(Hi there) And did my med supplier commit fraud with my Ins?

You might want to read these posts/threads......and/or do a forum Search on the word "reimburse".

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Basically, the way the insurance system is set up for the medical entities, it's a license to steal.....YOUR money.

The DMEs are going to give you the cheapest low-end equipment and charge your insurance the maximum allowable. It does NOT cost you any more to get better equipment.
There are a number of ways to get better equipment.
You may want to contact your doctor and have him write your prescription for a machine that has "A-Flex"......there's only ONE machine that has A-Flex.....the REMstar Auto with A-Flex. If you should decide to purchase online from CPAP.COM, all you need is a basic prescription that says CPAP and a pressure. You CAN purchase an Auto on a CPAP prescription from them.

Do lots of research on this before you get too far into the contract.

If you have deductibles and your insurance year starts over again at the beginning of next year, it's going to cost you more.

Den

searchbuffet wrote: ... I had no idea what the actual differences are between "renting" and "owning"...

The place said that Blue Cross would let me do either - rent or own. I asked the difference and she couldn't give me a straight answer, mostly just said that I was lucky because Medicare and some insurers make you rent it for 12 or so (I think it was) months and then you pay off the balance. ...

HORSEPUCKIES!!! Medicare (and many insurance companies) have provisions for a "capped rental" (in Medicare's instance the capped rental is for 13 months). Capped rentals are "rent to own". HOWEVER, there is the monthly rental for the set number of months THAT PAYS FOR THE MACHINE, there is no extra charge at the end of that rental to the best of my knowledge. This is true for Medicare. Maybe for some companies where the rental is just for 3 months or so to be sure that compliance is established and they aren't paying for something that is going to set in someone's closet unused there may be the need for a lump sum payment at the end of the short rental period.

searchbuffet wrote:... They had a couple masks that she said were the "best" for me to try. Here's another big question I had (I didn't ask her because I'm too darn shy). I'm a big time germ-a-phobe. Plus I'm extremely susceptible to getting sick because of the immunosuppressants I'm taking for the Lupus. When I got in the room, she already had my machine setup and the masks to pick from sitting there. I know they legally almost positively have to have them sanitized or a new product for health reasons, I have no idea if they were. For anyone that goes to a physical DME store to get their masks -- what do they do with the ones that you try on and don't like? I just had this sick feeling that they were all like dirty test masks that they use 10x a day. If not, how do they recoupe this cost (maybe from the $1200 they overcharge customers from? )

The masks that you try on at the local DME suppliers are new, unused masks. Those that the patients try but do not select are either 1[ returned to the manufacturer, 2] provided free to their FEW pro bono patients 3] donated to AWAKE or other organizations serving the needy, 4] provided to hospitals, sleep labs, etc. that DO have the legal right and the facilities, equipment to properly sterilize them. Respironics, Resmed and Fisher & Paykel replace FREE to the DME suppliers those masks tried and not selected or selected and returned (w/in 30 days) if the DME fills out the proper form and returns the mask to the manufacturer w/in 30 days.

searchbuffet wrote:I think I agree with you though that if you have a reliable local store that can help you test things out and find the right things, you'd might as well pay a bit more if you can just for the sake of being able to have a place to take it for repairs (uh oh) or whatever. But for hoses, and other goodies, maybe I'd be better off buying with cash from somewhere online.

The KEY is IF you have a good local DME supplier. Then you are right, at least at first, it is better and more helpful to stick w/the local DME supplier for your CPAP and service.

searchbuffet wrote:... it does seem like it might be helpful to be able to track your progress without having to go into a full-on sleep study. I would have thought that my doctor would have prescribed a model with one, or at least preferred that I get one if I could afford it (I wonder if Blue Cross would pay for it still). Now that I know it exists, I am kind of surprised and disappointed that my Dr. doesn't at least recommend getting one with a Smartcard and have the patient bring it in for him to look over the data (Does anyone's Dr. do this?) - seems like it would be much more reliable and useful than just asking me how I was doing...heck I'm hopefully sleeping, I have no clue.

