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[Equipment] Insurance Benefits
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Sleepster Offline
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Posts: 4,994
Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #21
RE: Insurance Benefits
(02-04-2013 02:09 PM)TheWerkz Wrote:  Are you saying the total price paid by both your insurance ($1,963.23) AND your out-of-pocket portion ($392.60) for a REMstar Pro including the mask, hose, humidifier and filters etc cost $1,963.23 + $392.60 = $2355.83 ???

Yes sir. And that's a very famous nationally known insurance company.

The DME presented a bill to the insurance company in the amount of $6830.00 for a Remstar Pro, humidifier, nasal mask, hose, and filters. The insurance company disallowed almost 2/3 of it!

Just keep in mind, Werkz, that if you were to become a DME you'd have to take quite a beating on this forum to make that kind of profit. It goes with the territory. Sad

Sleepster
Apnea Board Moderator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-04-2013 03:02 PM
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SuperSleeper Offline

Administrators

Posts: 9,970
Joined: Feb 2012

Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #22
RE: Insurance Benefits
(02-04-2013 08:53 AM)Sleepster Wrote:  If my co-pay is $190 with the brick then where does the incentive come from?

Apparently I'm not making myself very clear. Again, your co-pay has nothing to do with how much the DME was paid for the CPAP. Forget about that co-pay - it really has nothing to do with the DME's financial incentive to give you a brick. That co-pay amount is simply your portion of the total bill.

Let's take this from the top: The DME got paid roughly $1500 for the REMstar Pro as I said (actually $1,507.94, as you said). DMEs always get paid roughly $1500 to dispense CPAP, no matter what kind (Plus, Pro or Auto). That was exactly what happened in your situation.

Some of that $1500 was given to them through your co-pay, and some of that was through direct insurance company reimbursement, but the fact remains that the DME was paid a total of $1500 to give you a data-capable CPAP. The total amount the DME received (made up of the amount insurance paid plus your co-pay) would have been the exact same amount had you been given a REMstar Plus, REMstar Pro or REMstar Auto.

If the DME gets paid $1500 no matter what CPAP is given to you, that is where the financial incentive comes in: They benefit by giving you a cheap brick over a more expensive data-capable CPAP. It's pretty simple, really.

DME cares not that the $1500 was paid partly by insurance and party by your co-pay. They still got their flat $1500 fee for the CPAP as dictated by CMS guidelines.

Having said all that, the extra $100 "upgrade fee" (while legal) is bogus. That's simply the DME trying to extract more money from you.

Smile

SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.

02-04-2013 03:12 PM
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Sleepster Offline
Wiki Editor
Moderators

Posts: 4,994
Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #23
RE: Insurance Benefits
I made some calls today and found out some things, but I'm still waiting to hear more.

First of all it's not only possible, but quite probable, that when my DME told me I could get the brick for $100 less he was either mistaken or just plain lying. It's likely that if I had gotten the brick I would have paid the same amount.

Why do I say this? Well, two weeks after I got my CPAP I switched to a BiPAP and was charged an additional $260. I was told by the DME that this was an additional co-pay because the BiPAP was a more expensive unit.

I found out today that the DME has simply applied that money to my account. It's a credit that's been chipped away as I receive my regular supplies. I still have a credit of about $100.

So it could very well be that I would have been charged the same amount for the Remstar Plus as the BiPAP Pro! In fact, that's the only scenario that I can think of that explains the facts.

I am now insisting that my insurance company provide me with a list of the supplies I'm entitled to, and at what frequency, because I will no longer believe anything that any DME ever tells me again.

Sleepster
Apnea Board Moderator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-04-2013 07:33 PM
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Sleepster Offline
Wiki Editor
Moderators

Posts: 4,994
Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #24
RE: Insurance Benefits
(02-04-2013 03:12 PM)SuperSleeper Wrote:  Apparently I'm not making myself very clear. Again, your co-pay has nothing to do with how much the DME was paid for the CPAP.

I wasn't trying to argue against what you were saying. I was simply trying to get the facts, as I knew them, to either support or refute it.

At this point the most likely explanation is that you are correct and that the DME was either mistaken or outright lied to me. Either way, I've learned that DME's are not to be trusted.

Sleepster
Apnea Board Moderator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
02-04-2013 07:38 PM
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SuperSleeper Offline

Administrators

Posts: 9,970
Joined: Feb 2012

Machine: PR System One REMstar Auto (DS560)
Mask Type: Nasal pillows
Mask Make & Model: ResMed Mirage Swift II
Humidifier: none
CPAP Pressure: 12.5 - 18.5 cmH20 (auto range)
CPAP Software: SleepyHead

Other Comments: Have diabetes Type II

Sex: Male
Location: Illinois, USA

Post: #25
RE: Insurance Benefits
(02-04-2013 07:38 PM)Sleepster Wrote:  I wasn't trying to argue against what you were saying. I was simply trying to get the facts, as I knew them, to either support or refute it.

Oh I know, Sleepster. I wasn't angry at you - I was just frustrated that my writing skills aren't honed well enough to make my point plainly without being overly wordy or confusing. Ask Paula about that - I can never answer any questions in anything less than 500+ words. SHa_biggrin5 My fault, not your's. Smile

Quote:At this point the most likely explanation is that you are correct and that the DME was either mistaken or outright lied to me. Either way, I've learned that DME's are not to be trusted.

Welcome to the dark side. We've been waiting for you... Bigwink Too-funny

I'm not insistent that I know for absolute certainty what is going on in your particular situation. I'm just relaying information that a very large group of folks have communicated to me on how these things work, and the most likely reasons behind what's going on.

Thanks my friend. Let us know what else you find out. Coffee

SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.

02-04-2013 07:46 PM
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jgjones1972 Offline

Preferred Members-2

Posts: 516
Joined: Nov 2012

Machine: ResMed S9 AutoSet
Mask Type: Full face mask
Mask Make & Model: ResMed Quattro FX
Humidifier: ResMed H5i
CPAP Pressure: 18 - 20
CPAP Software: ResScan SleepyHead

Other Comments: CMS50I PulseOx

Sex: Male
Location: Ohio - USA

Post: #26
RE: Insurance Benefits
(02-04-2013 07:38 PM)Sleepster Wrote:  Either way, I've learned that DME's are not to be trusted.

We have been waiting for you.

Grouphug3
02-04-2013 07:55 PM
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