Curosity: Machine, Insurance and Compliance

[elg5cats]

Has anyone here successfully received insurance reimbursement after purchasing your machine online, submitting your own data for the typical "compliance" required by insurance for reimbursement. I'm considering giving this a try, but suspect someone here has already attempted with or without success.

elgcats.

[LSAT]

Start by contacting your insurance company and asking them about reimbursement. It doesn't matter if anyone here has done it...it is up to your specific insurance company. Insurance companies have different policies.

[poppi2]

Wulfman... was successful many years ago. He described how he managed it in the last week.

[Janknitz]

SOME insurers will reimburse your online purchase, MOST DO NOT. Medicare works with some online suppliers IF your supplemental policy permits it.

Unless you can afford it eat the whole cost, you'd better verify with your own insurance company first. Make sure you understand what documentation they will require.

Good luck!

[Wulfman...]

Wulfman... was successful many years ago. He described how he managed it in the last week.

Yep. I've related my original purchase and reimbursement experience a few times over the years........

viewtopic/t109712/search.php?keywords=r ... ulfman&fid

On a side note, I didn't have to prove my "compliance" with them. They figured that if I was buying it outright, I must be serious about using it.


Den

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[elg5cats]

[quote][/quotYep. I've related my original purchase and reimbursement experience a few times over the years........

viewtopic/t109712/search.php?keywords=reimbursed&terms=all&author=Wulfman&fid

On a side note, I didn't have to prove my "compliance" with them. They figured that if I was buying it outright, I must be serious about using it.


Dene]

Thanks, I suspect my insurance will not make any payment, but I plan to submit a claim and pen wrestle with some logic. Had I purchased my new machine via local DME I would have had to pay out of pocket $147 monthly x 10 months in addition to what insurance payment to DME. I purchased my machine at CPAP.com for $883 giving me a savings of $587. I over projected my contributions to my flex spending account, so once insurance denies, I will have mostly reimbursement from flex spending.

[wydazy]

Medicare has gotten stricter with Obama Care. They are refusing to pay for mine because they can't find that I had an oxygen test on my finger before the sleep test even though the sleep test said Severe Apnea. I had a finger oxygen test during (74) but they want one before. I had an endoscopy the week before and they are trying to use that oxygen reading but I'm waiting to hear. The DME doesn't do anything but hand me the machine and the settings were bad initially...I couldn't breathe and had chest pains so I set my own according to the sleep test recommendation. I would prefer to buy on line outright but the doctor's office said "I don't think that would be a good idea". I didn't like the mask they were trying to give to me so suggested the Dreamwear mask and I'm glad I did.

[Janknitz]

Had I purchased my new machine via local DME I would have had to pay out of pocket $147 monthly x 10 months in addition to what insurance payment to DME.

Are you certain about this??? If you are calculating a percentage of what they told you the monthly retail rental price was (assuming your insurance will pay the rest) you might not be calculating correctly. That's because every insurer sets the amount they will pay, and your share is based on the insurer's amount, not the fantasy price the DME wishes it would get. THE ONLY WAY TO KNOW WHAT YOU WILL PAY IS TO CONTACT YOUR INSURER. NEVER trust the DME to tell you what your out of pocket share would be.

[LSAT]

I agree with Janknitz...Insurance companies are not stupid...they are not about to allow DMEs to charge that huge amount. All insurance companies and Medicare have agreements with DMEs regarding how much they will allow for a medical product. Your DME may have a retail price of $1500 for a CPAP device, but the agreement with insurance will only allow for a $800 payment. This means that if you have a 20% co-pay, you pay $200 and the Insurance company pays $600. Same goes for the rental payment...I'll bet your portion of the monthly payment is about $30 or less. CALL YOUR INSURANCE COMPANY AND ASK.

[elg5cats]

Insurance companies are not stupid...

One would hope so, but there's always room to question????

