Need advice please!

Hello! I was diagnosed with OSA in May 2015. I actually don't mind using my cpap machine, however I have run into a problem with my insurance company. The first three months of treatment I had no problem, but the past three months have been very challenging health-wise and emotionally, so I go to bed with every intent of using my machine, but sometimes I fall asleep holding my mask and wake up in the morning (strangely feeling well-rested) and I often pull it off during the night, so I am below "compliance". I received a phone call today from the home care company assigned to me and they told me that my insurance company is no longer covering my cpap and that I have to give the machine back and reapply for coverage in three months.
I'm sorry, but I find that to be ridiculous. This is the first autumn/winter I have ever used a cpap in my entire life...I suffer from chronic sinusitis, I have tinnitus (ringing in ear) that worsens sometimes from cpap use...I'm just simply plugged up a lot! Plus, my grandmother died a few weeks ago. It's been hard and I've been crying off and on, which makes me stuffy...can't breathe.
I WANT to use my machine...I bring it with me when I go out of town! As everyone here knows, suddenly using a cpap at 40 years old is NOT the same as simply taking a prescribed pill each morning. Has anyone had trouble adhering to insurance guidelines even though you are trying? This machine has greatly changed my life...my ahi score was 0.1/hour after three months of initial use! I feel like a new person, have lost 15 pounds...but I am so incredibly discouraged.
Should I just pay out of the pocket for the remainder of what I owe for the machine?
I'm hoping someone out here can help me with some advice. Thank you!

mrrwny wrote:Hello! I was diagnosed with OSA in May 2015. I actually don't mind using my cpap machine, however I have run into a problem with my insurance company. The first three months of treatment I had no problem, but the past three months have been very challenging health-wise and emotionally, so I go to bed with every intent of using my machine, but sometimes I fall asleep holding my mask and wake up in the morning (strangely feeling well-rested) and I often pull it off during the night, so I am below "compliance". I received a phone call today from the home care company assigned to me and they told me that my insurance company is no longer covering my cpap and that I have to give the machine back and reapply for coverage in three months.
I'm sorry, but I find that to be ridiculous. This is the first autumn/winter I have ever used a cpap in my entire life...I suffer from chronic sinusitis, I have tinnitus (ringing in ear) that worsens sometimes from cpap use...I'm just simply plugged up a lot! Plus, my grandmother died a few weeks ago. It's been hard and I've been crying off and on, which makes me stuffy...can't breathe.
I WANT to use my machine...I bring it with me when I go out of town! As everyone here knows, suddenly using a cpap at 40 years old is NOT the same as simply taking a prescribed pill each morning. Has anyone had trouble adhering to insurance guidelines even though you are trying? This machine has greatly changed my life...my ahi score was 0.1/hour after three months of initial use! I feel like a new person, have lost 15 pounds...but I am so incredibly discouraged.
Should I just pay out of the pocket for the remainder of what I owe for the machine?
I'm hoping someone out here can help me with some advice. Thank you!

First of all.........NEVER take their (the DME's) word for ANYTHING!!!
Contact your insurance provider yourself and get the story straight from the horse's mouth.
Try to explain the situation to them and see if you'll get a sympathetic ear.

The MINIMUM use is considered 4 hours per night for 70% of the time.

Please tell us what specific make and model of all the equipment you have......including settings......and put them in your profile. Edit: I see you've already done that.

If nobody will budge on this, make sure you get your copy of the machine prescription (which your doctor should have given you) and consider buying one out-of-pocket. There are any number of online sellers who will provide you the same or better equipment for less money. https://www.cpap.com or http://www.secondwindcpap.com would be where I'd start if I were you.

And, one other question.......how did the DME know you were not in compliance? Does your machine have a modem on it to relay compliance to the DME?


Den

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Thank you so much for getting back to me! I will definitely put my settings in, equipment, and such. I did just join tonight, wish I had earlier, but now is better than never! I do use ResMed 10 for her, for starters. It has a humidifier. I do have a wi-fi system, which I love, because each morning (when I do use it) I enjoy seeing how I slept through an app on my phone. I know I need to consult with my insurance company, you're right not to let what I was told today be the 'end all'.

mrrwny wrote:Thank you so much for getting back to me! I will definitely put my settings in, equipment, and such. I did just join tonight, wish I had earlier, but now is better than never! I do use ResMed 10 for her, for starters. It has a humidifier. I do have a wi-fi system, which I love, because each morning (when I do use it) I enjoy seeing how I slept through an app on my phone. I know I need to consult with my insurance company, you're right not to let what I was told today be the 'end all'.

