Gearing up for war...

Guest · Post by **Guest** » Fri Jul 08, 2005 9:19 pm

I am not sure who the enemy is... But I do not have the machine that I want and think that I need, so that I can feel more in-control of my OSA treatment. Plus, I can't afford to have making this rent-to-purchase drag on past December when my $2500.00 deductible will kick in again.

Here is where I am at. The machine my DME is renting (price unknown at this point) me is a Remstar Pro with heated humidifier and all the other necessary gear. My dream machine is the Remstar Auto with humidifier, etc. But at this point I would settle for the Remstar Pro 2. What I am looking for is something to give me data on my progress. I know that I will have to pay for the cardreader and software.

I called my insurance company (Benecorp) and told them my need/desire for the better machine. I also mentioned that I felt like our (me and the insurance companys) best deal would be to purchase the machine from CPAP.com and that in the long run, having this type of machine would save both me and them money. According to them I need to have my Doctor say that I need the better machine and get that approved with some third party agency who will give my insurance Co the go ahead to purchase. So I figured, that armed with the information I have received here, I will have no problem convincing the doctor that this is what I need.

However,, there is a kink in all this. My insurance doesn't buy machines out right all they will do is pay a monthly rental charge which after so many months pays for the purchase of that machine. Their reasoning is that if my agency switches insurance companies before the machine is paid for, they will not be out the months left to cover the cost of the machine. This didn't seem to make as much since to me as buying a machine at the best price that may eliminate the need for us to have to pay for further sleep studies.

Since I wasn't sure how CPAP.com sold their products I called the 800 number and talked to a very helpful person who told me that they do not rent machines or break the charges down to monthly installments nor do they deal with insurance companies. Lucky them! My mission therefore is to get the insurance company to reimburse me for making the purchase and do that before the end of December.

I guess that I am writing this so that I can organize my thoughts and get some advice from the members of this forum about how to proceed with what is looking more and more like it is going to be a war.

Some of the strategies I am considering are... bombarding the insurance company with the numbers facts that proves this (buying through cpap.com) is the best deal for both of us.

Meanwhile doing the same with the Doctor to see if I can convince him that I need a machine that will give both of us important data so that we can keep an eye on my progress.

Another strategy might be to convince the DME to switch machines for the better one and bill the insurance company from now to December in a way that covers the cost of the machine by years end.

I have yet to talk to the DME or the doctor about any of this. I need to get organized first. I need opinions, Am I over looking a good strategy? Am I on the right track? Do I have a chance of pulling this off?

Sorry that this is such a long post.

zart · Post by **zart** » Fri Jul 08, 2005 9:30 pm

I am sorry, I thought that I was signed in.
I am not trying to hide.
The post above is mine.

zart

dirtsurfer57 · Post by **dirtsurfer57** » Fri Jul 08, 2005 10:49 pm

Hey Zart
Man that is exactly what I just went through, I tried to talk my insurance co. into buying from cpap.com, telling them it would save them over 1000.00, but they wouldn't hear of it, so I said ok it's your money. Thanks to several posters on this board though I did speak up about the machine I got, originally the DME tried to give me Remstar Plus but I really wanted to be able to track my progress like yourself, and so I called my insurance co., the sleep lab, my doc and low and behold I got my way and I'm getting the Pro 2 w/cflex, the reader and the software, with the swift mask, so persistence does pay off. Now I know there are more people out there that will jump in that are a whole wiser then me in this area of expertise, so I'm sure your post will be packed full of good ideas in the next day or two. Hang in there and keep us posted.
Later
Roger
H.I.T. (Hosehead in Training) still no machine but it's in the mail!!!!!!!!!

gracie97 · Post by **gracie97** » Sat Jul 09, 2005 1:13 am

Zart,

I'm in a very similar situation:

Want (and can justify) a RemStar auto and software...

...but currently renting from sleep doctor/DME RemStar Pro 2 priced at more than twice what the auto set-up can be purchased for from other sources!

Obviously insurance company policies about CPAP's have not kept pace with technology that can, as you note, save them a bundle over the long term. Given that the sleep docs stand to make money off their ignorance, it is up to us to wise insurers up.

Strategies I'm considering:

(Probably hopeless to appeal to current sleep doctor/DME: he stands to make more money by not changing his prescription.)

1. Asking my primary care provider to prescribe sleep equipment for me on the basis of the sleep test results.

2. Sleep doctor-shopping with my overnight sleep test data until I find one open to my arguments and willing to back me up.

3. Providing subsequent doctors and insurer with list of reasons why I am likely to need more overnight sleep tests ($1500 each) if I do not have ability to monitor my sleep breathing behavior at home as well as a break-down of what the savings and health advantages might be.

(Examples: I sometimes use prescription drugs for migraines that tend to increase apnea. My weight tends to seesaw enough that extra overnight testing may be required.)

I wonder if anyone has gotten the card reader and Encore software package paid for by insurance?

It bugs me, Zart, that we have to fight to get the equipment that will maximize our breathing improvement while minimizing our discomfort.

Grace

ozij · Post by **ozij** » Sat Jul 09, 2005 2:10 am

Here's Mikesus summary of how to go about it:
viewtopic.php?t=2262&start=0&postdays=0 ... 0d1554ea79

O.

gracie97 · Post by **gracie97** » Sat Jul 09, 2005 4:58 am

ozij wrote:Here's Mikesus summary of how to go about it:
viewtopic.php?t=2262&start=0&postdays=0 ... 0d1554ea79

O.

