on Medicare a month after I got ripped off by APRIA RIPOFF in 2006.(to top that off they would not refund it) I only got stuck with paying a yearly deductable when I started in 2005 I got stuck by APRIA Ripoff they day I got the machine. On 21Jun05, $150.00 and again in Jan 06 Same amount.

[Komodo]

My current insurance (1199) pays 100% with ~zero~ deductable, so long as, I go through their one and ONLY in-network DME. If I go out of network, they pay ZERO.
ALL the equipment, including hoses, masks, filters, are rented for 10 months, and then become mine.

I used to have Aetna. They started out with a $500 annual deductable, rented the machine for 13 months, 80/20 payments. The Cpap itself was the only thing rented, everything else, including the humidifier, was bought outright. Between the deductable, and the monthly rental I had to pay, my out-of-pocket was about twice what I would have paid if I bought everything outright online without the insurance.

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?

[Roman Hokie]

Komodo, I have to laugh. You rent a filter? Are these disposable or 6-month life?

[DreamStalker]

Just an informal survey. I was shocked and amazed yet again when I recently upgraded to a new machine. My employer is self insured and uses Aetna to manage the plan. DME coverage using an in-network provider is a 90%/10% split. Using an out of network provider it is a 65%/35% split. They REALLY try to press you into going to an in-network provider and tout how much higher the coverage is.

Here is what the in-network provider's charges, insurance allowed charges, and my cost (10%) are for my new equipment:
..............................Charged....Allowed.....10%
ResMed S9 AutoSet........$2350.......$2350.....$235
H5i Heated Humidifier.....$600.........$600......$60
H5i Water chamber.........$100..........$24.....$2.40
Filter...........................$50..........$19.....$1.90
SlimLine Hose................$80..........$51.....$5.10
Swift FX Mask...............$225.........$171....$17.10
Headgear....................$100...........$50........$5
Nasal Pillow...................$75...........$36.....$3.60

TOTAL.......................$3580........$3301...$330.10 Insurance Pays $2970.90


Here is what the EXACT same stuff would cost from https://www.cpap.com, and my costs at the %35 reimbursement:

...........................cpap.com.......35%
ResMed S9 AutoSet.......$853........$298.55
H5i Heated Humidifier...$219..........$76.65
H5i Water chamber.......INCLUDED
Filter........................INCLUDED
SlimLine Hose.............INCLUDED
Swift FX Mask.............$127.......... $44.45
Headgear..................INCLUDED
Nasal Pillow................INCLUDED

TOTAL......................$1199.......$419.65 Insurance would pay $779.35


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.

But ... but .... that is what healthcare for profit is all about --- creating jobs.

It is a lot like the stupid war on drugs. By outlawing recreational drugs, the narco-trafficers have jobs, the drug users need jobs to buy the drugs, the cops have jobs to put drug makers and users in prison, the prison guards get jobs, the banks get jobs to launder the drug money, the arms dealers get jobs too, and let's not forget the farmers who grow the plants used to make the drugs. The war on drugs is about creating jobs.

For-profit healthcare is NOT about health care, it is about creating jobs, the morality of those jobs or whether healthcare is efficient or fair or good or bad is irrelavent.

[Roman Hokie]

I've been on the hose 2 weeks. My claim hasn't caught up in the insurance database website. I just checked.

But then again, they're still working on a claim from a surgery I had 3 years ago. Really. I've already paid my portion so it's only between the hospital or maybe the anesthesiologist and the insurance. I'll own my S9 before they figure it out.

[hose head]

My insurance covers 100%. I also was covered 100% for both sleep studies. I can get new supplies when I need them not on a fixed schedule. I respect my great insurance by only getting supplies when I need them and I count my blessings every time they send out a benefit statement.

[mattsledge]

Luckily, my insurance covers everything including supply replenishment.

They also paid for the ResMed S9 Elite I got last week. It's a good little machine.

[Patrick A]

I went back in my records, I had my original Sleep Study in May of 2005. My insurance paid for the bill in full. I was put on Medicare 11 months after the first sleep study. (I am on disability) I had another sleep study last December Medicare and my Secondary insurance paid the full bill. Since then they have paid for all of my machine rental and supplies costs. 100%