A Confusing Situation

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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MikeL_Oh
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A Confusing Situation

Post by MikeL_Oh » Wed Jun 18, 2014 12:21 pm

Hello All -

I am a new member and hoping for some advice. I am a 57 y/o male recently diagnosed with OSA. My employer is based in Rochester, NY - yet I work from a home office in Ohio. My insurance, MVP Healthcare, is a New York company that uses Cigna nationally. My doctor sent the prescription for a cpap machine to a local DME supplier. They called me and advised that they are not in the network of my provider and I would have to pay 80% of the cost. They suggested that I find an "in-network" provider to mitigate the cost. I looked online at my insurer's website and they listed Lincare as the in network provider. I asked the local company to send the records to them. Several days later, I received a call from a company named Apria. They said that I was approved and everything is covered and wanted to make an appointment to come in for a "class" on using the machine. I made the appointment and then they said they would need a credit card number to keep on file. Somewhat taken aback, I asked why they would need that. She replied that the machine has a "modem" and that my insurance company keeps track of whether I'm using the machine or not. If I don't use it properly, they would charge me for the machine. This made no sense to me - so I cancelled the appointment and said I would get back to them. My wife (who works for my Doctor), called the insurer and got the name of another company - Americare. They called me and said that I was pre-approved for a machine and to schedule an appointment. Now a bit leery - I called MVP and they said Americare is not an in network provider. They also said that neither Apria or Americare had called for prior authorization. They said Lincare is the in network provider.

My question - has anyone had this kind of situation and what is the best I can hope for? Is Apria legitimate? Why do these providers tell me I have been pre-approved for a machine and yet they have never done the prior authorization required my MVP?

BTW - I also posted this on the Apnea Support Forum hoping for the most exposure.

Thanks in advance for anyone kind enough to reply.

Mike

Janknitz
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Re: A Confusing Situation

Post by Janknitz » Wed Jun 18, 2014 12:56 pm

Unfortunately, ALL three of those DME's are snakes. Put each of them in the search box above and you'll get an eyeful. In addition to looking for "Apria" look for "Crapria". That right there should tell you something.

I only have experience with Crapria, but I think we've heard less bad stuff about Americare, maybe because they are not as common as the other two.

Since they are already hooked up with your insurance, you should give them a try. BUT, before you do, click on "What you need to know before you meet your DME" in my signature below and read it.

Good luck walking into the lion's den.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

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RogerSC
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Re: A Confusing Situation

Post by RogerSC » Wed Jun 18, 2014 1:12 pm

If Lincare is the only insurance approved DME that's "in-network" for you, I'd work on getting them on the line, and get your information to them. You might have to get your prescription from your sleep doctor, and take it to Lincare, I'm not sure in your situation. I don't know how Apria got your information, unless your sleep doctor/sleep lab sent it to them (or they bought it somehow). But if your sleep doctor won't send your information to Lincare, then ask for your prescription so that you can do that.

Another choice is to go your own way, and use a low margin place like cpap.com, but it seems to be in your interest to give Lincare your business initially. I'd suggest that before you commit to anything with Lincare that you come on back here and talk about what Lincare wants to set you up with so that you can get the benefit of the vast experience base here in avoiding the usual pitfalls *smile*. And I would not deal with Apria at all, they have a terrible reputation, and you're not going to get your maximum insurance benefit using them, so I'd put them about last on my list.

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MikeL_Oh
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Re: A Confusing Situation

Post by MikeL_Oh » Wed Jun 18, 2014 1:19 pm

Hello Janknitz and Roger -

Sincere thanks for the great information. I was literally ready to put my head in the sand and just hope this would all go away - now, at least, I can formulate a plan. Janknitz - your blog page is a Godsend.

Roger - I will post what transpires when I contact Lincare and get the sage advice I so sorely need.

Thanks!

Mike

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70sSanO
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Re: A Confusing Situation

Post by 70sSanO » Wed Jun 18, 2014 1:25 pm

I agree with getting an appointment with Lincare. But you really need to read what Janknitz suggested.

The bottom line is that you want a data capable machine and if you can get an APAP (auto) you are even better off as you can run it in straight CPAP.

I'm sure this means nothing to you now, but it may mean everything to you down the road.

