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Why US health care costs so much
#1
Today I received in the mail a flyer from my local DME offering me supplies, and which included a brief list of what Medicare will pay for. Having just acquired a couple of Wisp cushions from Amazon for $22 and change, including shipping, I was curious how much my copay would be if I ordered them from the DME in the future. They said they billed Medicare $50 each, and that my copay would be 20% of that, or $20. For the $2 difference I think I'll just continue to buy them on Amazon.

My point here is that the Amazon merchant is clearly making a profit selling them to me at $11 each. The cost to the DME can't be much more than the Amazon merchant is paying, so their profit is enormous. Further in the conversation the DME representative told me that they would sell them to me for $25 each if I just paid cash in full so they wouldn't have to bill Medicare. She pointed out that they could sell them to me for half price because it costs them so much in paperwork to bill Medicare.

I have long felt that at least half the dollars we pay for health care goes for paperwork, and from the above example, it's probably far worse than that.
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#2
JJJ, you said: "I was curious how much my copay would be if I ordered them from the DME in the future. They said they billed Medicare $50 each, and that my copay would be 20% of that, or $20".

I want to know where the person at your DME went to school. First, there is an allowed amount no matter what the DME bills the insurance company. Secondly, 20% of $50 is not $20, it is $10 but would be $20 for 2 cushions. BUT, you never pay 20% of the cost that is billed to the insurance company; you may 20% of what the contracted price is with the insurance company. So, if the DME bills your insurance company $100 for 2 cushions, and the contracted price for 2 cushions is $60, then you only pay $12.

I only pay around $9 for 2 cushions and 2 filters each month.
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#3
I think JJJ might have meant $20 copay for 2 cushions.

Whenever the government gets involves in something, the cost rises; and the choices become limited.
And they sure love paperwork.

It pays to have a medigap policy if you're on US Medicare. The medigap policy pays that 20% -- and if medicare pays, they they cannot refuse to pay the 20%
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.
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#4
(03-12-2014, 05:02 AM)justMongo Wrote: I think JJJ might have meant $20 copay for 2 cushions.

Whenever the government gets involves in something, the cost rises; and the choices become limited.
And they sure love paperwork.

It pays to have a medigap policy if you're on US Medicare. The medigap policy pays that 20% -- and if medicare pays, they they cannot refuse to pay the 20%

Yea, I know that he meant $20 for 2 cushions but what I was trying to say is that the DME is misleading him because it doesn't matter what they charge medicare, there is a contracted price so it is doubtful that he would be paying $20 for 2 cushions.

I have a medicare advantage plan and I only pay $9 per month for 2 cushions and 2 filters.

I heard medigap plans are expensive (at least in the state where we live) but nobody in our household is eligible for medigap. You have to be 65 I think.

Not all states are created equal
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#5
I don't think you have to be 65 to get a medigap plan -- just be on medicare.
I get my medigap plan subsidized by my former employer.
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.
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#6
(03-12-2014, 08:09 AM)justMongo Wrote: I don't think you have to be 65 to get a medigap plan -- just be on medicare.
I get my medigap plan subsidized by my former employer.

https://www.medicaresupplement.com/eligi...fgodDUsALQ
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#7
I should have said in my original post that I have just Medicare A and B; no Advantage or Medigap plan. And I also should have mentioned that the DME employee led me to believe that $50 per cushion is what Medicare allows them to bill per cushion. And, as has been noted, the $20 figure I mentioned is what my copay would be for two cushions - that is what I was comparing to the $22 and change that I paid for two cushions and shipping on Amazon.

If they are allowed to bill Medicare $50 per cushion then Medicare will pay only $40 of it, but that is still outrageous.

It would be interesting to see exactly what Medicare will pay for all the various things that we use. I'm sure a list is on the net somewhere, but I have to get to the university right now, so googling will have to wait.
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#8
(03-12-2014, 09:50 AM)me50 Wrote: https://www.medicaresupplement.com/eligi...fgodDUsALQ

Interesting link... I did not know that.

I looked up one of my MSN statements for my DME supplies.
On 30 September 2013, I got 3 mask cushions: Here's how it broke down per cushion.
They billed $72.99
Medicare allowed $40
Medicare paid $31.36
my share would have been $8
However my Medigap paid the $8
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.
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#9
Amount billed $79.98
Exclusions $35.84
Plan paid $30.90

so $44.14 is the allowed amount for 2 wisp nasal cushions.

In network provider I would pay $8.82

Out of network provider I would pay $13.24

This is medicare. The thing to remember is that there are usually individual contracts with each provider even with medicare. So it pays to shop around if you have that option in the area you live in.

While I think what the DME is getting paid for 2 cushions is outrageous, at this stage in my life, I can only be concerned with what I have to pay.

Hope this helps explain it a little better.
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#10
I'm in one of those Medicare competitive bid areas. DMEs bid to be suppliers; and if they didn't hit the low-ball mark, they cannot bill medicare.

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.
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