I'm particularly happy to know that there's just one code for CPAP that includes APAP!

So if one has a simple prescription for a CPAP, it appears that ONE CAN BUY ANY CPAP or APAP ONE WANTS?

And then if eligible otherwise -- compliance data and letter of medical necessity as described in Mikesus' second post on that thread -- insurance reimbursement shouldn't be too hard to get.

ozij · Post by **ozij** » Sat Jul 09, 2005 5:27 am

I just ran into this now while searching for other info.

Puritan Bennett's reimbursment guide

O.

ahujudybear · Post by **ahujudybear** » Sat Jul 09, 2005 6:31 am

WOW!!!

Great information there, Ozij!!!

Thanks!!! (As my "Favorites" links under BiPAPs begin to take over my comp!!!)
- JB

wading thru the muck! · Post by **wading thru the muck!** » Sat Jul 09, 2005 3:24 pm

Hey Zart,

Your insurance companies rent to own requirement is getting you screwed. All it does is protect the DMEs pocket book. I bet three months of rental is that same as the cost of the machine from cpap.com. This story about them paying for the whole machine and then you switching insurance is a bunch of crap. They know exactly how long your insurance contract runs and I bet it's atleast three months. Just forget about the insurance company. Buy the machine you want yourself from cpap.com. In the long run it will save you big bucks.

Guest · Post by **Guest** » Sun Jul 10, 2005 7:12 pm

Listen to the Muckster. He's really smart. DMEs are really sneaky. So are some Docs and sleep centers since they are the DMEs.

Gomer

Denny · Post by **Denny** » Mon Jul 11, 2005 6:06 am

I went through the same thing when I was looking into my machine a few mos back and what I did was get my ins agent and bc/bs involved in a 3 way. I got many of the same answers from them as you did, but when I said that if 2000 dollars is no big deal to them I would just not pay my premiuns for 3 mos. They got more cooperative and they did end up covering the machine. The catch was I had to pay for the machine up front and turn in the bill to them. It took about a month to be reimbursed.

zart · Post by **zart** » Tue Jul 12, 2005 1:50 pm

Well I called the DME supplier and we had a discussion with the receptionest and then the owner about trading machines. I have the Remstar Pro and want to trade for the Remstar Pro2 The receptionist said that they don't trade machines because now it is used and they only rent to own. She insisted that the machine that I have gives the same information that the Pro2 does and that she didn't think that I would be able to get and use the software anyway because that was just for doctors or suppliers not for consumers. When I asked to talk with the manager/owner he was conviently not in so I asked that he call me back. I waited all day and finally gave in and called them back myself. The owner was finally in and we talked for a while. He asked me why I wanted to own a machine and the software and I explained that I wanted to be proactive with this treatment. He did finally say that if I got my Dr to perscribe the Pro2 spacifically they would honor that and give me the machine that I want. But I feel like he was thinking that I would not be able to convince my doctor to do this for me. He also told me that the price they charge for the machine that I have now is #1200.00 (CPAP.com charges $594.00) and that he thinks that the charge for the Pro2 will be $1400.00! isn't that increadable! He also told me that they don't typically carry that machine and will have to order it.

My next battle will be to confront my doctor to see what he can do for me. Then after that contacting the insurance company again.

Here is a new kink though... on August 1 my insurance will be with PHP does anyone know anything about them and what I can expect from them?

chrisp · Post by **chrisp** » Tue Jul 12, 2005 2:36 pm

As long as you are doing battle why not fight for something worth the hastle. Ask your Doc for an auto. It will give all the information that you desire and will help your therapy because YOU can actually do something about it. Possibly spend most of the night at lower pressure.. Now thats worth fighting for.

Explain t him that it can always be used as a straight cpap if needed. It may also save you the hastle and expense of another sleep study.

Or just get a Rx for a cpap and order an Auto online at cpap.com if you can spend your own $$$$. You will be ahead in the long run.

Cheers,

Chris

gracie97 · Post by **gracie97** » Tue Jul 12, 2005 3:28 pm

Zart, you're still better off than I am because my doctor is my DME and will probably be quite unwilling to prescribe another machine if it means taking a used machine back.

I really recommend that people find out beforehand if a sleep specialist insists on being the DME provider and avoid such situations.

(He didn't spring this on me until I was just waking up after a night in the lab.)

My doctor/DME is planning to charge "about $1700" for a RemStar Pro 2 with C-flex! Already billed about $350 for a Breeze mask that costs about $90 at cpap.com!

I'm going to have to find another doctor to prescribe. But the big fight may be getting the rip-off doctor/DME to take back the using Pro-2.

(I suspect there are some laws that might apply: E.g. shoving papers at me to sign when I was barely awake from a night in the lab, forcing me to buy such wildly over-priced equipment with no chance to compare prices)

chrisp · Post by **chrisp** » Tue Jul 12, 2005 4:03 pm

I believe medicare requires docs to disclose their relationship with DMEs. Just ask. If they tapdance, BEWARE. If you aren't covered under medicare ask anyway.

Gearing up for war...

Gearing up for war...

First Battle...