John
AHI: 2.5
Central: 1.7
Obstructive: 0.3
Hypopnea: 0.5
Pressure: 6.0-8.0cm on back with cervical collar.
Compliance: 15 Years

Janknitz
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Re: A Confusing Situation

Post by Janknitz » Wed Jun 18, 2014 1:29 pm

Sorry, I should have said that if Lincare is in network for sure, that's who you should start with, not Americare.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm

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Bill44133
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Re: A Confusing Situation

Post by Bill44133 » Wed Jun 18, 2014 3:41 pm

I also have CIGNA insurance, and am also in OHIO everything that I want to purchase I have to go to CareCentrix http://www.carecentrix.com/.

Before you get into some trouble check in with CareCentrix 1-877-466-0164 first to make sure you are going about
in away so that you are covered.

CareCentrix manages all CIGNA customers cpap needs.

Edit:

http://www.carecentrix.com/contact.html
Your MVP is listed under Sleep Service : 1-888-497-5337

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Last edited by Bill44133 on Wed Jun 18, 2014 8:17 pm, edited 1 time in total.

purple
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Re: A Confusing Situation

Post by purple » Wed Jun 18, 2014 8:01 pm

Part of your question is well answered in Janknitz blog about why you need to know before you meet your DME. I tend to say that many insurance models for how they pay for treatment is some variation of Medicare (I guess because I have Medicare). It is normal for the insurance company to link Compliance with what they pay for.

I have read here that approximately fifty percent of those who go through the sleep tests, gets machines, masks, quit treatment because of the frustrations. So Medicare try to limit their costs by doing a 13 month rent to own. Prove you use it, and it is yours, else, used to be they want their machine back. Since a DME is not supposed to supply a used machine to anyone, not sure why they much would want them back.

The modem is only part of this nonsense of proving compliance, altho in some cases, I have heard that the doc can look at data night to night and perhaps call with specific changes for the machine settings, or if you are not using it, give you a call to see how he can help.

While Janknitz is exactly right about how insurance companies, and DME's seem to conspire to make our treatment more difficult and miserable, I have only had great experiences with DME's. I now use Lincare, and based upon the good nature and kindness of the local Lincare office people I deal with, I have learned to like them. (I have no affiliation with them except as a customer) Might be they are nice because I live in east Texas and businesses need to keep customers, rather than having customers who are an "Insurance carrier hostage", that is, the customer has to be there because that is the DME who their insurance will pay.

Realize that not everyone in the DME office can answer every question you have. The receptionist who answers the phone usually can not help with anything but trying to get you connected to someone else (that is usually the person who is busy, not there whenever you call) There is person who can help fit masks.

No one in my local office can answer specific questions about money, what you owe, what you will have to pay. They will say, and I think it is honest, that depends on what your insurance does. Money things are handled in another office. Be careful to keep records of what you pay, I have had (with another DME) not had my payments posted, or something. The clerks who do the money are low paid, overworked, and in another state.

However the local offices have some individuals who are only interested in helping me, and they do not care about how much their company makes. Find a person who is on the level of helping you select a mask, give you advice, then cultivate your friendship with them. Then you will be past all the problems others have with DME's. but do not get run over, read what JanKnitz has to say.

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bwexler
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Re: A Confusing Situation

Post by bwexler » Wed Jun 18, 2014 9:53 pm

Generally speaking Lincare and Apria seam to be in a contest to see which on can over charge, under perform, send the wrong products and anger the patients the most.
Don't ever give a DME your credit card!!!! If you owe a ballance pay with a paper check or an online transaction you initiate from your bank web site. There are many stories about Apria charging large inappropriate amounts to the credit cards on file. I have been dealing with Apria but many folks with Lincare claim they are worse.
I picked up a supply order from Apria Monday. They had 1 item correct out of of 5 items ordered.

Be sure to read about which machine you should specify. I would (and have) sellect the machine you want and have the doctor prepare a new prescription specifying the exact machine, mask and supplies. Then have him wright "Dispense exactly as written" on the prescription.

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MikeL_Oh
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Re: A Confusing Situation

Post by MikeL_Oh » Thu Jun 19, 2014 1:32 pm

Many thanks to everyone who has provided this valuable information. I am about to call MVP and find out what I need to know before calling Lincare. I will update as things progress - unfortunately I had a busy morning at work and couldn't take a minute until now.

Thanks again!!

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BlackSpinner
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Re: A Confusing Situation

Post by BlackSpinner » Thu Jun 19, 2014 1:45 pm

Go in with the attitude that these guys make secondhand car dealers owned by the Godfather look like honourable, helpful citizens.

