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Is my local DME crooked or is this normal?
#41
RE: Is my local DME crooked or is this normal?
Sadly, this discussion makes me feel better AND worse.  

I've been a nurse for 37 years with a Master's degree.  Never understood why so many patients with OSA didn't use a CPAP.  Then about 16 mo ago, I was diagnosed with SA, both central and obstructive.  What.A.Ride.  

This forum and a couple others have taught me so much.  My DME was WORTHLESS.  And I have made my sleep neurologist and NP aware of it. They were stunned when I showed them the cheap, amatuer YouTube video the DME considered "individual, professional education."  The local DME can't even be reached by phone for help or questions. But I've received some great support from online suppliers.  

I have excellent insurance.  The DME didn't give me any choices on masks or machines. They tried to make me take a Dream station, but I insisted on an AirSense 10 for Her.  They knew NOTHING about it.  I had to force them to give me the AirSense.  Obviously they get a better cut on the DreamStation.  Now my machine is "paid for" so I have instructed them not to send me any supplies until I request them.   I bought my owant DreamWear mask because they "couldn't" get it for me.

When I look at my claims and see them charging my insurance $400 for a new mask, I want to scream.   

Patients are tracked like prisoners to prove compliance, yet DMEs prove NOTHING.  But hospitals and physicians get penalized because chronically ill patients aren't getting better.  SMH.  

Forums like this are SO important.  So is de-regulation of healthhcare supplies . If I WANT to buy a glucometer to check my blood sugar without a diagnosis of diabetes, who cares?  If I want my insurance to pay for an over-the-counter med, I'm going to need a prescription for it.  

You CAN negotiate with your insurance carrier to pay for your items from the online retailer of your choice.  It takes some work and some phone calls, but it can be done. 

I fully expect a few years' from now most insurances will REQUIRE us to get our supplies from online suppliers.  There will be a local rep to do a fitting, then all supplies shipped to you.   Just like many require we get 90-day supplies of prescription meds from mail-order pharmacies, and why CVS and Walgreen's have 2 of the largest mail-order pharmacies. 

Please.  Keep encouraging everyone who comes here. Help them get the education and support they need.  What matters is that EVERYONE understands that sleep is the basis of EVERYTHING. SLEEP IS EVERYTHING. It is at the root of heart disease, multiple cancers, diabetes, Alzheimer's...many of the top 10 killers.  Do not give up!  

 In time, insurance will expect everyone to have a sleep study by 30 or 40 yrs of age, just like a mammogram or colonoscopy by 40 or 50 years. Advances take documentation of research and statistics.  Keep doing what you're doing. You are making a difference. 

After a year, I still struggle...but my average AHI is down from 10 to under 4.  Heading to under 2.  Making progress.  I'm still tired, but not exhausted.  My ADHD is better and my life-long anxiety about sleep is so much better.  I actually look forward to going to sleep at night.   Most everything Ive learned..has come from people like YOU! ♥️♥️♥️  I honestly believe if my sleep apnea hadn't been diagnosed lady year, I would have died by now.
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#42
RE: Is my local DME crooked or is this normal?
(11-09-2018, 06:04 PM)jaw2004 Wrote: Sadly, this discussion makes me feel better AND worse.  

I've been a nurse for 37 years with a Master's degree.  Never understood why so many patients with OSA didn't use a CPAP.  Then about 16 mo ago, I was diagnosed with SA, both central and obstructive.  What.A.Ride.  

This forum and a couple others have taught me so much.  My DME was WORTHLESS.  And I have made my sleep neurologist and NP aware of it. They were stunned when I showed them the cheap, amatuer YouTube video the DME considered "individual, professional education."  The local DME can't even be reached by phone for help or questions. But I've received some great support from online suppliers.  

I have excellent insurance.  The DME didn't give me any choices on masks or machines. They tried to make me take a Dream station, but I insisted on an AirSense 10 for Her.  They knew NOTHING about it.  I had to force them to give me the AirSense.  Obviously they get a better cut on the DreamStation.  Now my machine is "paid for" so I have instructed them not to send me any supplies until I request them.   I bought my owant DreamWear mask because they "couldn't" get it for me.

When I look at my claims and see them charging my insurance $400 for a new mask, I want to scream.   

