Long time reader... first time poster

Hello there! So... I'm new. I've been having issues with snoring and EDS for the last year or so, and I finally spoke to my PCP about it after the holidays. He referred me to a sleep clinic and a pulmonologist/sleep specialist at the same time. I had my first appt with the pulmonologist about a week ago, and after listening to my concerns he recommended a split night study.

I had the study done this past Sunday night, the tech told me that if I had 40 'events' in two hours, then they would wake me up and hook me up to a cpap machine. Which is exactly what happened. So after the study was over, I was pretty much in a fog, but I think I was told that my PCP/Pulmonologist would be in touch with me about the results - or she might have said that the sleep lab doctor would be in touch - I really can't remember because I was still pretty groggy when they sent me on my way - but I do know that the tech told me that she could not give me any information about the study. However, I would think that the fact that they put me in the mask in less than 2 hours was pretty indicative of a problem.

So now it's two days later and I'm really, really anxious to just get started... and I'm wondering if any of you might have some advice for me. Should I just call my PCP/Pulmonologist to inquire about the results? Should I call the sleep lab?

Is this the time when I need to be contacting my Ins company to find out what kind of machines they might cover (I have an HMO) The sleep study exhausted my deductible, and I have 0% co-insurance for DME with a $2000 yearly cap, so I'm thinking that means that I won't have to pay any out of pocket for the machine or accessories as long as it's less than $2000... but when I called my Ins company prior to the study to ask, they wouldn't give me any information without CPT codes.

And other than knowing that I want a machine that provides efficacy data, how on earth do I even begin to know what type of machine (brand/model) I want to get?

Even though I've read and read and read on this site (and a few others) I still feel like I know absolutely NOTHING and I'm anxious and a little terrified and I don't want to be a pain an anyone's ass, but I also just want to get some freaking sleep.

So, hi! Thanks for being here and offering whatever advice, anecdotes, or personal experience - I truly appreciate all of the information and knowledge that this board shares.

Those who know more about the tech aspects of the various machines will be along to advise you. I do know that until you have a prescription in hand, you will not know precisely what your needs are. You may need only straight cpap, or bipap, or an ASV machine. When you get the results of your sleep study and your RX, post the results here because we will need to see them in order to advise you.

Ask your doctor to specify an Auto cpap on your prescription, this will get you a better class of machine and is a very reasonable request on your part. Also ask for a heated hose on your prescription.

I believe the current most popular machine is the ResMed Airsense 10. It is full featured and has all the latest bells and whistles. My DME was going to give me a ResMed Airsense 10 and I refused it and told them I wanted a PR System One model 560 because is uses a 12v power supply which makes it more efficient to run on a battery when I go camping.

There are several other machines out there from several different manufactures but those 2 are a couple of the most popular. There are some really small CPAPs that are great for traveling but you usually loose some features by going with the smaller units.

It all depends on what attributes are most important to you?

DME's make a lot of money off of you for doing hardly anything. Tell them what CPAP you want and have them tell you how much insurance will cover. If they wont tell them you will find a DME that will.

Yes: call the Doc, be nice, but tell them you feel like crap and need to know your test results. Grease that wheel! Tell the doc that you have researched the machines and that you want a Resmed Airsense 10. Tell him you need an auto pap machine. It works on low pressure and when an apnea event occurs, it will ramp the pressure up to treat the event, then the pressure will lower back to a comfortable level. The airsense will also work in the cpap mode (straight pressure)... whichever you want. Tell him it is a full data machine and you need to monitor your results every morning. That'll shut him up.

Sheriff

Be sure to read my blogpost below: what you need to know before you meet your DME. The models mentioned are out of date, DME info is still relevant. With an gmo you may be limited in choice of dme's, but only Kaiser seems to dictate make and model.

I want to say thanks to all of you for your advice and comments. Thank goodness I'm not a backsleeper, ChicagoGranny, so that's one less adjustment I'll have to make - I'm a lifelong side sleeper.

I went ahead and called the sleep center today - the person I spoke with said that the test has been read and I have been diagnosed with Severe Sleep Apnea - my AHI was 125. Her suggestion was that I immediately contact my PCP and my Pulmonologist and request an Rx be written based on those results. I've called and left messages with both doctors, now I'm just waiting to hear back from someone.

I've also called my insurance company and was told that they pay by HPCP codes and that there is no 'list' of machines that are not allowed - as long as they are billed under the correct HPCP code, that the allowable amount for a CPAP varies from DME to DME and as an HMO participant in Florida, it is against the law for a DME to balance bill me over the allowable amount. Does all of this sound right?

The insurance company provided me with a list of DME providers and there are 6 on the list that provide CPAP - American Home Patient, Apria Healthcare, Edgepark Medical Supplies, Landauer Metropolitan, Lincare and Rotech... are there any of these that I should be be wary of... or is it more about the local distributor and less about the national DME?

And finally -

Janknitz wrote:Be sure to read my blogpost below: what you need to know before you meet your DME. The models mentioned are out of date, DME info is still relevant. With an gmo you may be limited in choice of dme's, but only Kaiser seems to dictate make and model.

no need to direct me to your blogpost, Janknitz, I've read it so many times that at this point I think I have most of it memorized.

Apria is known as 'Crapria' here and has been for years with good reason... can't speak for the others.