One thing.......the humidifier should already be yours. They usually don't take those back and charge the user/insurance up front for them.

Beyond that, if you have decent insurance, see if you can convince them to keep paying because you've had a rough time getting started with your therapy.......and you REALLY, REALLY want to keep using it. If you've had little or no support from your DME, tell them that, too. Too often, the DMEs turn the patients loose with these things and just say......"You figure it out.".


Den

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I have 50% coverage, which I am happy with! Dealing with the DME company has been...trying. They overbilled me in the beginning and then I haven't received a bill in months, only received their automated 3-month auto-call last week asking if I need equipment. I inquired why I haven't received a bill lately and they said that my insurance company decided back in August that they weren't providing coverage for my equipment. It's November 23rd! I called them back immediately when they called me...I think it's terrible they haven't contacted me until now. Had I known right away/sooner that this was going to happen...
I hope this just ends up being a learning experience through which I can share my experiences with others!

If you use it while watching TV or reading, that time will count towards compliance for insurance.

Cardsfan wrote:If you use it while watching TV or reading, that time will count towards compliance for insurance.

Hello! I know...I did that when I first started to get used to wearing it, but I don't have a TV in the bedroom and with my work schedule lately...I have such little time to myself before bed, I don't want to be sitting, only to then have to go to bed! I wish I could wear it while washing dishes, vacuuming, etc. Ha ha!!! Thank you for your advice!

Check online pricing. Sometimes 50% of the "insurance" price is close to 100% of the online price (even better if you buy used, lots of S9s out there now which will suit you fine). That would put you in control for not many more $s.

While the humidifier is usually billed out separately and often a purchase up front....the AirSense machines can't be broken apart to keep the humidifier like past machines when people have to return the blower but get to keep the humidifier.

I would be looking closely at the paperwork from the insurance company about how they paid for the humidifier or was it all part of the rent to own monthly thing.

Does make me wonder what the DMEs are going to do with Medicare patients where the humidifier is billed out separately and paid for in the first month (and patient pays their share) with these new machines that the humidifier can't be removed.
I can see it now...you have to return the whole thing and too bad you paid for the humidifier it goes back too.
I would be pitching a hissy fit for sure.

Do you have anything in writing that states that you must continue meeting compliance past 3 months? If there is nothing in writing, and nothing explained to you, then you might have a case for appealing since you didn't know. You might also be able to get your doctor to help you appeal. Especially if you were close to compliance and can show all the data from your continued use during that time period.

Ask your insurance if a doctor's request could extend your coverage time. I had that happen once and the doc wrote the order and the insurance didn't argue. Probably depends on the insurance.

mrrwny wrote:I have 50% coverage, which I am happy with! Dealing with the DME company has been...trying. They overbilled me in the beginning and then I haven't received a bill in months, only received their automated 3-month auto-call last week asking if I need equipment. I inquired why I haven't received a bill lately and they said that my insurance company decided back in August that they weren't providing coverage for my equipment. It's November 23rd! I called them back immediately when they called me...I think it's terrible they haven't contacted me until now. Had I known right away/sooner that this was going to happen...
I hope this just ends up being a learning experience through which I can share my experiences with others!

Definitely call your insurance company. If the insurance notified them in August, that would mean that they had a problem with your compliance in the first three months. They will be able to give you the best information about what is going on and when everything transpired.

I'm just guessing here but if you have IHA (I know at least some IHA plans do 50% coverage for DME), I know they have a 180 day appeal policy for most things so even if they did notify the DME in August, you are still within the timeframe. Secondly, if you do end up having to give the machine back, you may want to find a new DME, depending on your insurance. There are tons in this area but call around, you have a wonderful machine (one that I am fighting for with my DME) and if your prescription wasn't written for that exact machine, you will want to find out who will provide it for you. If your prescription was written for that exact machine, would you mind PMing me the name of your doctor?