RIGHT ON! Yes, some doctors DO care enough to insist that their patients be given ONLY a fully data capable xPAP. Most don't. They rely on how you say you are feeling. Are you sleeping any better? Feeling more refreshed? Or, more likely, they could care less and never bother w/you again leaving you to your own devices and that of your family doctor or referring doctor.

I contacted BCBS PPO regarding the cost of the white filters that was being charged by my DME. The cost is not in front of me but it was around $30 for 2 filters...a ridiculus fee. The BCBS rep said that BCBS sets a standard price and has agreed to pay a certain amount to the DME...which was around $15. Then I had my 20% copay...which to me basically equaled the price the filters should be in the first place. Anyway, that is what is contracted and the DME uses the difference as a write-off, hence forth saving $$ on their taxes in their profit and loss statement. Makes me want to barf.

I have never ordered online but I believe you can submit your own claim to BCBS and pay the out of network percentage...will still be cheaper in the long run. Inaddition, I am concerned due to my younger age and other medical problems that my lifetime benefit will be cap out beofre I croak. I think I am going to do the online route for the next PAP and mask.

I'm going to try and take the stupid thing back, if that's true that they charge the same for the cheapest model vs a better model to my insurance; and then rake every penny out of me as well - that is maddening.

I called Respironics the other day to see if they'd tell me the suggested list price, but they wouldn't. I'd love to know how much these things are actually sold to the DME's for. Adding up the prices, the ~$430 that I paid in cash probably comes out to what they paid, and then they make double from insurance. Business is business, but there has to be a limit somewhere.

The problem is that I don't have a copy of any contract or anything of the sort. I signed something there, and I have a copy of it that says refer to the terms on the back; but there is no back on my copy...arg.

When referring to my "sleep Dr." I was meaning he's a Pulmonologist
I'm just so sick of calling around to all of these places...so annoying. The whole apnea thing is bad enough -- I'm having a really hard time adjusting so far, a really really hard time with it, even with Ambien. It's so completely depressing to think that I have to wear this thing EVERY night for the rest of my life, I'm only 30. I don't think it's really even hit me yet, but I'm really overwhelmed with it all.

I'm still not exactly sure how the billing process works with insurance. If the DME I went to has some pre-negotiated price with Blue Cross, would it be set-in-stone, meaning that they would actually know what my 30% payment would be exactly to the cent (Again, they said it was "pre-authorized", but when asking Blue Cross, they said nothing has been authorized or processed as of friday)? The new supplier said No, they wouldn't know an exact price to charge me on the spot. But I'm curious as to how these pre-negotiated prices DME's have with insurance -- and if it is some exact price, then if they might know the price that they charged me. I'm just trying to find out everything I can before pursuing this.

searchbuffet wrote: When referring to my "sleep Dr." I was meaning he's a Pulmonologist
I'm just so sick of calling around to all of these places...so annoying. The whole apnea thing is bad enough -- I'm having a really hard time adjusting so far, a really really hard time with it, even with Ambien. It's so completely depressing to think that I have to wear this thing EVERY night for the rest of my life, I'm only 30. I don't think it's really even hit me yet, but I'm really overwhelmed with it all.

I'm in the same boat SB, I turned 30 in June, and was only diagnosed with Severe OSA in August. I've gone back and forth with depressive bouts because of it. I've shed a fair number of tears, and still every once and a while something new about the situation hits I hadn't thought about before, and I reach another low. What has helped me is the people on this board and the support. Plus thinking about those that are a lot worse off than myself. I may need to sleep with a machine big deal but there are those who would take that problem in a moment over what they are going through. Plus I keep thinking if I'm successful other parts of my life will improve, so that keeps me going as well.

Now I can't help with the insurance at all, but if you need a shoulder feel free to send me a PM. I hope you can get your money back and a better machine. Good Luck.