You may need to get a written summary of how much the HMO pays and how much you pay.
Get this from the benefits manager at work (or personnel). Get the doctor to either specify
the make and model of machine, or "patient access to detailed event and leak data".

chunkyfrog wrote:You may need to get a written summary of how much the HMO pays and how much you pay.
Get this from the benefits manager at work (or personnel). Get the doctor to either specify
the make and model of machine, or "patient access to detailed event and leak data".

My DME coverage is 0% co-insurance with a $2000 yearly maximum after my deductible is met (which it has been) So my HMO will pay 100% of the cost of the CPAP and accessories, up to $2000. How likely is it that the DME provider's allowable amount for CPAP and Accessories is more than $2000?

Does that sound right? I swear, I've been paying for insurance for years, but this is the first time I've had any cause to access it for anything more than standard doctor visits. So even though I'm a fully grown adult, this is making me feel a little wet behind the ears.

Chairman Meow wrote:How likely is it that the DME provider's allowable amount for CPAP and Accessories is more than $2000?

You might make it this year with the cost of the machine but it is unlikely that you will make it next year with only the mask's cost or replacement items (nasal pillows or cushions depending on the mask you end up using).

For the machine...at all depends on what the DME charges and what your insurance actually allows. Sometimes the allowed amount is greatly reduced and sometimes it isn't reduced...it all depends on the insurance plan.
Example...the DME might charge $1500 for the entire machine/humidifier package (masks are always separate) and your insurance might only allow $900 or it might allow $1500 or anywhere in between and the allowed amount is what you are responsible for and would thus apply towards your deductible. Non allowed amounts don't apply towards the deductible.

If CPAP equipment (machine, humidifier, masks) are a totally separate deductible then you most like would be money ahead to just buy privately or use cpap.com. It all depends on which machine your DME wants to supply and how much your insurance will allow for that item.

Pugsy wrote:

Chairman Meow wrote:How likely is it that the DME provider's allowable amount for CPAP and Accessories is more than $2000?

You might make it this year with the cost of the machine but it is unlikely that you will make it next year with only the mask's cost or replacement items (nasal pillows or cushions depending on the mask you end up using).

For the machine...at all depends on what the DME charges and what your insurance actually allows. Sometimes the allowed amount is greatly reduced and sometimes it isn't reduced...it all depends on the insurance plan.
Example...the DME might charge $1500 for the entire machine/humidifier package (masks are always separate) and your insurance might only allow $900 or it might allow $1500 or anywhere in between and the allowed amount is what you are responsible for and would thus apply towards your deductible. Non allowed amounts don't apply towards the deductible.

If CPAP equipment (machine, humidifier, masks) are a totally separate deductible then you most like would be money ahead to just buy privately or use cpap.com. It all depends on which machine your DME wants to supply and how much your insurance will allow for that item.

I think I've been unclear, or I am just completely missing something. I have already met my deductible for this calendar year - because my deductible has been met, my DME benefit covers 100% of my DME expenses for the rest of this year, up to $2000. Once I "spend" $2000 on DME supplies (CPAP machine, masks, hoses, pillows are all included in that) then I'm paying out of pocket for the rest of the year. My hope is that the DME's allowable amount for the machine and any accessories I need, will be less than $2000, so that I won't have to pay anything out of pocket - at this time anyway. Does that make sense or am I hopelessly lost?

Insurance usually does not pay the DME their asking price.
What they pay is usually less. Often a lot less.
You need to find out what the insurance allows for the machine and the mask, to avoid surprises.
The allowable is determined by insurance, not the DME!

Sorry....I misunderstood. I thought the DME coverage was a separate deductible (it can happen depending on insurance plan) so let me amend what I said.

It's going to depend on what your insurance allows for the most expensive part of this equipment process...the machine and the humidifier as to whether you exceed that $2000 maximum this year.
If they allow my example of $1500 for the machine and humidifier..then that leaves only $500 left for masks and replacement mask items...and that $500 will be eat up real fast as masks are expensive.
If they allow 900 for the machine and humidifier then you will have a lot more left for those other mask and replacement expenses.

Some insurance companies will allow close to the billed amount and others will drastically cut the allowable charges.
Some DMEs will bill out close to what the allowable amounts are and some will bill out at nearly double the amount (or more) in hopes that they will make a windfall.

So you need to find out what the allowable amount is from your insurance company and that's often easier said than done.
They normally pay by HCPCS code though and the billing code for the machine is E0601 and the humidifier is E0562 - CPAP Heated Humidifier and the hose is something else...the DME will break everything down even if it all comes in one box.
http://www.bestcpapprice.com/Reimbursem ... _35-1.html
The machine and humidifier are the highest priced items though. Call up your insurance company and ask if they can give you what they allow for the E0601 and E0562...and that should then tell you how much is left for the other supplies.

Each time I get information on here I feel better armed to deal with this process, I feel so empowered!

In regards to the machine and humidifier being two different codes, would that apply even in the case of the Airsense 10 where the humidifier is built in?

Thank you all so much, you have given me such peace of mind now that I'm not floundering around in the dark!

Chairman Meow wrote: In regards to the machine and humidifier being two different codes, would that apply even in the case of the Airsense 10 where the humidifier is built in?

Good question...I bet it will still be separate but I don't know for sure...perhaps one of the forum members who has recently seen their Explanation of Benefits could tell us ....