Patients are tracked like prisoners to prove compliance, yet DMEs prove NOTHING.  But hospitals and physicians get penalized because chronically ill patients aren't getting better.  SMH.  

Forums like this are SO important.  So is de-regulation of healthhcare supplies . If I WANT to buy a glucometer to check my blood sugar without a diagnosis of diabetes, who cares?  If I want my insurance to pay for an over-the-counter med, I'm going to need a prescription for it.  

You CAN negotiate with your insurance carrier to pay for your items from the online retailer of your choice.  It takes some work and some phone calls, but it can be done. 

I fully expect a few years' from now most insurances will REQUIRE us to get our supplies from online suppliers.  There will be a local rep to do a fitting, then all supplies shipped to you.   Just like many require we get 90-day supplies of prescription meds from mail-order pharmacies, and why CVS and Walgreen's have 2 of the largest mail-order pharmacies. 

Please.  Keep encouraging everyone who comes here. Help them get the education and support they need.  What matters is that EVERYONE understands that sleep is the basis of EVERYTHING. SLEEP IS EVERYTHING. It is at the root of heart disease, multiple cancers, diabetes, Alzheimer's...many of the top 10 killers.  Do not give up!  

 In time, insurance will expect everyone to have a sleep study by 30 or 40 yrs of age, just like a mammogram or colonoscopy by 40 or 50 years. Advances take documentation of research and statistics.  Keep doing what you're doing. You are making a difference. 

After a year, I still struggle...but my average AHI is down from 10 to under 4.  Heading to under 2.  Making progress.  I'm still tired, but not exhausted.  My ADHD is better and my life-long anxiety about sleep is so much better.  I actually look forward to going to sleep at night.   Most everything Ive learned..has come from people like YOU! ♥️♥️♥️  I honestly believe if my sleep apnea hadn't been diagnosed lady year, I would have died by now.

Wow what a story. I'm glad to hear that you are making progress!!
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#43
RE: Is my local DME crooked or is this normal?
(11-09-2018, 06:04 PM)jaw2004 Wrote: I fully expect a few years' from now most insurances will REQUIRE us to get our supplies from online suppliers.  There will be a local rep to do a fitting, then all supplies shipped to you.   Just like many require we get 90-day supplies of prescription meds from mail-order pharmacies, and why CVS and Walgreen's have 2 of the largest mail-order pharmacies.

I think it'll take more than a few years, but it's fun to fantasize about some related things ... I'm imagining an eventual opening-up of the sleepydoc trade to make it much more accessible to patients, with a procedure for getting the hardware that would be a lot more like the current situation with blood-pressure meters, glucose monitors, orthotic insoles, knee braces, wheelchairs ...

I think every hospital of any size should have a large sleep clinic operated as just another everyday (or everynight) department like radiology or endoscopy.  A patient arrives in the evening with his or her overnight bag, goes through a cardiac ultrasound scan (which should be routine for a new sleep-apnea patient), and is assigned a bed in a cubicle.  The pressure titration is done that night if at all possible, the Rx is issued in the morning, and the patient can go across the street to the 24-hour WalgCVS store (by that time the only retail drugstore corporation in existence after the mergers, with five million locations worldwide) to get a machine and mask from a huge selection in the store's Sleep Department.

Machines with outrageously high prices?  Why?  Everyone's got CPAP machines in that hypothetical future, just like glucose monitors and Fitbits, so they cost $100 instead of $1000 and the insurance approval for the purchase is a rubber stamp.  A mask is $15, which accurately reflects its manufacturing & distribution costs, and you can try half a dozen makes & models in your first week.

But it gets even better, because I also predict that there will be an APAP smartphone app.  Or actually two of 'em, one from Resmed and one from Philips (but the Philips app will require a PIN that you have to buy from Apple or Google).  You'll plug the hose from your mask into the air outlet of your smartphone.  Then you can watch the usual crap on the phone while you fall asleep.

And if you visit your local unemployment-benefits office, you'll meet a lot of RTs hanging around.  The rich doctors who formerly owned DME companies as tax shelters will have closed those down and bought Bennigan's franchises to replace 'em.
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#44
RE: Is my local DME crooked or is this normal?
(11-09-2018, 06:04 PM)jaw2004 Wrote: When I look at my claims and see them charging my insurance $400 for a new mask, I want to scream.   