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MikeL_Oh
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Re: A Confusing Situation

Post by MikeL_Oh » Mon Jun 23, 2014 11:01 am

I wanted to update the kind folks who provided such valuable advice to me. I spoke at length with MVP (my insurer) and got satisfactory answers to my questions regarding what they pay and how often supplies are approved, etc. I then spoke with the sleep clinic to find out what they had recommended to my doctor and finally to my doctor. I had him add full efficacy data with AHI and leak data to the order. They had already specified the mask, the ramp feature and the heated humidifier. Next I called Lincare and had my doctor fax the order to them. They said they would start the process and get back with me.

More to come......

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MikeL_Oh
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Re: A Confusing Situation

Post by MikeL_Oh » Mon Jul 21, 2014 3:27 pm

Hard to believe that it's been a month since I last spoke about this experience. Thanks to the great advice received here, I knew what to ask for and what to not stand for. It was actually painless; I ensured the prescription was written with all of the features I wanted. After a week or so, Lincare called back and gave me the details - nothing out of line or unreasonable. She said a therapist would call to set up an appointment in a few days. I had a couple of business trips and finally set up the appointment for today. I was surprised to hear that they would come to my house to demonstrate and instruct on using the machine. They brought a ResMed S9 AutoSet with an H51 heated humidifier with slimline air tubing and a Mirage Quattro full face mask. The nurse was a very pleasant young lady and we sat at the dining room table while she went through all of the details and operating instructions. It does have full data capabilities and, in anticipation of doing my own tracking, I downloaded Sleepyhead software.

Tonight is the big night as I saddle up for the first time. Overall, everything went as well as it could have and I hope the new adventure into CPAPing goes just as well. Sincere thanks to everyone on this forum - not only those kind enough to respond to my cry for help, but for everyone who takes the time to post such meaningful information. I feel a lot less isolated knowing that all of you are out there facing the same battle I am engaged in.

Best,

Mike

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woodworkerjunkie
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Re: A Confusing Situation

Post by woodworkerjunkie » Mon Jul 21, 2014 5:48 pm

I want to wish you the best of luck with your therapy and hope everything goes smooth for you. If things don't go as planned, be sure to read and ask all the questions you can. Just don't ever give up!!! If you let it slide and give up, like a few of us did, you may end up regretting it later. The problem is not going to go away, it's better to face it now and save your body from the damage that can be done from not treating your S/A.

When I was first diagnosed, I tried for over 4 months to get this to work. The DME didn't work with me, and I had no clue about this or any other website about S/A. It was the mask that I was fitted with, that was causing my problems (didn't know it at the time). I finally gave up and just went back to sleeping as before. About a year later, I found myself being rushed to the hospital, with tingling and numbness from the top of my head to the bottom of my feet. Ended up in 2 different hospitals, the first one (small hospital) wanted to put in a pacemaker, diagnosed me with congestive heart failure without running any test! The second, (larger heart health hospital) ran a stress test on my heart and assured me they were 99.95% sure it was not my heart. The only thing that they could consider it being was a mini stroke. That is when I got on the computer and found this site and a couple of others and got very serious about treating my S/A. Long story short, don't let something like this happen to you, before you decide to take this treatment seriously. At least you are smart enough to research all of this before major problems set in, unlike me! You will find a lot of people on this board are very helpful and will try to help in any way they can. So, don't ever be afraid to ask a question. Again, best of luck to you!

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Janknitz
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Re: A Confusing Situation

Post by Janknitz » Mon Jul 21, 2014 5:59 pm

You know, in re-reading your original post, something disturbed me. You said both Apria and Americare contacted you claiming they had your prescription, they had contacted your insurer for pre-authorization, and claimed they were in network with your insurer when they were not.

I believe there was a violation of your privacy under HIPAA laws. I'm guessing you may have authorized the sleep doctor/sleep clinic to contact A DME, but it almost sounds like they put your info out there to multiple DME's who could try to be first to get your business when you didn't know better. The sleep clinic or sleep doctor "threw you to the dogs" in a manner of speaking. Otherwise, how would THREE DME's have your information???

I've seen this before and since, and I think there's a clear violation of the privacy of your medical information, originating from your sleep doctor or clinic. Not sure if you'd care to pursue it, but one of these days, someone deserves to get in trouble for this.
What you need to know before you meet your DME http://tinyurl.com/2arffqx
Taming the Mirage Quattro http://tinyurl.com/2ft3lh8
Swift FX Fitting Guide http://tinyurl.com/22ur9ts
Don't Pay that Upcharge! http://tinyurl.com/2ck48rm