Surviving DME with Medicare

[Comfortably Numb]

First of all, my primary insurance is with Medicare and I have an excellent secondary health plan. I am willing to pay 100% out of pocket in order to get the exact equipment that I want if that's what it takes to avoid hassles and attempted ripoffs from the DME. Obviously, I would like for my insurance to kick in as much as possible, but I'm not willing to go through a typical car buying experience with something like this. I've already read enough on this forum to understand how some DME's try to maximize their profits by steering people to certain low end devices even though Medicare pays the same amount regardless of equipment. I don't intend to have that experience.

There are 5 Medicare contract suppliers in my immediate vicinity. I'm going to try to get my doctor to be very equipment-specific when he write the Rx. But, assuming that I simply get a generic Rx specifying cpap with heated humidity, I want to have a game plan in mind to get what I want before going to these DME's. Could this be as simple as me putting together a very specific list; presenting this along with my Rx and insurance information to each DME in order to get my cost; and then contacting Medicare and my secondary insurance to validate the cost estimates? I realize that none of the DME's are going to to want to do business this way, but I'm in control, I can pay 100% if necessary, and I can walk.

What am I overlooking in this process? Will they be unwilling to give me a cost estimate unless I surrender my Rx? Will they still want to show me a Ford when I specifically requested a BMW? And most importantly, will it be impossible for me to corroborate their estimates of my cost by contacting Medicare and my supplemental carrier? thanks in advance

[ChicagoGranny]

Could this be as simple as me putting together a very specific list;

If you are talking about a list of machine features, don't do that. You need to give them the exact model number of one or two brands that are acceptable.

Forum members can help you with model numbers. In order to help, they will need to know your diagnosis and your prescription. It usually works out that there is one ResMed machine and one comparable Respironics machine that will be recommended to you.

then contacting Medicare and my secondary insurance to validate the cost estimates?

It's always better to get from your insurance companies the amount they will pay and the amount you are responsible for.

I am willing to pay 100% out of pocket

Given your insurance situation, you shouldn't do this. You've been paying premiums for Medicare and your supplement; now, use the benefits.

[LSAT]

All DMEs are different ...some very accommodating, some not. If you have 5 suppliers in your area, you are in good shape. If one will not give you what you want tell them you are going to another and see how quickly they are willing to give you what you want. you are anticipating problems that may never occur. Be sure you have you own copy of prescription and sleep study. Don't just assume the doctor will handle everything. With documents in hand...you are the boss.

[Comfortably Numb]

I've been through an office examination by a SleepMed Internist, an "at home" sleep study to confirm OSA, and a sleep lab titration study. My diagnosis is moderate OSA. I won't have any of the other data or a RX until I have a follow up visit soon. After reading this forum and experiencing the cpap firsthand, I know the exact cpap unit, mask, and hose that I want. Obviously my doctor may disagree and things could change, but my question remains the same relative to the DME's, etc. I will eventually go there and tell them exactly what I want. If I approach it that way given all that I've said, is there anything I'm missing?

[ChicagoGranny]

If I approach it that way given all that I've said, is there anything I'm missing?

Yes, you are missing the part where you walk out if they become uncooperative.

I know the exact cpap unit, mask, and hose that I want.

We don't know what you've been reading and what conclusions you have come to. You might want to be open with the forum and reveal that information. It's the best way to get help and prevent regrettable mistakes.

[AirPump]

Hi -
I just went through this in the Seattle area. If your sleep doc has been taking Medicare patients, he'll know that he can't just write a "generic" prescription for you. For Medicare reimbursement, the prescription has to be specific brand and model of the CPAP unit and mask etc., so if you know the Machine you want, get your doctor to support that decision.

As for Masks, keep an open mind. Discuss it with your doctor. If you're new to CPAP, you should expect that you'll be trying out different masks before you find one that works well for you. So structure your DME relationship and question list to include "How do I return/exchange a mask that doesn't work for me?"

