Hi Folks,
I've done my titration study and await results to be transmitted to my Dr. I'm currently building my case for my Dr. to prescribe APAP. I'm trying to be positive, have worked around the system plenty in my life, and am prepared to push for what I want. I just want to know what I'm pitting my Dr. against.
A CPAP guidance document ("Choosing a CPAP") from the American Sleep Apnea Association (funded by industry) makes the statement, "More sophisticated machines ... may be covered with a specific physician prescription and documented failure to respond to standard CPAP."
I have:
a) been diagnosed with allergies,
b) a documented history of sinus problems, &
c) intend to lose about 25 lbs by next summer.
When I meet with my Dr. I intend to argue with the following rationale for getting an APAP.
1) no extra cost to insurer
2) anticipated weight loss (Dr. wants me to drop 25 lbs)
3) reduced or no returns for later titration studies (@ $1650 a night)
4) potential for flawed titration study in strange environment
5) accommodates varying pressure needs that may arise due to occasional stuffiness, having an evening cocktail, stress, anomalous sleeping conditions due to camping or travel
My Question:
Are there strict insurance guidelines AGAINST prescribing APAP without the "documented failure to respond to standard CPAP" or do y'all think I have a snowball's chance in Hell of getting APAP for my first machine without the plain CPAP trial and error?
Thanks,
--Andy
PS - if you know of other reasons for getting APAP that I can provide my Dr. please let me know!
Currently I want to get a Respironics M Series Auto CPAP w/ Heated Humidifier:
https://www.cpap.com/productpage-bundle ... undle.html
_________________
Getting APAP w/o "documented failure to respond to CPAP
14 posts
• Page 1 of 1
reason
I just told the doc that I wanted to keep track of my progress by using the software. He was happy that I had been 100% compliant and said OK. He likes for people to do that. Come back in 3 to 4 months.
He wrote a prescription for the exact machine I wanted but warned me that the DME might charge me extra for it. As it turned out, I didn't have to pay extra, but my son did. Same doctor, same DME, different RT. Go figure. My son did not have the exact prescription, so that may be the difference.
Catnapper
He wrote a prescription for the exact machine I wanted but warned me that the DME might charge me extra for it. As it turned out, I didn't have to pay extra, but my son did. Same doctor, same DME, different RT. Go figure. My son did not have the exact prescription, so that may be the difference.
Catnapper
_________________
| Machine: DreamStation BiPAP® Auto Machine |
| Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear |
| Humidifier: DreamStation Heated Humidifier |
There is a little bit of a very common confusion in what you are looking at and what you are asking.
As is commonly referenced, Insurance Companies do not have a specific code set up for an APAP. CPAP has a code of E0601. Insurance Companies do not as a rule cover an auto unit due to the insurance companies considering it to be a luxury/not medically neccessary.
However, since an APAP *DOES* fulfill the defination of the code E0601 it CAN legally be provided as a E0601. There is a little bit of an important distinction there. It's not that they just don't have a seperate code for the autot, it's that they have deemed it not neccessary but since it also meets the criteria for the other unit it can be billed that way if the provider wishes to do so.
The reason that distinction is important to this is the statement that you copied above:
"More sophisticated machines ... may be covered with a specific physician prescription and documented failure to respond to standard CPAP."
This statement refers to the workaround for an auto unit not having a HCPC code. There is a catch-all code - E1399. This is the code used for something that doesn't have another code. It (generally) requires going through the insurance companies Medical Review board and is MUCH more labor intensive and time consuming.
In cases where a patient has a documented failure to respond to CPAP therapy and Bi-Level doesn't seem appropriate an attempt could be made to bill an Auto unit as an E1399 and go through the review process. This could potentially result in coverage for the Auto unit and with reimbursement determined by the insurance company.
Now, all that being said... the typical reasons an insurance company might consider an auto claim would be for things like uncontrolled aerophagia, etc.
Insurance companies will almost never consider it for things like potential future weight loss (Future possibilities generally don't matter to them), desire for monitoring (Smart-Card CPAPs will do this), less future titrations (Again, future possibilities don't matter and a low percentage of people need regular re-titration).
The easiest option is to work with your doctor and your DME provider. Talk to them. It's not uncommon for a DME company to be willing to provide an Auto unit under the E0601 code. This mostly depends on what the reimbursement for your particular policy is. Sometimes they will be willing to provide it under that code and bill you a small upcharge. Some policies allow upcharging, though many do not.
Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.
I hope some of that helps.
mattman
As is commonly referenced, Insurance Companies do not have a specific code set up for an APAP. CPAP has a code of E0601. Insurance Companies do not as a rule cover an auto unit due to the insurance companies considering it to be a luxury/not medically neccessary.
However, since an APAP *DOES* fulfill the defination of the code E0601 it CAN legally be provided as a E0601. There is a little bit of an important distinction there. It's not that they just don't have a seperate code for the autot, it's that they have deemed it not neccessary but since it also meets the criteria for the other unit it can be billed that way if the provider wishes to do so.
The reason that distinction is important to this is the statement that you copied above:
"More sophisticated machines ... may be covered with a specific physician prescription and documented failure to respond to standard CPAP."
This statement refers to the workaround for an auto unit not having a HCPC code. There is a catch-all code - E1399. This is the code used for something that doesn't have another code. It (generally) requires going through the insurance companies Medical Review board and is MUCH more labor intensive and time consuming.
In cases where a patient has a documented failure to respond to CPAP therapy and Bi-Level doesn't seem appropriate an attempt could be made to bill an Auto unit as an E1399 and go through the review process. This could potentially result in coverage for the Auto unit and with reimbursement determined by the insurance company.
Now, all that being said... the typical reasons an insurance company might consider an auto claim would be for things like uncontrolled aerophagia, etc.
Insurance companies will almost never consider it for things like potential future weight loss (Future possibilities generally don't matter to them), desire for monitoring (Smart-Card CPAPs will do this), less future titrations (Again, future possibilities don't matter and a low percentage of people need regular re-titration).
The easiest option is to work with your doctor and your DME provider. Talk to them. It's not uncommon for a DME company to be willing to provide an Auto unit under the E0601 code. This mostly depends on what the reimbursement for your particular policy is. Sometimes they will be willing to provide it under that code and bill you a small upcharge. Some policies allow upcharging, though many do not.
Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.
I hope some of that helps.
mattman
Thanks Matt for the lowdown on the potential for coverage and the DME point of view. I had a very congenial and informative talk with a DME today who seemed to think that I wouldn't have much trouble getting an APAP.
What amazed me today was that the cpap.com website bundle would be about +/- $900 for my desired package (everything but card reader and software). The DME priced out the same package at +/- $2,700. Fortunately its all being paid for by insurance but I can't help think that somewhere in here is the reason for our nation's skyrocketing health insurance and medical costs. Now I will appreciate the home visit/setup and know that a tech has to be paid and the truck maintained and paid for, and I know that there's some cost involved in the billing and so forth, but it sure seems like there's going to be some profit SOMEWHERE in the difference!
It seems like if the rules were a bit different I could get the machine online and pay $100/hr for a consultant to a few hours to visit and set it up, and still contain costs much better than the current system. The Doctor's not prescribing a Ferarri but someone's sure driving one with our health care dollars!
--Andy
What amazed me today was that the cpap.com website bundle would be about +/- $900 for my desired package (everything but card reader and software). The DME priced out the same package at +/- $2,700. Fortunately its all being paid for by insurance but I can't help think that somewhere in here is the reason for our nation's skyrocketing health insurance and medical costs. Now I will appreciate the home visit/setup and know that a tech has to be paid and the truck maintained and paid for, and I know that there's some cost involved in the billing and so forth, but it sure seems like there's going to be some profit SOMEWHERE in the difference!
It seems like if the rules were a bit different I could get the machine online and pay $100/hr for a consultant to a few hours to visit and set it up, and still contain costs much better than the current system. The Doctor's not prescribing a Ferarri but someone's sure driving one with our health care dollars!
--Andy
You might also want to check cpap.com's sister website... billmyinsurance.com. They are very nice there and I talked to them several times with questions. You *might* be able to get this through your insurance using billmyinsurance.com. They can tell you if they can direct bill your insurance.
_________________
| Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear |
| Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
| Additional Comments: original pressure 8cm - auto 8-12 |
My first reaction would be to think that that is the submitted amount, rather than the allowable. *Most* policies are setup by the insurance companies like this:ColoZZZ wrote: The DME priced out the same package at +/- $2,700.
BCBS set the price for us for an E0601 at $850.00. However, they also only pay 40% of the charges submitted to them.