That's what they're billing, but that is a fantasy number that the insurance company doesn't pay. They will only pay the pre-negotiated rate which from what I see from my own insurance company is within a few dollars of what the online CPAP suppliers charge for most supplies.

My DME billed my insurance $303.60 for my Resmed N20 mask. My insurance paid $95, which is $3 less than the current price on a popular online CPAP supply website.
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#45
RE: Is my local DME crooked or is this normal?
(11-19-2018, 06:18 PM)foxfire Wrote: My DME billed my insurance $303.60 for my Resmed N20 mask. My insurance paid $95, which is $3 less than the current price on a popular online CPAP supply website.


This is a very valid point. Although I will say that several insurance policies cover around 80% of durable medical equipment and supplies, so in your case above (if you had insurance like I used to have) you'd be paying 20% of that $303.60 (about $60 out of pocket), not 20% of the $95 ($19), even though that's the negotiated rate between insurance and the DME. This is what makes many people skip the frustrating experience of dealing with an insurance company and pay for some supplies outright online themselves. It's just not worth the hassle to go through insurance when the price difference is only $35 or so per mask between your out-of-pocket insurance cost and simply buying one online without insurance. And you get the mask much faster as well, with far less stress.

I hate the way our current insurance billing is done. The patient usually has no clue as to what the real numbers are.
SuperSleeper
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#46
RE: Is my local DME crooked or is this normal?
(11-19-2018, 10:03 PM)SuperSleeper Wrote:
(11-19-2018, 06:18 PM)foxfire Wrote: My DME billed my insurance $303.60 for my Resmed N20 mask. My insurance paid $95, which is $3 less than the current price on a popular online CPAP supply website.


This is a very valid point.  Although I will say that several insurance policies cover around 80% of durable medical equipment and supplies, so in your case above (if you had insurance like I used to have) you'd be paying 20% of that $303.60 (about $60 out of pocket), not 20% of the $95 ($19), even though that's the negotiated rate between insurance and the DME.  This is what makes many people skip the frustrating experience of dealing with an insurance company and pay for some supplies outright online themselves.  It's just not worth the hassle to go through insurance when the price difference is only $35 or so per mask between your out-of-pocket insurance cost and simply buying one online without insurance.  And you get the mask much faster as well, with far less stress.

I hate the way our current insurance billing is done.  The patient usually has no clue as to what the real numbers are.

None of the insurance plans I've had for the past 30 or so years has calculated coinsurance that way. Coinsurance has always been a percentage of what the insurance company pays, not the fictitious number the provider (in this case DME) charges. I pay 20% of the $95 for my mask after I reach my deductible, not 20% of the $303.60.

Even before I reach my deductible I still find it better to buy supplies from my local DME because the prices I get because of my insurance are reasonable and count toward my deductible.
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#47
RE: Is my local DME crooked or is this normal?
(11-19-2018, 10:03 PM)SuperSleeper Wrote:
(11-19-2018, 06:18 PM)foxfire Wrote: My DME billed my insurance $303.60 for my Resmed N20 mask. My insurance paid $95, which is $3 less than the current price on a popular online CPAP supply website.


This is a very valid point.  Although I will say that several insurance policies cover around 80% of durable medical equipment and supplies, so in your case above (if you had insurance like I used to have) you'd be paying 20% of that $303.60 (about $60 out of pocket), not 20% of the $95 ($19), even though that's the negotiated rate between insurance and the DME.  This is what makes many people skip the frustrating experience of dealing with an insurance company and pay for some supplies outright online themselves.  It's just not worth the hassle to go through insurance when the price difference is only $35 or so per mask between your out-of-pocket insurance cost and simply buying one online without insurance.  And you get the mask much faster as well, with far less stress.

I hate the way our current insurance billing is done.  The patient usually has no clue as to what the real numbers are.

My experience has been different in that my copay has always been 20% of the negotiated price and not the billed price. My wife’s health insurance is my secondary. It will pick up 100% of the copay as long as both deductibles have been met or 80% of the price my insurance negotiates if my insurance deductible hasn’t been met but the deductible on hers has been. In all cases the most I am ever responsible for is the price my insurance negotiates until one of the deductibles is met and then then my responsibility drops to, at most, 20% of the negotiated price. It worked out really well until the company I work for went with a high deductible policy a couple of years ago.
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