Shop your local DMEs. I spent a morning calling six DMEs in my area that were green-lighted by my Medicare Advantage program. It was easy to narrow those six down to just a couple based on those conversations. As others have pointed out, the "retail" price of the gear from a given DME doesn't matter to you. Medicare is not a high-deductible insurance plan where you're paying out of pocket for the first thousands of dollars. The cost to you should be the same (for a given machine) no matter what the DME's "retail" price is.

For example, a PR DreamWear fit-pack mask is $119 online. My new Medicare approved DME charges $229 for the mask and headgear. Crazy. But my out-of-pocket under Medicare Advantage was $11. Online, each replacement cushion is $38. My DME gave me seven replacement cushions with the mask.
In all cases, Medicare (and most private insurance) requires us to RENT a new CPAP machine for 13 months, at which time you own it. If you're not compliant with your therapy, they'll hassle you or stop paying the monthly rent.

It takes some patience and time, but from my limited experience so far, it will save you serious money on equipment and supplies.
And a good DME can be very helpful when it comes to fitting masks, helping with machine problems etc., especially if the economic disadvantage of going locally is removed by your Medicare coverage.

Good Luck.

[LSAT]

I have a Medicare Advantage Plan. when I wanted a new CPAP, my Primary Care Doctor wrote a prescription that said Auto Cpap pressure range 10-15.
(I told him what to write since I have no regular "Sleep Doctor"). There was no need to write anything about masks or supplies. Medicare Advantage Plans follow Medicare Guidelines. I have a very nice local "mom & pop" DME.

[Guest]

First of all, my primary insurance is with Medicare and I have an excellent secondary health plan.

IF this is a Medicare Advantage plan you need to mention that here and you need to contact them as they will determine many things and can advise you so that the DME doesn't mislead you. That is step 1.

There are 5 Medicare contract suppliers in my immediate vicinity.

If you would list them here that will help tremendously on advising you. We don't know what you know or what is going thru your mind. Let me start by saying I would avoid any DME's that begin with A or L.

You do have a notebook you are writing all this in, right? Write questions you have leaving room for the answers and also write who you speak to with date/time.

IF you know the make & model you want I would call the DME to ask if they could provide you with that specific make & model advising them you will refuse anything else. That should save you time & gas from driving around. But if/when they fail to deliver what you requested I would refuse anything from them as it is a sign of future problems. Believe me it does happen that they will promise then not deliver, so be prepared to walk.

Medicare does require the DME to deliver and setup your equipment in your home - so if your DME casually asks you to come pick it up they will not be of any help in the future as any Medicare providers are fully aware of their guidelines.

The A & L providers are known for this and future problems including billing. DO NOT provide your credit card for that (any) reason - IF you feel you must use a pre-paid card or you are just asking for troubles. IF they insist move on to the next DME.

IF you will pay Out-of- Pocket (OOP) - I would never buy from a local DME as they will charge you what they charge the insurance - they have to by contract with the mfg's. If buying OOP check cpap dot com for their prices and service just keep in mind that cpap dot com does not bill any insurance esp. Medicare.

Always be sure to ask about their mask return policy. ALL mask mfg's allow for a 30 day window to exchange any mask not working for you. The DME only has to file some paperwork but most will let you keep the mask as they can't resell it.

You can also get an idea of what is required to order the equipment on cpap dot com. What is commonly referred to as a prescription is in reality a "Detailed Written Order" (DWO) for a licensed doc. Keep in mind it can come from a Primary doc or even a dentist. Just has to have certain things on it of the DME will not act on it. Most DME's will request any missing info directly from the doc. I do believe the DWO needs to mention if a heated hose is needed and durable supplies. Mask can say "Mask of patients choice". I don't think Medicare is silent on this at all.

The biggest advantage of buying from a local DME is if you have troubles with anything esp your mask fittings. But there is a post on here from last nite about a DME saying they couldn't help with a mask leak problem which is pure BS.

The sleep business is loaded with people who are in it just for the money.