So, in order to achieve the dollar amount they have set for this item, $2125 has to be submited.
Factor in the same for the mask and humidifier and you can see how it gets up there!
I have never personally come across any policy that genuinely pays that kind of money for a CPAP. I've heard some people say that's what they've been charged but I have not personally seen proof that showed it wasn't a misunderstanding of some sort. Anything is possible, to be sure but I wonder about it!
The only drawback in this case would be since he was concerned about the high dollar amount is that billmyinsurance will charge the same amount his DME does since the rates are determined by the insurance company rather than by the DME company or billmyinsurance.yardbird wrote:You might also want to check cpap.com's sister website... billmyinsurance.com. They are very nice there and I talked to them several times with questions. You *might* be able to get this through your insurance using billmyinsurance.com. They can tell you if they can direct bill your insurance.
That issue aside I've seen many posts that said the folks there were very helpful.
mattman
ALLOWABLE by my insurance. What the insurance company will PAY for a cpap machine (apap or cpap)... (you're right... a supplier can BILL whatever they want but the ALLOWABLE is what they get payed)...
$1,385.15
That's just the machine. Humidifiers are equally inflated. When you buy a new mask the insurance company gets billed for a mask AND HEADGEAR as 2 separate items...inflating THAT cost as well. I have the numbers written down as I just went through this a little while ago, but I don't have them sitting here by the computer.
STAGGERING is the best way I can describe it.
If I get a machine through the local DME... ASSUMING I can get what I want, I have a 50% co-pay on durable medical equipment. JUST to replace my remstar auto, my out-of-pocket through the DME would be half of that $1,385.15 figure. Like.... $692 and change.
If I buy a remstar auto from cpap.com and then I submit the same billing code to my insurance.... I think I'd MAKE money. The remstar auto is about $600 from cpap.com. If I submit the ALLOWABLE to my insurance of $1,385.15 and then they reimburse me for HALF of that.... I'd make money in the deal.
$1,385.15
That's just the machine. Humidifiers are equally inflated. When you buy a new mask the insurance company gets billed for a mask AND HEADGEAR as 2 separate items...inflating THAT cost as well. I have the numbers written down as I just went through this a little while ago, but I don't have them sitting here by the computer.
STAGGERING is the best way I can describe it.
If I get a machine through the local DME... ASSUMING I can get what I want, I have a 50% co-pay on durable medical equipment. JUST to replace my remstar auto, my out-of-pocket through the DME would be half of that $1,385.15 figure. Like.... $692 and change.
If I buy a remstar auto from cpap.com and then I submit the same billing code to my insurance.... I think I'd MAKE money. The remstar auto is about $600 from cpap.com. If I submit the ALLOWABLE to my insurance of $1,385.15 and then they reimburse me for HALF of that.... I'd make money in the deal.
_________________
| Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear |
| Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control |
| Additional Comments: original pressure 8cm - auto 8-12 |
The best way to get the APAP is to get the prescription that says what you want and find a DME that is willing to do it.
As stated above, they can provided it under E0601 if they wish (mine did). They also can do that other billing code mattman mentioned, and then it falls into your insurance compainies lap.
The insurance company has its own doctors, and although they never met you and are most likely not OSA speciailists, will KNOW without question what you need better than you or your doc ever could (sarcastic) but that is how it is.
If your insurance company is one who considers APAP deluxe, then you will lose that battle and put your doc through hoops trying to justify something that really can't be justified (other than your comfort, treatment optomization, and the financial justification -- savings to the insurance company (and to you) for avoid future titration studies, etc which the insurance company doesn't care about saving -- how very sad). They don't really care about your comfort or you getting the optimal treatment. They just care that your are an OSA patient and they only pay out this amount for a standard item. Typical big business today. Many won't even pay what they would have for a standard unit toward an upgrade (mine wouldn't).
If your company is enlightened and allow you to pay a "REASONABLE" upgrade (and I mean the difference you see online since you take no more of their time to process or to service than if you had a standard machine so it is only the cost of the machine they are out), then you are in somewhat better shape.
Your best bet is to get the DME to provide it under the standard code with no extra cost and the insurance company will never be the wiser. You will have a cpap (an auto is a cpap) and the DME gets the money.