Are you certain about this??? If you are calculating a percentage of what they told you the monthly retail rental price was (assuming your insurance will pay the rest) you might not be calculating correctly. That's because every insurer sets the amount they will pay, and your share is based on the insurer's amount, not the fantasy price the DME wishes it would get. THE ONLY WAY TO KNOW WHAT YOU WILL PAY IS TO CONTACT YOUR INSURER. NEVER trust the DME to tell you what your out of pocket share would be.

This is my insurance company's response to my question about CPAP coverage.
"durable medical equipment is replaceable after 5 years with a prescription from your physician. You will need to obtain any equipment and supplies from a network medical supplier for best benefits. Online purchases are not reimbursable. A CPAP is a rent to own item with a 10 month rental period and is subject to 10% coinsurance in network, 40% coinsurance out of network up to the $1700.00 out of pocket maximum in network, $2000.00 out of network."

I do question if the quote I was given is for an out of network price although I'm not out of network.....I have a professional relationship with the DME (not an employee of the DME, in my job I do have assist patients in obtaining DME supplies), I will check with a management employee out of curiosity. However, when I purchased my machine 8 years ago, I had to pay nearly $70 monthly for the 10 months in a in network DME...I realized quickly I was paying more than reasonable. My intent from the beginning is to use my flex spending account to pay for my machine. I will have to file a claim with my insurance and get a denial before I can submit for flex spending reimbursement. I think it offers an educational moment for the insurance company as well. I'm going to challenge that CPAP.com is a out of network DME...however, I recall 2 years ago being told machine has broken to be replaced even at 5 years....this should get interesting!!!!

[Thatgirl]

Something to keep in mind, regarding those out of pocket copays. If you play on the insurance company's terms with a local DME, all of those copays you make toward their lease to own program are applying toward your insurance out of pocket maximum for the year. I had a 13 month lease to own program, spanning the end of 2014 and the entirety of 2015. In early 2015 I had a bad arm injury and had to go to therapy twice a week at a $20 copay each time- plus x rays, an MRI, seeing ortho a bunch of times, and all of my other medical needs. In October I met my out of pocket maximum. I believe all insurance plans need that now with the affordable care act. In October, I had no copays for anything for the rest of the year. That meant I never even ended up making my last 3 payments toward my cpap. Every insurance plan has a different max out of pocket- mine was a highly reasonable $3000. Just something to keep in mind. Obviously I have no idea about your insurance plan or other predicted medical expenses.

[elg5cats]

Something to keep in mind, regarding those out of pocket copays. If you play on the insurance company's terms with a local DME, all of those copays you make toward their lease to own program are applying toward your insurance out of pocket maximum for the year. I had a 13 month lease to own program, spanning the end of 2014 and the entirety of 2015. In early 2015 I had a bad arm injury and had to go to therapy twice a week at a $20 copay each time- plus x rays, an MRI, seeing ortho a bunch of times, and all of my other medical needs. In October I met my out of pocket maximum. I believe all insurance plans need that now with the affordable care act. In October, I had no copays for anything for the rest of the year. That meant I never even ended up making my last 3 payments toward my cpap. Every insurance plan has a different max out of pocket- mine was a highly reasonable $3000. Just something to keep in mind. Obviously I have no idea about your insurance plan or other predicted medical expenses.

Unfortunately my insurance sets up DME and out of pocket expenses separately from other medical care. I have insurance through a employer with self insurance plan which has some rules different from larger company insurance companies. In most respects the insurance is a good plan with good coverage. We have a flex spending option that allows up to put $ into an account which takes $ our of our pay and prevents that $ from being taxed. Then if the $$ is not used by the end of the year, the company gets to keep the $$$. This year I over projected and was at risk of losing $$$ so decided to purchase a machine to prevent losing $$$ and lower my actual cost of my machine and not have to deal with the DME resistance to getting the machine I wanted vs. machine they can have biggest profit off!