[Woody]

My experience was a little different. My prescription was for a Cpap set to 14 cm.
But when I went to pick it up I was given a DreamStation Auto . But as per the
prescription it was set for cpap mode and 14 cm . I used it one day like that, had a
AHI of 6.81 . So I switched it to apap mode 12 to 18 and now get an AHI between
1 and 3 but please don't turn me in to the cpcp pressure police !

[Comfortably Numb]

Thank you all for you excellent comments on this topic. I will try to select a few quotes where I either have or still need further clarification:

"We don't know what you've been reading and what conclusions you have come to. You might want to be open with the forum and reveal that information. It's the best way to get help and prevent regrettable mistakes."
One has to go no further than this article to understand why I am concerned and why I want to be prepared:
https://maskarrayed.wordpress.com/what- ... me-part-i/
Also, here is a forum discussion link that makes it a little more real:
viewtopic/t116568/Medicare-and-CPAP.html

"I just went through this in the Seattle area. If your sleep doc has been taking Medicare patients, he'll know that he can't just write a "generic" prescription for you. For Medicare reimbursement, the prescription has to be specific brand and model of the CPAP unit and mask etc., so if you know the Machine you want, get your doctor to support that decision."
If true, this is very encouraging. My internist is with SleepMed and I am a Medicare patient. I'm not certain but I recall statements in the Wordpress.com article linked above that led me to believe that most doctors do not write Rx's for specific equipment. From what you're saying, my doctor MUST be very specific because I'm a Medicare patient. This could end up solving any perceived problems.

"IF this is a Medicare Advantage plan you need to mention that here and you need to contact them as they will determine many things and can advise you so that the DME doesn't mislead you. That is step 1."
I have plain old Medicare as my primary insurance and a state health plan (former employer) for secondary. There is no "Advantage" in my plan so do you still think I can contact Medicare and get the same guidance that you mention? For what it's worth, I've been on Medicare for 4 years and have had many doctor visits, including a couple of surgeries. I have yet to pay one cent out of pocket.

"If you would list them here that will help tremendously on advising you. We don't know what you know or what is going thru your mind. Let me start by saying I would avoid any DME's that begin with A or L."
Here they are:
Beacon Respiratory Services of Georgia, Inc.
Lincare, Inc.
LIFEHME, Inc./Long Term Care, Inc.
AHP Alliance of _ _ _ _ _ _ _ _/American Homepatient, Inc.
SleepMed Therapies, Inc.
Medical Services of America/Medical Home Care, Inc.

"My experience was a little different. My prescription was for a Cpap set to 14 cm."
If you are a Medicare patient and if your doctor is required by Medicare to be very specific concerning equipment (see above comment), then how could this happen?

Thanks again to everyone who has responded. I hope all of this will be of help to others who read this forum. I'm encouraged (but not yet convinced) that my doctor may be required by Medicare to be very specific when writing the Rx; and that I can call Medicare in advance to get prepared for the DME (somehow I think that may only apply to "Medicare Advantage" which I don't have).

[Hang Fire]

It seems uncomfortably numb that you are keeping secret the model of the machine you want from forum members who are trying to help you.

[Pugsy]

"My experience was a little different. My prescription was for a Cpap set to 14 cm."
If you are a Medicare patient and if your doctor is required by Medicare to be very specific concerning equipment (see above comment), then how could this happen?

Woody was given the DreamStation Auto CPAP machine....in short terms an APAP.
This happens is because an "APAP" machine is a cpap machine with auto adjusting pressure mode capabilities.
Medicare pays by HCPCS billing codes.. E0601 for cpap or single pressure machine.
Woody's DreamStation Auto IS A CPAP machine but just has 2 modes of operation...cpap or single fixed pressure or auto (apap) with single auto adjusting pressure.

The other HCPCS billing codes for xpap machine are for bilevel machines with and without back up rates.

