Newbie w High deductable - bother with local DME?

Newbie here with a $5000 annual deductable which just reset. Is it even worth it to visit with a DME locally after our titration study? Or just go online and get what we want given our budget? I guess I will price out what the allowable charge is on various machines just to see if the DME is cheaper. But I've just read through so many complaining comments on DME's, is there any added benefit to dealing with them? Our insurance (UnitedHealthare) told us Apria, Lincare, and RoTEC are contracted with them. Although, our doctor usually works with American Homecare.


thanks!
D

dkeller wrote:Newbie here with a $5000 annual deductable which just reset. Is it even worth it to visit with a DME locally after our titration study? Or just go online and get what we want given our budget? I guess I will price out what the allowable charge is on various machines just to see if the DME is cheaper. But I've just read through so many complaining comments on DME's, is there any added benefit to dealing with them? Our insurance (UnitedHealthare) told us Apria, Lincare, and RoTEC are contracted with them. Although, our doctor usually works with American Homecare.

your best bet if you don't care about brand new would be secondwind cpap, if you want new, someplace like cpap.com.

or, of course, craigslist if you really want to save

You should be able to talk to those DME providers and ask what their allowed costs are through UnitedHealthCare. Chances are, with that high deductible you will pay 100% out of pocket and it will be at least 3X the cost of going through an Online DME. Bigger savings are available here on the forum and through Craigslist. You are already paying a lot for the sleep study and titration.

If it was me, I'd take the diagnosis, and get a prescription for an auto CPAP, masks and accessories and self-titrate, using an auto and best-priced equipment. It really depends on how comfortable you are with doing that and taking charge of your therapy. Most titrations seem to provide a good starting point, but I'd wager a majority here have made significant changes in equipment and pressure on their own. You will spend more for a titration study than for all the equipment to get started.

I agree with the above - UNLESS - you expect to hit your maximum out of pocket for the year.

It also depends on if you will reach your annual deductible and how good your coverage is thereafter. In my case, deductible is $5k but I am expecting twice that in medical expenses. With my insurance, coverage after the deductible is at 100%; therefore, the expensive DME would merely help bring me to the out of pocket max sooner. End of the day I pay the same $5,000 whether the DME is a good deal or rip off.

- Flappy

You'll be waaaay ahead money-wise and have fewer headaches if you go through an online seller like CPAP.COM as opposed to a local DME. And, be sure to get the physical copy/original of your prescription.


Den

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dkeller wrote:Newbie here with a $5000 annual deductable which just reset. Is it even worth it to visit with a DME locally after our titration study? Or just go online and get what we want given our budget? I guess I will price out what the allowable charge is on various machines just to see if the DME is cheaper. But I've just read through so many complaining comments on DME's, is there any added benefit to dealing with them? Our insurance (UnitedHealthare) told us Apria, Lincare, and RoTEC are contracted with them. Although, our doctor usually works with American Homecare.

Depends on if that is your annual out of pocket limit and not your actual deductible.

I have an $800 deductible with $4000 annual out of pocket max expenses. they are two separate counters. the deductible means that means the first $800 come completely out of my pocket (also reduces the out of pocket max), but after that, the insurance pays 80% and I have a 20% co-insurance. Once I reach the max out of pocket then I have no co-insurance payments. I had UHC last year.

My local DME which is not Apria or Lincare wasn't that bad. Hassle over co-pays that eventually got straightened out. This year, I would just go through either CPAP.com or find a good deal on CL or elsewhere.

$5000 is the in-network deductible, out of pocket max is higher! (I know, high, but we have an individual policy). Good thing is that the original sleep study was and the titration study will be covered 100%. not even a copay. PAP machine, however, I realize will be 100% out of pocket, at least for now, as we don't expect any other major medical expenses this year.

I'm curious to hear that most people use the original diagnosis only as a starting point to self titrate. DH hasn't had his titration done yet. How do they determine whether he should get a Rx for an APAP vs CPAP vs BiBAP? Or is there just a general Rx and through costly trial and error of renting/buying/returning machines does DH figure out which he likes best?