Yes you could try CPAP and "fail" real or otherwise and maybe get an APAP. Who would really know if you have aerophagia or not? Seems like a waste to me since now the DME has a used machine on their hands when they have to upgrade you. Has to cost them more than just giving you the APAP the first time. But seems like some have to go that way.
What I did is got the prescription and insisted on what was on the prescription. Took a little extra time but I got it. I was happy, I didn't bother the DME again and trade machines, or switch masks etc. My guess is the extra $200 they spend on providing me my machine was less of a cost than the person who trades masks a couple times and comes back later for an upgrade etc. I figure I did my homework up front and probably cost them less than many who get straight CPAP. I figured I got what I wanted and why abuse the DME? I really didn't want to use a DME anyway but my insurance co forced me to in order to get any benefit, another sad reality of American healthcare.
If your DME is not willing to provide the APAP as prescribed under E0601 check others that are in network. Maybe someone else will to get your repeat busiiness.
One could argue all day about the costs the local DME's recoop vs the online prices. There are many types of customers. Those like me who walk in and get the machine and don't bother them again, and there are those who are in often for this and that. Some customers cost more and some less. Does it even out so that the 2x or more one pays for the machines is really what the DME needs to operate? I tend to think they are still making good money. If not why are they in business? Very few businesses operate for long in the red. Just how much they make I would never venture to say since I am not privy to their books. What I can say is with a customer like me they are making plenty. I also don't want their services and would much rather be billed by the hour for it. Rather similar to the group who goes out for dinner and splits the check vs. each paying for what he ate and drank. Who is to say what is right? Insurance by its very nature is a system that is supposed to minimize the risks for a given population and provide monetery assistance to those in need of medical attention when they need it. Obviously someone always overpays and someone always underpays. Actually we all should hope we are healthy enough that we are the ones overpaying and not the ones running up big surgical bills and in pain. Without knowing the DME's bottom line we on this forum can't tell if we are ALL overpaying or not.
As stated above, they can provided it under E0601 if they wish (mine did). They also can do that other billing code mattman mentioned, and then it falls into your insurance compainies lap.
The insurance company has its own doctors, and although they never met you and are most likely not OSA speciailists, will KNOW without question what you need better than you or your doc ever could (sarcastic) but that is how it is.
If your insurance company is one who considers APAP deluxe, then you will lose that battle and put your doc through hoops trying to justify something that really can't be justified (other than your comfort, treatment optomization, and the financial justification -- savings to the insurance company (and to you) for avoid future titration studies, etc which the insurance company doesn't care about saving -- how very sad). They don't really care about your comfort or you getting the optimal treatment. They just care that your are an OSA patient and they only pay out this amount for a standard item. Typical big business today. Many won't even pay what they would have for a standard unit toward an upgrade (mine wouldn't).
If your company is enlightened and allow you to pay a "REASONABLE" upgrade (and I mean the difference you see online since you take no more of their time to process or to service than if you had a standard machine so it is only the cost of the machine they are out), then you are in somewhat better shape.
Your best bet is to get the DME to provide it under the standard code with no extra cost and the insurance company will never be the wiser. You will have a cpap (an auto is a cpap) and the DME gets the money.
Yes you could try CPAP and "fail" real or otherwise and maybe get an APAP. Who would really know if you have aerophagia or not? Seems like a waste to me since now the DME has a used machine on their hands when they have to upgrade you. Has to cost them more than just giving you the APAP the first time. But seems like some have to go that way.
What I did is got the prescription and insisted on what was on the prescription. Took a little extra time but I got it. I was happy, I didn't bother the DME again and trade machines, or switch masks etc. My guess is the extra $200 they spend on providing me my machine was less of a cost than the person who trades masks a couple times and comes back later for an upgrade etc. I figure I did my homework up front and probably cost them less than many who get straight CPAP. I figured I got what I wanted and why abuse the DME? I really didn't want to use a DME anyway but my insurance co forced me to in order to get any benefit, another sad reality of American healthcare.
If your DME is not willing to provide the APAP as prescribed under E0601 check others that are in network. Maybe someone else will to get your repeat busiiness.
