DMEs and Prior Authorizations

Hello! New to the community.

Prescribed CPAP (19.5mm) one week ago. Currently awaiting trial period.

In anxious anticipation, I'd stumbled upon this forum, where I'd hoped to familiarize myself with the various brands of machines. I learned about the sketchballs and their stripped-down equipment, so I prodded my DME for information about what they offer.

They have ResMed 10 Airsense Autosets on the shelf, but everyone gets a regular Airsense 10. The Autosets are "display models only." Apparently they only hand out the Autosets on a temporary basis if there's an issue like the pressure needing to be recalibrated. Long story short, they sounded like they were bullshitting me, and I don't feel the need to argue with them at all.

It's my understanding that I can walk into any DME with an Rx and a Prior Authorization and walk out with a machine. My question is, will the PA be submitted before the start of the trial period (scheduled 10 days from now) or after I follow up with the doctor? I'd prefer to skip the DME entirely and vet my list of participating vendors until I find a reasonable one.

Question 2: My current DME is directly attached to the office of the sleep physician, leading me to conclude (perhaps falsely) that they are somehow more integrated with my case management than a different DME. They all work together in the same office. If I decide to take my business elsewhere, will they be in similar communications with the sleep physician? Any experiences with this would be appreciated.

Unless you are in an HMO, they cannot BY LAW force you to use any particular DME.
Find out who is in network for your insurance.
Do NOT take any crap.

If you want an Autoset, which you do, make sure that it is on your prescription. That is what they are REQUIRED to dispense. If they can't get it in, then go elsewhere. They are not integrated with your case. Your prescription can be used by ANY DME. If you need changes later, I suggest accessing the clinical panel yourself (hold down Home Button and knob for about 5 seconds) .

Call your insurance company to see which is in network.

I agree....get your doctor to specify "autoset" on the prescription. The DME must fill as prescribed. Check with your insurance company as to what DMEs are in network...you can go to any DME with your prescription. Be sure you have a personal copy of your sleep study and prescription.

I agree that the key is to get the doctor to give you a new prescription for a specific machine like Resmed AirSense 10 Autoset. Explain that you want to be very involved in your therapy and closely monitor your progress using the recorded data.

The insurance will pay the DME the same amount no matter which machine he gives you. If he gives you a lower end machine, he makes more profit and you are getting less for your money and will not have access to the data you need to monitor your therapy and troubleshoot any issues that may come up. Sometimes, threatening to take your business and prescription elsewhere can bring them to their senses.

LtDanMacallan wrote: They have ResMed 10 Airsense Autosets on the shelf, but everyone gets a regular Airsense 10. The Autosets are "display models only." Apparently they only hand out the Autosets on a temporary basis if there's an issue like the pressure needing to be recalibrated. Long story short, they sounded like they were bullshitting me, and I don't feel the need to argue with them at all.

It's my understanding that I can walk into any DME with an Rx and a Prior Authorization and walk out with a machine. My question is, will the PA be submitted before the start of the trial period (scheduled 10 days from now) or after I follow up with the doctor? I'd prefer to skip the DME entirely and vet my list of participating vendors until I find a reasonable one.

Question 2: My current DME is directly attached to the office of the sleep physician, leading me to conclude (perhaps falsely) that they are somehow more integrated with my case management than a different DME. They all work together in the same office. If I decide to take my business elsewhere, will they be in similar communications with the sleep physician? Any experiences with this would be appreciated.

For the most part an auto PAP is preferable to a CPAP set at a fixed pressure, just as being in control is better than being controlled. Your life is the one you care about most. In terms of the relationship between the DME and sleep doc: I consider it highly unethical if the doc is being guided in his prescriptions dependent upon the profit motive of the DME (even if he owns it). If he will not write you based on your needs and your commitment to be thoroughly engaged in your therapy, find another doc. Keep in mind, ANY doc in any specialty can write the script - even a dentist.
If you can get the doc's cooperation, see if you can get a script that covers as many contingencies as possible. For example: "Pt needs APAP machine brand and model to be specified by pt - unit must be fully data-capable with initial range set for xx-yy cm H2O; Unit must include and be activated with breathing relief such as AFlex or EPR; all typically included components must be present, including hose (prefer heated), humidifier, case, data card, manuals, etc. Pt will be fitted with mask of his choice."
If you can get this, you should be able get what you want, not what they want to give you.
Regarding "case management," for many DMEs "compliance" is the operable concept. Going forward, they get paid based on you "doing your time" and little else other than providing supplies. For the most part, they couldn't care less what your data looks like as long as you use the machine at least 4 hours per night in at least 75% of the nights you have it. On the other hand, you are the one who really should care how well you are doing - your data will help you discover that. Grab any lever you can to take control - let go and you can run into the ditch very quickly.
Finally, no DME is going to turn your business away - keep looking within your network to find the one who will cooperate most and not fight you for control.

What's the Lt in front of your name stands for?

Question 2: My current DME is directly attached to the office of the sleep physician, leading me to conclude (perhaps falsely) that they are somehow more integrated with my case management than a different DME. They all work together in the same office. If I decide to take my business elsewhere, will they be in similar communications with the sleep physician? Any experiences with this would be appreciated.

Reply:
Medicare (and most other insurers) don't allow Sleep Physicians who prescribe treatments items to own or be part owners of DME companies who sell the items. You can ask this question from the owner of the DME provider which you deal with. They all know it and follow these regulations. But it is nice to deal with all these entities who know each other.

Question 2: My current DME is directly attached to the office of the sleep physician, leading me to conclude (perhaps falsely) that they are somehow more integrated with my case management than a different DME. They all work together in the same office. If I decide to take my business elsewhere, will they be in similar communications with the sleep physician? Any experiences with this would be appreciated.

What you should "conclude" is that your doctor has a vested interest (overt or covert) in the DME's business and profits. So decisions about your equipment needs may be based on what's profitable for the DME, not what's necessarily best for you. That's why your doctor won't necessarily go to bat for you if you want the Airsense Auot instead of the Brick (Airsense 10)--less profit for the DME, less kickback for him.

It's almost always bad news when a doctor is closely affiliated with a DME. Can you spell "conflict of interest"?

Janknitz wrote:

...if you want the Airsense Auot instead of the Brick (Airsense 10...

The AirSense 10 CPAP is the "brickish" one; the ELITE, AutoSet, and the "For Hers" are all fully data-capable. The AirSet models are all bricks (even the autos).

[quote="avi123"]What's the Lt in front of your name stands for?


I assume Lt stands for Lieutenant, but you'll have to to wait until the OP comes back to give the definitive answer.