Should I buy through the DME, Hospital or Online?

[Ailu]

Okay, so I called my insurance (Blue Shield) to find out what my choices for DME providers are. The said only one: "Apria".

APRIA? The one I'd heard all the horror stories about? Surely there must be other choices! "Nope".

So I called the sleep center where I am going to get my prescription from, to see if they knew of any other way around this. Thankfully, they knew of Apria's rep, and said they use the nearby hospital instead, with the blessing of Blue Shield. Yay!

At least, this was my initial reaction. But now, in thinking about it, hospitals tend to waaaay over-inflate their prices. (For instance, our doc sent my hubby to have a chest x-ray at the nearby hospital and the bill came to over $4200! We had the same copay regardless, but that's just crazy, ya know?) So here's my questions:

What are the pros & cons of using a hospital vs DME? And if the price is cheaper online vs the copay, what value would I be missing by buying online? For instance, do they allow switching out machines, masks etc? Easier returns? More patient education? Is there any reason worth going through one vs the other, in your opinion?

[me50]

With insurance, they pay based on the contracted price. Your co pay depends on in network or out of network. It doesn't matter how much any facility charges because they won't get paid a dime more than the contracted amount by the insurance company's portion along with your co pay.

where you go to purchase your machine and/or supplies depends on your needs. I don't need help with supplies and can make an appointment with the local DME office if I have an issue with my machine so I prefer to call and tell what supplies I want and have them mailed to me.

While Apria may be a preferred provider (I have yet to see why as they screw up more than they do right), most insurance companies have more than one option. Someone at BCBS may have been too lazy to really look into the answer to your question.

[Sleeprider]

If you are covered for DME without significant deductibles, then the equipment will be purchased at the contracted approved price by your insurance company, and you will owe whatever copay applies. Generally the contract price is competitive with what you see as online prices. The problem is, you won't know what that is until you see the billing statement.

The invoice you ultimately receive will have the equipment full price, insurance discount, covered amount and balance due. For those without insurance, the full price applies...ouch! With your BCBS coverage, you can probably depend on a negotiated price for CPAP of around $800 to $1000, and masks and equipment may increase that by another $200. Base your estimates of copay and deductible from that. With Apria, it gets complicated because they may try to sell on a rental basis over 13 months, and they may try to provide the cheapest machine that applies under the billing code. This is where things get frustrating. The actual acquisition of CPAP equipment can be delayed a long time for Apria to get their billing sorted out, and dispense a machine. It is the time and hassle that is the problem in the end, not the money, assuming you have good coverage.

The hospital may be no better, or they might be very good. If BCBS has a pre-negotiated allowance for the DME, then the same process actually applies. The bottom line is, using any DME may delay your possession and choice of the equipment, and that can be frustrating.

[Ailu]

With insurance, they pay based on the contracted price. Your co pay depends on in network or out of network. It doesn't matter how much any facility charges because they won't get paid a dime more than the contracted amount by the insurance company's portion along with your co pay.

where you go to purchase your machine and/or supplies depends on your needs. I don't need help with supplies and can make an appointment with the local DME office if I have an issue with my machine so I prefer to call and tell what supplies I want and have them mailed to me.

Thanks for your reply!

While Apria may be a preferred provider (I have yet to see why as they screw up more than they do right), most insurance companies have more than one option. Someone at BCBS may have been too lazy to really look into the answer to your question.

That's what I thought. But in researching it further, Apria definitely has a monopoly on Blue Shield, at least within 200 miles of where I live. There is absolutely no other DME choice available - unless you go through a hospital. Crazy eh?

[justMongo]

If Apria asks for a credit card... Say NO!

[Ailu]

Thanks for the info regarding cost. Regarding using a DME, is there any added value to using them besides the insurance paying?

If you are covered for DME without significant deductibles, then the equipment will be purchased at the contracted approved price by your insurance company, and you will owe whatever copay applies. Generally the contract price is competitive with what you see as online prices. The problem is, you won't know what that is until you see the billing statement.

The invoice you ultimately receive will have the equipment full price, insurance discount, covered amount and balance due. For those without insurance, the full price applies...ouch! With your BCBS coverage, you can probably depend on a negotiated price for CPAP of around $800 to $1000, and masks and equipment may increase that by another $200. Base your estimates of copay and deductible from that. With Apria, it gets complicated because they may try to sell on a rental basis over 13 months, and they may try to provide the cheapest machine that applies under the billing code. This is where things get frustrating. The actual acquisition of CPAP equipment can be delayed a long time for Apria to get their billing sorted out, and dispense a machine. It is the time and hassle that is the problem in the end, not the money, assuming you have good coverage.

The hospital may be no better, or they might be very good. If BCBS has a pre-negotiated allowance for the DME, then the same process actually applies. The bottom line is, using any DME may delay your possession and choice of the equipment, and that can be frustrating.

