Treading Lightly with Insurance

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Ants
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Treading Lightly with Insurance

Post by Ants » Wed Jan 11, 2017 4:48 pm

Hi all!

I was diagnosed with mild sleep apnea in 08... took me about 2 hrs to finally adopt CPAP - my insurance back then didnt cover much so I opted to buy private party.

Fast forward to now. Ive decided its time to upgrade. I renewed my RX and sent it to a local DME.

Theyre now asking me whether I have a CPAP machine - and whether there are any issues...

Do I tell them the truth? My original unit was purchased out of my own pocket... why should they get to know?

Thanks all!
Last edited by Ants on Wed Jan 11, 2017 6:44 pm, edited 1 time in total.

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Sheriff Buford
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Re: Treading Lightly with Insurance

Post by Sheriff Buford » Wed Jan 11, 2017 6:07 pm

Probably doesn't matter if you answer that question or not. Ask them why they ask that. If you are payin' outta your pocket there are no compliance issues. When I used to ask suspects questions, they would respond, "If I say yes, then what will happen?" If they didn't like my response, they would ask, "If I say no, what will happen?" Then they would pick the best response... for their hide!
Sheriff

Ants
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Re: Treading Lightly with Insurance

Post by Ants » Wed Jan 11, 2017 6:43 pm

Thanks Sheriff,

I paid out of pocket for my first machine... this next machine I'm goin through insurance bc they'll cover 90% of the costs after my deductible. Should net out cheaper.

linuxman
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Re: Treading Lightly with Insurance

Post by linuxman » Wed Jan 11, 2017 6:50 pm

You're not in a court of law here or anything, and certainly are not under any obligation to tell them anything. Tell them whatever you want to tell them.

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chunkyfrog
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Re: Treading Lightly with Insurance

Post by chunkyfrog » Wed Jan 11, 2017 6:59 pm

I second that.
What happened in the past should stay there.
None of their beeswax.
If they need any documentation that you need and use cpap, let them get that from the doctor.
You need not tell them you already have a machine, it's probably "rented".

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Last edited by chunkyfrog on Wed Jan 11, 2017 7:02 pm, edited 2 times in total.

Guest

Re: Treading Lightly with Insurance

Post by Guest » Wed Jan 11, 2017 7:00 pm

Like Sheriff says find out why they ask. It may be they want to know how much help you will need or it could be they want to give you a bottom line no data cpap. You can always say yes I have one but it is not working right now and you need - quote the make/model you want.
Make sure they don't give you a dataless cpap.

MrGrumpy
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Re: Treading Lightly with Insurance

Post by MrGrumpy » Wed Jan 11, 2017 7:37 pm

You sound like you are apologizing for buying a new machine with your own hard cold cash. Thats what this country is coming to, people think SOMEBODY ELSE should always be paying for their own shit. Insurance for that, insurance for this, blah blah blah.

Here is the way it works. If you have CASH and you have a current, valid, legal prescription and its not some sort of controlled substance or something, you can buy whatever the hell you damn well please. If you want FIVE AutoPaps, top of the line and you have a valid rx and you pay for them yourself, so be it you can have FIVE (or more) top of the line APAPs. I have four myself, three purchased myself, one is an insurance purchase.

Dont apologize for wanting to buy something you actually need and want. If you want a current, top of the line APAP, and have the money, go out and buy it and dont apologize to ANYBODY!
Id be dead by now if I didn't use my CPAP gear every night.

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chunkyfrog
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Re: Treading Lightly with Insurance

Post by chunkyfrog » Wed Jan 11, 2017 7:46 pm

If you (or your employer) PAYS for your insurance, the insurance company is contractually obligated
to honor any and all legitimate claims.
You are welcome to spend your own money for a second machine (timing irrelevant)
but that does not permit the insurance to shirk their side of the deal.

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LSAT
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Re: Treading Lightly with Insurance

Post by LSAT » Wed Jan 11, 2017 7:57 pm

MrGrumpy wrote:You sound like you are apologizing for buying a new machine with your own hard cold cash. Thats what this country is coming to, people think SOMEBODY ELSE should always be paying for their own shit. Insurance for that, insurance for this, blah blah blah.
I think you are the one in a previous post that said the following.....

Masks....every six months by default. I dont care if they still look and feel as if they could make it another six months, when the six month mark hits, BAM my mask gets replaced with a brand new one

Mask cushions: mask cushions are arguably the nastiest piece of CPAP gear. Those cushions get disgusting and I dont even have oily skin! I have dry skin. The max for a mask cushion is three months, two months is what I prefer. Ive noticed my DME is telling me "every month" now. Thats changed from when I first got into CPAP in 2007, then it was "every three months." The way you tell a mask cushion is worn out is, 1) time...how long youve been using it, 2) as soon as it gets flimsy and the silicone starts getting this thinned out, real super floppy feel to it...thats time to replace it with a NEW cushion

Hoses: every three months replace it, or whenever you get a pinhole near either end, they say these modern machines "compensate" for loss of pressure if you have a leak. HORSE PUCKEY! Ive had pinhole sized leaks (just one) in a hose before and did not know it. Id just start feeling absolutely awful again, had no reason why. I'd call my DME, they'd tell me to wash my cushion and my face to make sure I was getting a good seal, they'd tell me to examine the hose for small holes...BINGO! Id fine them and trash them. Soon as I had a new hose with no pin hole in it, my therapy went back to normal and I felt normal again.