Christy

AdmiralCougar wrote:Now I can't help with the insurance at all, but if you need a shoulder feel free to send me a PM. I hope you can get your money back and a better machine. Good Luck.
Christy

Thank you very much. Yes, I guess in many/most ways we're pretty luck in the whole scheme of things, it's just hard to remember that sometimes...well every night lately
But I guess it's just like putting shoes on and is something that we must do. I'm just hoping that my body will hurry up and get used to the damn thing quickly and realize that it's supposed to be there.

I dread the nighttime now. Before taking Ambien, I used to dread sleeping and have anxiety every evening when it came time for bed because I just couldn't sleep. I never thought I was claustrophobic at all, and maybe it's not even that as my mask doesn't cover anywhere near my eyes - but my body and brain literally go nuts now when it comes time for bed.

I realize that it just takes getting used to it, but the past couple of nights since starting the CPAP, I've gotten so extremely frustrated - almost out of my mind - and kicked the wall. That's the first time since I was about 10 that I've done that, I almost put a whole in it lol. Seriously though, I don't know if I will be able to handle this if it doesn't get easier very quickly. Before my last sleep study with the CPAP test, I was reading about it online and saw all of the issues of "non-compliance". I thought to myself - NO WAY, I would use it every night without a second thought. Since then, my brain has done a 180. Probably even freaked myself out even more from the anxiety of it now, that it has made it 10 times worse.

Sorry, I'm just venting away. Moderators ----> please feel free to delete all of my posts

Searchbuffet,

I am sorry you are having a difficult time with your DME. Unfortunately, that is all too common. There are better ones out there in many cities, so you may want to see which other DMEs are on your insurance plan. You mentioned that you signed a paper that refers to terms on the back, but yours is blank on the back. I recommend you get that complete paperwork from the DME ASAP to make sure you know what you agreed to with your signature.

searchbuffet wrote:The whole apnea thing is bad enough -- I'm having a really hard time adjusting so far, a really really hard time with it, even with Ambien. It's so completely depressing to think that I have to wear this thing EVERY night for the rest of my life, I'm only 30. I don't think it's really even hit me yet, but I'm really overwhelmed with it all.

It is fairly natural to be depressed and overwhelmed with beginning cpap therapy, particularly for someone as young as you. I encourage you to try to re-frame your thinking about it. There are many people on this forum who began cpap therapy later in life after they had experienced some of the common complications, such as high blood pressure, diabetes, heart disease, stroke, etc. The fact that you are beginning therapy at age 30 probably means you can avoid many of those health problems. Hard to believe right now -- but you are lucky to have found out now that you have a condition that is treatable.

Yes, it may be for the rest of your life, but it makes it a little easier if you try to think of it as something you have to do tonight, as opposed to for the next 50 years. Sort of a one night at a time philosophy. You know in the back of your mind it is long term, but really all you have to do today is make a commitment to wear it tonight. Tomorrow you can make another commitment about tomorrow night. It likely will get easier with each passing night (with maybe a setback here and there). Eventually it will become something that you do without thinking much about it.

Good luck to you and keep coming back here to ask questions and to let us know how you are doing.

Janna

in response let me interject this--- most insurance companies in trying to controll costs make agreements with me's which allows the dme's to make a certain percentage of profit , helping them stay in buissness. unfortunately the dme's have found ways to bill the insurance (by itemizing every item, includung patient support) thereby increasing thier already high profit margins. although this was not the insurance company's intent, our paperwork society and lawyers wanting everything documented have created a self inflaming paranoid out of control monster. (i wonder if lawyers have these problems?) as for the rental- it is designed in case the patient can't for some reason use the equipment the ins co is not out big money. i an checking to se with my ins co if i can buy my own equipment and be reinbursed for it. i know there will be a ton of paperwork involved but maybe i can get what i need - not what a dme seems fit for me.

