Shocked (in a good way) by my insurance

[Boomer]

I have to say, I have made some negative comments about my insurance (Aetna) on this board, but I was very surprised when I found out, yesterday, that they are paying 80%, which is my in-network rate, for the items I purchased from cpap.com, including, and this really blew me away, 80% for the software and card reader for the APAP!!
It did take them over a month to make the decision, but I was in no hurry.

I never had to deal with their DME, Apria, just got my Rx and ordered here.

What a pleasant surprise.

Boomer

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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, DME, APAP

[dsm]

I am envious. Our insurance companies here only dole out a flat fee for OSA purchase (about half of the cost of the cheapest unit & mask available) & will not even entertain paying for the software.

I am going to have to wait for a while before I can justify the all up cost to get it for my RemStar.

Cheers

DSM

[ldemmery]

Hey congrats! I too had a lucky experience with my insurance.

My cat pierced my hose. Anyways, I bought a new hose from a Canadian supplier (in British Columbia) over the internet. I didn't get it pre-approved, I bought it from an internet supplier and out of province...

I figured I'd get a hassel, but they paid 100% for it. And there was the fact that the old one was only 6 months old. But I got a cheque in the mail last week. Whooo hoo!

Lynne

[jessedog]

I had Aetna last year the hospital they contracted with said they rented my CPAP for a few months then paid for it here in Colorado. They told me DME was 100% covered . Now I have another insurance Cigna as Aetna no longer contracts with my employer and I have been paying for my replacement parts like hoses out of pocket as the DME provider which is a sub contract wants us to fight the insurance and get pre approval, get scripts for every thing etc. It shouldn't have to be this complicated.

[rested gal]

Wow, boomer! You got reimbursed for the software and card reader?! Double, triple WOWSERS!!!

You're right, jessedog...nothing about this should be as complicated as they make it.

[Boomer]

Well, I don't have the check in hand yet, but according to my EOB I viewed on line, that is what they are saying. They processed the entire (itemized) invoice from cpap.com as an in-network provider. The claim status is complete, so, I hope that means "the check is in the mail".

Boomer

[m_l]

Boomer,

I have Aetna through my job. What did you do in order to make this happen?

BTW congrats
Mike

[Guest]

I'm trying right now to press Aetna Open Choice PPO to authorize the equipment of my choice. Advice would be welcome. In case it's helpful to others, here's my experience to date and how I intend to move ahead.

(My employer's HQ is in Washington DC, but I live in NY, if that's relevant.)

After reading this board for a couple of weeks, I persuaded my doctor to write a scrip for a PB420e and H2O heated humidifier. (I'll buy the software myself, that seemed hopeless). The doctor's recommended DME, American Oxygen, has been fairly responsive and helpful. The DME confirmed that Aetna normally authorizes a simple CPAP, not APAP, and that my machine was a "special order" and much more expensive. Aetna, the DME said, would have to authorize the order.

I drafted talking points for a letter of medical necessity and persuaded my doctor to write it. It said that my titration study had been too brief (there was only one hour of monitoring left by the time techs settled on a recommended pressure of 12cm) to ensure that optimum settings had been discovered. APAP would permit ongoing monitoring and adjustment for maximum effectiveness. The letter also said I travel twice a week on business, which is true, and need a very lightweight machine to carry with me.

I'm now waiting for "preauthorization" from Aetna, without which the DME can't go forward. Aetna's member services rep told me on the phone today that the average review time is 6 to 8 weeks. Feh. I asked to speak to a supervisor, got the supervisor's voicemail, and left a message.