Filters: The DME/insurance standard is "every three months." I think you can get by on that, but personally I am proactive and replace my filters once a month. I dont wait until my filter gets dirty looking or clogs up slowing airflow. Filters cost so little and you can buy them OTC off the Internet for practically nothing...it makes more sense to me and my health to just replace them monthly

Humidifier pot: I change mine once a year. I know the DME/insurance standard is every six months (if I remember correctly). I change mine every six months. Get the tougher, dishwasher safe plastic humidifier pots. My first APAP lasted three and a half years, I loved it. I think I could have gotten another six months out of it, maybe another year. I ruined it by using a cheapo, flimsy plastic Resmed humidifier pot and the plastic cracked inside the humidifier, water went everywhere and the machine went bad maybe a few weeks afterwards.

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MrGrumpy
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Re: Treading Lightly with Insurance

Post by MrGrumpy » Wed Jan 11, 2017 8:15 pm

I do both. I buy some of my gear from insurance. I get what I can get from my insurance. What I cant I buy on my own. Thats it, I dont apologize for it either. Insurance only pays but for so much and when it does I dont like having to wait...and wait...and wait. I like straight lines and hard cold cash, just give me the rx and let me buy my own stuff half the time, my stress level goes down a lot that way I hate dealing with insurance. I hate insurance.

Maybe one day when I turne 65 and get Medicare, which is this nice, neat federal government supervised medical care plan I will change. Until then and I have to continue dealing with PRICK private health insurance plans in super conservative North Carolina, I will continue preferring to just buy out of pocket if I can afford it.

I also dont like the idea of third parties (insurance) paying for critical medical gear and care that is basically life or death stuff. I think insurance is basically a huge financial conflict of insurance and would love to get rid of insurance for that one reason alone. Insurance wins when they withhold needed medical care and they frequently do just that. I learned my lesson a long time ago on insurance.

LSAT wrote:
MrGrumpy wrote:You sound like you are apologizing for buying a new machine with your own hard cold cash. Thats what this country is coming to, people think SOMEBODY ELSE should always be paying for their own shit. Insurance for that, insurance for this, blah blah blah.
I think you are the one in a previous post that said the following.....

Masks....every six months by default. I dont care if they still look and feel as if they could make it another six months, when the six month mark hits, BAM my mask gets replaced with a brand new one

Mask cushions: mask cushions are arguably the nastiest piece of CPAP gear. Those cushions get disgusting and I dont even have oily skin! I have dry skin. The max for a mask cushion is three months, two months is what I prefer. Ive noticed my DME is telling me "every month" now. Thats changed from when I first got into CPAP in 2007, then it was "every three months." The way you tell a mask cushion is worn out is, 1) time...how long youve been using it, 2) as soon as it gets flimsy and the silicone starts getting this thinned out, real super floppy feel to it...thats time to replace it with a NEW cushion

Hoses: every three months replace it, or whenever you get a pinhole near either end, they say these modern machines "compensate" for loss of pressure if you have a leak. HORSE PUCKEY! Ive had pinhole sized leaks (just one) in a hose before and did not know it. Id just start feeling absolutely awful again, had no reason why. I'd call my DME, they'd tell me to wash my cushion and my face to make sure I was getting a good seal, they'd tell me to examine the hose for small holes...BINGO! Id fine them and trash them. Soon as I had a new hose with no pin hole in it, my therapy went back to normal and I felt normal again.

Filters: The DME/insurance standard is "every three months." I think you can get by on that, but personally I am proactive and replace my filters once a month. I dont wait until my filter gets dirty looking or clogs up slowing airflow. Filters cost so little and you can buy them OTC off the Internet for practically nothing...it makes more sense to me and my health to just replace them monthly

Humidifier pot: I change mine once a year. I know the DME/insurance standard is every six months (if I remember correctly). I change mine every six months. Get the tougher, dishwasher safe plastic humidifier pots. My first APAP lasted three and a half years, I loved it. I think I could have gotten another six months out of it, maybe another year. I ruined it by using a cheapo, flimsy plastic Resmed humidifier pot and the plastic cracked inside the humidifier, water went everywhere and the machine went bad maybe a few weeks afterwards.
Id be dead by now if I didn't use my CPAP gear every night.