BTW - on our location, Blue Shield & Blue Cross are two completely different insurance companies.

[Sleeprider]

If you don't care about maximum insurance compensation, then by all means don't use a DME. You can buy through any provider of your choice by having a copy of your your prescription (you should anyway). The used (Craigslist) market is available without a prescription, but the choices and prices are all over the place.

You can purchase equipment from any supplier, then submit an out of network claim form to insurance. It will reimburse you at a lower rate on approved, prescribed DME. Check your insurance website or call them about out of network providers and reimbursement.

[Mosquitobait]

I second Sleeprider. Call and find out how to get reimbursement or at least apply the cost to your deductible. If you feel you don't have an average face, it may behoove you to get your first mask through that hospital or even Apria provided that you can switch masks until you find the right one. Don't give Apria your debit card. Stick with a Visa or MasterCard. If they do unauthorized charges, your card will go to bat for you and can bar Apria from charging in the future. Make sure anything you sign states that you will not pay more than the negotiated price with your insurance company.

[becker44a]

I second Sleeprider. Call and find out how to get reimbursement or at least apply the cost to your deductible. If you feel you don't have an average face, it may behoove you to get your first mask through that hospital or even Apria provided that you can switch masks until you find the right one. Don't give Apria your debit card. Stick with a Visa or MasterCard. If they do unauthorized charges, your card will go to bat for you and can bar Apria from charging in the future. Make sure anything you sign states that you will not pay more than the negotiated price with your insurance company.

Hi Ailu,
Welcome to the forum!

My insurance, at the time I acquired my S9 Autoset used Apria. I no longer do business w/ Apria, and (thankfully) the credit card I originally used with them is defunct. I have good and bad to report about Apria. First, the rep I dealt with to get my machine was cooperative, and told me how the prescription needed to be written to get the machine I wanted. I pushed this and it worked out well. Also the RT who instructed me regarding the unit was competent, and answered whatever questions I asked. Later, she was the first person to suggest that sleeping on my back might not work well for me.

The negatives: When I called to order supplies, I got inaccurate, uninformed, wrong information nearly every time. The billing was very confused and confusing. They substituted generic parts for Resmed name-brand parts without informing me of the substitution. The last time I ordered supplies, shortly after, I received a separate envelope with a pages long form they wanted signed that I received and was using the items. The items listed were not accurate to what I actually received, and the prices listed were absurd, in some cases several times what I was actually charged. I have not/will not sign this document.

In your case, since you haven't really started, one of the most significant issues may be their mask trial policy. As it was explained to me, when you order a mask from Apria, you can return it for replacement within 30 days, ONE TIME AND ONE TIME ONLY. What this means is that if you order a mask from Apria, you will end up owning that mask or one other mask, even if the only change is in sizing.

Compare this to the policies of many online suppliers, where you can return a mask within 30 days, for replacement or full refund, as many times as needed. Since the mask is generally deemed to be the most difficult part of CPAP therapy, Apria's mask exchange policy seems unrealistic, and shifts the burden to the patient.

Suggestions:
(1) Get a paper copy of your CPAP prescription. You need to have this for several reasons.

(2) Make sure whatever machine you end up with provides full data. This is critical. Refuse to accept any machine that doesn't meet this requirement. Member Archangle here has a Wiki article about choosing machines.

(3) I recommend an Auto-PAP. Even if you find that you are in the group that doesn't tolerate rapidly changing pressure well, all Auto-PAP units can be set to operate in fixed-pressure mode. This means that you can periodically set the machine in auto-adjust mode to help zero in on what pressure works for you, Many sleep centers do their titration study by sending you home with an Auto-PAP to get data for their pressure recommendation. Having your own Auto-PAP means that you can repeat your own titration study as often as needed, with the added benefit that you are sleeping in your own normal environment, so the results are often more meaningful.

Best wishes, and good luck on your CPAP journey.

[Ailu]

Thanks everyone!

Suggestions:
(1) Get a paper copy of your CPAP prescription. You need to have this for several reasons.

(2) Make sure whatever machine you end up with provides full data. This is critical. Refuse to accept any machine that doesn't meet this requirement. Member Archangle here has a Wiki article about choosing machines.

(3) I recommend an Auto-PAP. Even if you find that you are in the group that doesn't tolerate rapidly changing pressure well, all Auto-PAP units can be set to operate in fixed-pressure mode. This means that you can periodically set the machine in auto-adjust mode to help zero in on what pressure works for you, Many sleep centers do their titration study by sending you home with an Auto-PAP to get data for their pressure recommendation. Having your own Auto-PAP means that you can repeat your own titration study as often as needed, with the added benefit that you are sleeping in your own normal environment, so the results are often more meaningful.

Best wishes, and good luck on your CPAP journey.

Thanks Becker for the very valuable tips! I know I want a PR System One Auto, but beyond that, I am not sure what the differences are between the submodels. Any clarifications on the differences are very welcome!