My inclination is to ask the supervisor for a fax number for the Preauthorization Department, and an address to which I can send return-receipt mail. (The first-level phone rep claimed there was no such thing.) I thought I'd send a letter by both methods, polite but firm. What I'm thinking of writing is:
(1) I've been told this is a serious condition that requires immediate treatment, and ask for expedited review because delay could be harmful to my health;
(2) My physician and I intend to monitor my treatment actively to ensure effective settings, and if Aetna does not authorize APAP we will have to schedule an additional sleep study or studies, which would cost much more than the marginal expense of APAP;
(3) Having received my doctor's best medical advice, I am determined to follow it, and if need be will take every recourse available to me in internal and external appeals. When Aetna has declined to pay bills in the past, I've found it helped change their mind to give them a date by which I intended to send our correspondence to the state review board, and to specify the address of that board to show I knew where to go.

I'd also like to ask whether I can order direct from cpap.com and be reimbursed.

Anyone have any other magic words to include or avoid to give me best prospects with Aetna?

By the way, I was pleasantly surprised to find that the DME was willing to tell me its negotiated prices for CPAP equipment (the price it charges Aetna):

standard cpap machine 452
humidifier 151
mask 59
headgear 18
------
total 680

I asked what the DME would charge Aetna for the PB420e, the machine I want. They said:

PB420e 940
humidifier 151
mask 59
headgear 18
------
total 1168 ($488 more)

So I'm asking Aetna to pay a little less than $500 than it usually does. If I bought this machine on cpap.com, by the way, I'd pay $393 less than the DME is charging for the PB420e and humidifier.

According to the DME, my copayment is 10 percent of the approved equipment purchase. DME also said Aetna normally requires several months rental first, but the rental price is applied in full toward purchase. I'll want to hear both those things directly from Aetna.

[chrisp]

https://www.cpap.com/productpage/1540 GK 420E w/H20 humidifier $698

Throw in another $90 for a top shelf mask with headgear.

Ask your DME to beat that !

And they wont take out the clinician manual to sell on ebay .



:twis ted:

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CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, humidifier, DME

[Guest]

Thanks for responding. I know about the cpap.com price, which is why I said buying from there would save Aetna (or someone) $398 over the DME's price (which is still, by standards of other DME's cited on this board, pretty tame).

But Aetna certainly won't reimburse me any of that without preauthorization, and may not reimburse at all unless I go through the DME.

So what I'm looking for is advice or experience with getting insurance co's to pay for the machine you want, not the basic one they want to give you.

[Boomer]

Boomer,

I have Aetna through my job. What did you do in order to make this happen?

BTW congrats
Mike

All I did was get a rep, from Aetna on the phone, to say that if I bought from CPAP.com and submitted a claim, they would process it as an out-of-network provider, which they pay 70%, on my plan. I did not get it in writing, just got the rep's name and extension number.

My thinking was, it is going to be hard enough to get used to the cpap therapy, without having to deal with equipment I didn't want, or didn't work for me, so I figured, if they pay a portion, fine, if not, fine, I'm getting what I want.

I put it on plastic and am making payments. I still do not have the check in hand for the re-imbursement, but the EOB on-line shows the claim is completed and payment has been made. It may be that it takes a week or 2 to get the checks mailed out. We'll see.

Boomer.

[m_l]

I just got off the phone with a Aetna rep. Under my plan it covers 70% also. They are going to send me the paper work I need to fill out. I'm crossing my fingers I get reimbursed, if not I got the machine I wanted and sooner rather than later.

Seems like should get that check soon.

Good luck and let us know when you receive the check.

Thanks
Mike

[CandyADiva]

Well I didn't have a hard time with my insurance company I have. My doctor order a cpap with pressure at 13 and all the supplies. So far My Cpap Machine is working very well and the pressure is not hard for me to breeze in and out. everything was brand new and every 6 months they will replace the filters hose and mask and headgear. The DME was very nice and they show me how to use the machine how to take care of it. We talk for an hour about my machine she even explain my sleep study with me and telling me why I need a Cpap Machine.

[Boomer]

Got the check today!! They paid 80% of the entire invoice, including the software and card reader. Now I can pay off that credit card

Boomer

[m_l]

Nice 80% instead of 70%

Congrats
Mike