I know for many of you it is hard to accept that you are diagnosed when you are young.

My story is the other side of the coin. I am 53 and just recently diagnosed. I can remember telling my doctors that I was ALWAYS tired 20 years ago. Of course it was blamed on many things -- on me having 5 kids (4 of them in 5 years), being too active, not being active enough, my weight -- that I wasn't eating enough and then when I put on weight that I was eating too much, always something different. One excuse after another.

I have GERD, am up a minimum of 2 times to use the bathroom due to nerve damage with my bladder (was operated on but I waited too long and it couldn't be reversed) insomnia, etc, and still nothing was said about doing sleep study .

I like my doctor and one day this summer was telling her the frustration of the extreme exhaustion that haunted me. At the end of school I was barely functioning (I teach). I felt horrible and all I wanted to do was sleep and everyone thought I was just being lazy.

She suggested I see if the insurance would pay for a sleep study (I had checked a few years ago and they wouldn't and we didn't have the money to pay for it). I checked and they now cover it 80% after you meet the deductable.

I asked her to set me up and she obliged. It took almost 6 weeks to get in at the sleep lab for the study.

It was a relief to me that I could finally put a name on it and know that I wasn't crazy, lazy, etc.

I just wish I could go back in time and maybe, just maybe, my health would be better as I have some of the secondary illnesses associated with sleep apnea.

I am not trying to downplay your depression -- it is just I wish I was your age and not have wasted so many years dealing with the exhaustion, fatigue, sickness, etc.!!

SleepBuffet, you might want to look into Sleep Guy's Pur-Sleep product to help you adjust to cpap. Many have reported an easier time adjusting to CPAP by using it. The website is http://www.pur-sleep.com. If you do a search on pur-sleep, you will find several topics on it.

Good luck with the evil DME.

Sleepy Dog Lover wrote:SleepBuffet, you might want to look into Sleep Guy's Pur-Sleep product to help you adjust to cpap.

Thanks, actually I ordered the starter pack about a week ago, hopefully it'll be here soon. I got the email saying it shipped, but no tracking number yet. I figured it couldn't hurt, even though I'm not really one for strong smells. What the heck, right

searchbuffet wrote: They had a couple masks that she said were the "best" for me to try. Here's another big question I had (I didn't ask her because I'm too darn shy). I'm a big time germ-a-phobe. Plus I'm extremely susceptible to getting sick because of the immunosuppressants I'm taking for the Lupus. When I got in the room, she already had my machine setup and the masks to pick from sitting there. I know they legally almost positively have to have them sanitized or a new product for health reasons, I have no idea if they were. For anyone that goes to a physical DME store to get their masks -- what do they do with the ones that you try on and don't like? I just had this sick feeling that they were all like dirty test masks that they use 10x a day. If not, how do they recoupe this cost (maybe from the $1200 they overcharge customers from? )

Welcome, searchbuffet!

Sorry to hear about your problems with the DME!

Regarding the germs question: I am also on immunosuppressives for a cousin of SLE so I'm very "germ-conscious". Through our host, I purchased the germicide kit with "Control 3". From what I understand, sleep labs use that or something like it to disinfect masks so they can reuse them. I have it on-hand so that if I swap masks with someone, I can make sure it is disinfected. I also plan to use it on my regular equipment when I have a cold or flu.

Regarding costs, I was lucky - my insurance paid for all and my DME gave me an itemized bill showing their charge and what my insurance paid. What insurance actually paid is *much* less - so unfortunately it's the folks without insurance (or without good insurance) who get shafted.

I hope you can get things straightened out so you can get what you need. Having a machine with a Smartcard is very helpful. I've shelled out the high $ to get the card reader and software but am using it to closely monitor my therapy. In the not to distant future, we are all hoping Respironics will live up to it's statement that it will provide software for patients (should be less expensive, we hope).