One could argue all day about the costs the local DME's recoop vs the online prices. There are many types of customers. Those like me who walk in and get the machine and don't bother them again, and there are those who are in often for this and that. Some customers cost more and some less. Does it even out so that the 2x or more one pays for the machines is really what the DME needs to operate? I tend to think they are still making good money. If not why are they in business? Very few businesses operate for long in the red. Just how much they make I would never venture to say since I am not privy to their books. What I can say is with a customer like me they are making plenty. I also don't want their services and would much rather be billed by the hour for it. Rather similar to the group who goes out for dinner and splits the check vs. each paying for what he ate and drank. Who is to say what is right? Insurance by its very nature is a system that is supposed to minimize the risks for a given population and provide monetery assistance to those in need of medical attention when they need it. Obviously someone always overpays and someone always underpays. Actually we all should hope we are healthy enough that we are the ones overpaying and not the ones running up big surgical bills and in pain. Without knowing the DME's bottom line we on this forum can't tell if we are ALL overpaying or not.
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ColoradoDreamer
- Posts: 126
- Joined: Thu Oct 19, 2006 6:31 pm
I will be seeing my ENT on Thursday to show that I am compliant w/ the rental and have a list similar to yours to justify upgrading/purchasing an APAP. I feel that this will be the first hurtle to overcome. I will go with my sleep log and my excel graphs when I see him. If anything, it should show him how interested I am in monitoring my health. Next is the DME. Then the Ins. Co.
My justification list also includes
-My pressure is what they gave me the night of my first and only visit to the lab. The tech said that I would be coming back for titration study. My report and ENT never mentioned going back. Just wrote prescription with the lab pressure.
-My Excel graphs, created using the data off the machine’s screen, shows that my AHI goes up when I am on my back, my preferred position, and with a FFM. So I am trying to sleep on my side and am using a nasal mask to keep it down. It works. I know that the data from the machine is far from perfect but my DME will not give me copies of the info from the smart card. Only to the Dr.
-the APAP can be set to CPAP too. Pretty lame, I know.
I will tell the ENT that I will get the software and am able to make modifications to the machine. I will also promise not to exceed the prescribed pressure w/out his approval/new prescription. I think my ENT will be like some of the other Dr’s mentioned on this forum that are happy and supportive when a patient takes an interest in their own health.
I have printed out my recommendations for inclusion in the new prescription to include the APAP model/manufacturer,humidifier, pressure settings, setup manual and mask of my choice. I will request the original prescription for future purchases and for when I'm traveling.
Good luck, let us know how it turns out.
My justification list also includes
-My pressure is what they gave me the night of my first and only visit to the lab. The tech said that I would be coming back for titration study. My report and ENT never mentioned going back. Just wrote prescription with the lab pressure.
-My Excel graphs, created using the data off the machine’s screen, shows that my AHI goes up when I am on my back, my preferred position, and with a FFM. So I am trying to sleep on my side and am using a nasal mask to keep it down. It works. I know that the data from the machine is far from perfect but my DME will not give me copies of the info from the smart card. Only to the Dr.
-the APAP can be set to CPAP too. Pretty lame, I know.
I will tell the ENT that I will get the software and am able to make modifications to the machine. I will also promise not to exceed the prescribed pressure w/out his approval/new prescription. I think my ENT will be like some of the other Dr’s mentioned on this forum that are happy and supportive when a patient takes an interest in their own health.
I have printed out my recommendations for inclusion in the new prescription to include the APAP model/manufacturer,humidifier, pressure settings, setup manual and mask of my choice. I will request the original prescription for future purchases and for when I'm traveling.
Good luck, let us know how it turns out.
Here is another thread discussing good arguments for getting an Auto.
viewtopic.php?p=98351&highlight=apap+doctor#98351
viewtopic.php?p=98351&highlight=apap+doctor#98351
_________________
| Machine: DreamStation Auto CPAP Machine |
| Humidifier: DreamStation Heated Humidifier |
| Additional Comments: Compliant since April 2003. (De-cap-itated Aura). |
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DenverCathy
- Posts: 38
- Joined: Mon Dec 04, 2006 11:37 am
- Location: DenverCO
I picked up on you post and it was most helpful to me. Am getting my equipment this Thurs. and am not sure about what I'm getting, at least initially. Since my insurance coverage is important to me, it'll be so helpful to have the info contained in your post. We "newbies" need all the advice and info we can get!mattman wrote:There is a little bit of a very common confusion in what you are looking at and what you are asking.
mattman
DenverCathy
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DenverCathy
- Posts: 38
- Joined: Mon Dec 04, 2006 11:37 am
- Location: DenverCO
14 posts
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