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kteague
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Re: Treading Lightly with Insurance

Post by kteague » Thu Jan 12, 2017 3:39 pm

Wondering if the provider is asking because part of the required documentation is asserting that the patient uses and benefits from CPAP treatment. Not sure where you stand with current sleep study etc, just thinking what was required from my doctor before insurance would cover equipment. Maybe their inquiry is just routine with no intention of underhanded dealings. Most (some?) insurances have replacement schedules if they paid for the previous machine, or if the machine fails. You might want to look at the wording in your policy to see if replacement refers to items they paid for or any previously acquired item. It shouldn't be any of their business what you bought privately, but who knows what kind of language might be in a policy.

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LoBattery
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Re: Treading Lightly with Insurance

Post by LoBattery » Thu Jan 12, 2017 5:12 pm

If you bought a machine in 08, I can't see how either answer would matter, the machine is beyond its life expectancy.

I do feel your cosmic angst. I'm a virgin coming up on my first six months. I already bought a replacement mask on my own on the internet since it was cheaper than my copay from the local DME I got set up from. Needed a spare because you never know when the dog might think it is a chew toy. Now I would like to get another spare hose, mask and humidifier. I have no deductible built up yet this year and don't know this stuff applies to it and maybe I should wait. I call up the insurance company and they seem to know less about it than I do. I tried to be an informed shopper when I first got the stuff, just a nightmare of insurance codes. Well, got another month at least I can avoid doing something. You have to spend money to get an education. I learn fast that way.
Seeing and believing are often both wrong. FOW

MrGrumpy
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Re: Treading Lightly with Insurance

Post by MrGrumpy » Thu Jan 12, 2017 7:07 pm

If I get a machine paid for by my insurance company and I decide two months later, "hey, I want a second machine as a backup or travel APAP" and I go out and get my doctor to write me a prescription and fax it to an Internet CPAP supplier and pay for it out of pocket, so be it. We are still a free enterprise system and I dont care about the health insurance company language.

I would continue to use the machine paid for by my insurance, because "they paid for it." But it never is a bad thing to have two machines, one for backup and travel.

Health insurance has too much of a hold on our healthcare system, too many people are afraid of their health insurance company and thats bad.

kteague wrote:Wondering if the provider is asking because part of the required documentation is asserting that the patient uses and benefits from CPAP treatment. Not sure where you stand with current sleep study etc, just thinking what was required from my doctor before insurance would cover equipment. Maybe their inquiry is just routine with no intention of underhanded dealings. Most (some?) insurances have replacement schedules if they paid for the previous machine, or if the machine fails. You might want to look at the wording in your policy to see if replacement refers to items they paid for or any previously acquired item. It shouldn't be any of their business what you bought privately, but who knows what kind of language might be in a policy.
Id be dead by now if I didn't use my CPAP gear every night.

SewTired
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Re: Treading Lightly with Insurance

Post by SewTired » Fri Jan 13, 2017 11:05 am

Ants wrote: Theyre now asking me whether I have a CPAP machine - and whether there are any issues...

Do I tell them the truth? My original unit was purchased out of my own pocket... why should they get to know?
Up to you, but I'm thinking that they just want to know your history as to solving any problems or making recommendations. If you don't wanna talk about it, then don't. I just as soon skip the 'informational segment' as required by Medicare since I already had a machine. Just wanted to know the stuff that was different from the machine I had and the new one and they happily complied. So, my visit was less than 10 minutes instead of 30-45 min.

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Ants
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Re: Treading Lightly with Insurance

Post by Ants » Sat Jan 14, 2017 1:52 am

Thanks for all the responses everyone!

So to clarify...

I purchased my very first machine in 08 out of pocket because my insurance back then stunk. Since then I've been purchasing masks and such out of pocket as well.

I've had I want to say 6 different insurance providers in the span of 8 years (few job changes, and a few companies switching insurance providers). In that time, I tried 2 other times just poking around to see whether I could get my masks covered. I may not have put forth sufficient effort and possibly gave up too early but I'd fail to get insurance to reimburse and I'd usually wind up paying out of pocket.

This year I'm at a new job with what seems to be fairly solid insurance... my machine is old - my mask is possibly over a year old... Its really time to see this through and make sure the insurance I'm paying for is going to properly cover my medical expenses.

I took The Sheriff's advice and asked them why they needed to know.

They said my 08 study + most likely getting a unit then and also that if a unit is less than 5 years old - insurance will not cover a replacement machine just because I want one. There would need to be a problem with the unit along with a doctors note requesting replacement.

The way it was worded plus my distaste for DMEs probably caused me to be overly hesitant. I really wanted to ask... if I were issued a unit in 08... that would mean its 8-9 years old already... so why are you asking??? I decided to let them know I had a unit in 08 and it was out of pocket. To which they responded that they could bill insurance for a new device

I'm sure I made this a bigger deal than it should have been so thanks everyone for your input!!

Ants