Mindy

[quote="searchbuffet"]I'm going to try and take the stupid thing back, if that's true that they charge the same for the cheapest model vs a better model to my insurance; and then rake every penny out of me as well - that is maddening.

I called Respironics the other day to see if they'd tell me the suggested list price, but they wouldn't. I'd love to know how much these things are actually sold to the DME's for. Adding up the prices, the ~$430 that I paid in cash probably comes out to what they paid, and then they make double from insurance. Business is business, but there has to be a limit somewhere.

The problem is that I don't have a copy of any contract or anything of the sort. I signed something there, and I have a copy of it that says refer to the terms on the back; but there is no back on my copy...arg.

When referring to my "sleep Dr." I was meaning he's a Pulmonologist
I'm just so sick of calling around to all of these places...so annoying. The whole apnea thing is bad enough -- I'm having a really hard time adjusting so far, a really really hard time with it, even with Ambien. It's so completely depressing to think that I have to wear this thing EVERY night for the rest of my life, I'm only 30. I don't think it's really even hit me yet, but I'm really overwhelmed with it all.

I'm still not exactly sure how the billing process works with insurance. If the DME I went to has some pre-negotiated price with Blue Cross, would it be set-in-stone, meaning that they would actually know what my 30% payment would be exactly to the cent (Again, they said it was "pre-authorized", but when asking Blue Cross, they said nothing has been authorized or processed as of friday)? The new supplier said No, they wouldn't know an exact price to charge me on the spot. But I'm curious as to how these pre-negotiated prices DME's have with insurance -- and if it is some exact price, then if they might know the price that they charged me. I'm just trying to find out everything I can before pursuing this.

What a DME get reimbursed is based on HCPC code E0601. All CPAPs fall within this code. According to the government, there isn't a medical need for CPAPs that provide compliance data, efficacy data, or auto-titrating. I haven't seen a study that says these more expensive CPAPs work better than a basic CPAP. They usually say "works as well" as a regular CPAP.

This is important because most if not all insurance companies follow Medicare guidelines. When they negotiate reimbursement for a CPAP, they negotiate based on code E0601. If a DME bids a price that is based on the most expensive CPAPs, they will lose the bid. One major insurance company reimburses about $430 for a CPAP. Even with a basic CPAP, it's tough to make a profit.

It's interesting that many of you blame only the DMEs. Why do the manufactures charge so much extra for the higher end machines? I really doubt they cost twice as much to manufacture. Why don't the insurance companies pay a higher reimbursement for the high-end machines? Don't they think you're worth it?

Please don't take this as I'm sticking up for DMEs. I know there are a lot of bad ones out there. DMEs are a part of a bad health care system. IMO, patients should be financially motivated to shop around for the best price/service. For items such as CPAPs, the insurance companies should just pay their money to the patients in the form of a "spending" account and let the consumer demand a great product and service for THEIR money. Competition and consumer choice is a beautiful thing.

DME_Guy wrote:It's interesting that many of you blame only the DMEs. Why do the manufactures charge so much extra for the higher end machines? I really doubt they cost twice as much to manufacture. Why don't the insurance companies pay a higher reimbursement for the high-end machines? Don't they think you're worth it?

Please don't take this as I'm sticking up for DMEs. I know there are a lot of bad ones out there. DMEs are a part of a bad health care system. IMO, patients should be financially motivated to shop around for the best price/service. For items such as CPAPs, the insurance companies should just pay their money to the patients in the form of a "spending" account and let the consumer demand a great product and service for THEIR money. Competition and consumer choice is a beautiful thing.

I guess we all take out our frustrations on someone! I feel very fortunate both for the insurance I have and the fact that I had a sleep doc who was very knowledgeable about equipment and a DME who was very helpful.

I like your idea for handling CPAPs. I would probably still have gone with my DME because they "added value" for me. For future purchases, I'd need to think about it more if there's no real change from current technology. I don't like to take advantage of my good insurance ... I still value the best bang for the buck.

Mindy