I'm curious to hear that most people use the original diagnosis only as a starting point to self titrate. DH hasn't had his titration done yet. How do they determine whether he should get a Rx for an APAP vs CPAP vs BiBAP? Or is there just a general Rx and through costly trial and error of renting/buying/returning machines does DH figure out which he likes best?

Worse than that. For APAP vs. CPAP, the DME will try to foist a CPAP on your husband UNLESS the doctor specifically prescribed an APAP with a range of pressures. A CPAP can be run like an APAP, so it's best to get the versatility of the APAP, but the vendor makes more money with a CPAP, and if your doctor later thinks an APAP would be better, you're out of luck until it's time for the insurer to cover a new machine (which could be as long as 5 years from now).

Most insurers require you to "fail" CPAP before they will cover a BiPAP, so if your insurance requires you to buy a CPAP/APAP outright or with a short capped rental period, then you'll have to go through the hoops to fail before you can get a BIPAP and start the insurance games all over again.

Fun.

So if you can afford to buy outright, then it depends on how the titration goes, and what the doctor recommends.

dkeller wrote:$5000 is the in-network deductible, out of pocket max is higher! (I know, high, but we have an individual policy). Good thing is that the original sleep study was and the titration study will be covered 100%. not even a copay. PAP machine, however, I realize will be 100% out of pocket, at least for now, as we don't expect any other major medical expenses this year.

I'm curious to hear that most people use the original diagnosis only as a starting point to self titrate. DH hasn't had his titration done yet. How do they determine whether he should get a Rx for an APAP vs CPAP vs BiBAP? Or is there just a general Rx and through costly trial and error of renting/buying/returning machines does DH figure out which he likes best?

Out of pocket you can decide to go immediately with an APAP, and make a deal. Grayghost4 on this forum is currently selling a brand new Philips Respironics System One Auto machine for $350. Just passing along the good Karma. That machine has the ability to self-titrate and gives data that lets you optimize therapy, assuming you don't need a lot of hand-holding, the forum can help you interpret the data. If you can get a prescription for a mask, you'd be on your way for an investment of less than $500. If it makes financial sense to go through insurance, and get a higher level of service (and a lot of delay for titration study, equipment approval, procurement, issuance) then by all means to that. Otherwise, I'm suggesting take the bull by the horns, get the prescription and start treating the problem.

Janknitz wrote:

I'm curious to hear that most people use the original diagnosis only as a starting point to self titrate. DH hasn't had his titration done yet. How do they determine whether he should get a Rx for an APAP vs CPAP vs BiBAP? Or is there just a general Rx and through costly trial and error of renting/buying/returning machines does DH figure out which he likes best?

Worse than that. For APAP vs. CPAP, the DME will try to foist a CPAP on your husband UNLESS the doctor specifically prescribed an APAP with a range of pressures. A CPAP can be run like an APAP, so it's best to get the versatility of the APAP, but the vendor makes more money with a CPAP, and if your doctor later thinks an APAP would be better, you're out of luck until it's time for the insurer to cover a new machine (which could be as long as 5 years from now).

Most insurers require you to "fail" CPAP before they will cover a BiPAP, so if your insurance requires you to buy a CPAP/APAP outright or with a short capped rental period, then you'll have to go through the hoops to fail before you can get a BIPAP and start the insurance games all over again.

Fun.

So if you can afford to buy outright, then it depends on how the titration goes, and what the doctor recommends.

Other way around. An APAP can be run in CPAP (single pressure) mode, but a CPAP cannot be run in a range of pressures.

I know she knows the difference, I think her fingers mis-typed the sentence.


Den

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Do you expect to hit your deductible during the year even without the CPAP? If so, you get the money back later in the year because your deductible ends sooner.

A local DME makes mask fitting and exchange easier. Repairs are also easier. Many doctors are too stupid or lazy to read your CPAP data themselves and depend on the DME to do so. You probably won't get the online monitoring if you don't go through a local DME.

Consider all that, check prices and make your decision.