Medicare doesn't care if you get a machine that will do auto adjusting..they just care if you meet the criteria for the E0601 machine.
Woody's DME gave him the "APAP" and just set it to cpap mode and thus fulfilled the RX requirements stated on the order.
Legally that is all they had to do. Some DMEs routinely dispense APAP machines in this situation because that's just what they have elected to do. Yeah, it may cost them a bit in terms of profit margin but it's just their choice. They did nothing wrong.
The DMEs who say "you can't have apap capable because your Medicare won't pay" are flat out telling a whopper. Medicare doesn't care....they just care about E0601.

Guest (edited...it was AirPump) gave you some information that isn't true for all areas of the country. It might have been true for the DMEs in his area but it's not necessarily true for other areas. I think most likely his DME told him a story and blamed it on Medicare...wouldn't be the first time.
Medicare doesn't care about brand or model...all they care about is if your diagnosis supports the criteria for whatever billing code machine you get....single vs bilevel pressure.
Assuming your OSA is plain jane vanilla OSA and your pressure needs don't support the need for a bilevel...you will get an E0601 billing code machine.

Lincare.......avoid them at all costs. While some local offices are good folks...Lincare and Apria are notoriously difficult to work with. My first DME office was a Lincare affiliate. I lost count of the number of lies they told me and that was before I even got a machine from them. They were fired before I ever got a machine. When I told them I wouldn't accept the crap machine they were trying to pawn off on me I told them to "keep it and a couple of not so nice words"...
They said "you refusing treatment"....I said "No, I am going to get the machine ...just not from you"...and that was that.

Most docs do just write generic RX unless they happen to have a specific preference and some do.

DMEs can dispense and apap machine with a cpap RX because an apap machine is a cpap machine. All apap machines have the 2 modes of operation available...cpap mode or fixed pressure and apap mode or auto adjusting pressure.
To fulfill the RX all they have to do is set the machine to cpap mode at whatever pressure is stated. Easy and quite legal.

Woody's DME did nothing wrong and Guest's DME may have fed him a line of BS. What guest told you is not what Medicare typically does....but does fit what DMEs typically feed as BS to patients.

Getting the doc to write the RX stating brand and model...gives you more ammunition if yoru fun across a DME who is more interested in profit margin than in anything else. Some doctors will do that because they don't care and they think a happy patient is more apt to be a successful patient. Some doctors are just hard assed with preconceived notions against anything but cpap and think that if there was a titration study there is no way the titration study got it wrong.
My doc was the later...hard assed. Part of the reason I haven't seen him since Aug 2009.

If I were in your shoes I would call each of the DMEs that you have available locally to you...and just say
"I have been recently diagnosed with sleep apnea and I have Medicare and I will be getting a cpap machine soon"
"What brand and model E0601 machine do you typically dispense"
See what they say...they may typically dispense the machine you want...if they don't then you just say
"thank you but that is not what I have decided I want and I will go elsewhere".

If they tell you they don't know because they haven't seen the RX...just state E0601 machine which tells them you have already done your homework and they won't likely be as able to feed you a line of BS. It's amazing how quickly a DME will come into line when faced with a hard assed patient who knows what they want and won't accept anything less.
Or...they might be like my local Lincare office was...hard ass and a bunch of bitches in the office and they were as glad to get rid of me as I was to get rid of them.

[Comfortably Numb]

It seems uncomfortably numb that you are keeping secret the model of the machine you want from forum members who are trying to help you.

Not at all. Based upon my diagnosis, reading this forum, and my limited experience with cpap, I have selected the following:
Airsense 10 Autoset with Humidair heated humidifier
Amara View mask
Heated hose
My doctor may have other ideas. I'll find out on April 11th. I want to be prepared for him and the DME's which is why I'm doing my homework in advance.

[Guest]

Guest gave you some information that isn't true for all areas of the country. It might have been true for the DMEs in his area but it's not necessarily true for other areas. I think most likely his DME told him a story and blamed it on Medicare...wouldn't be the first time.
Medicare doesn't care about brand or model...all they care about is if your diagnosis supports the criteria for whatever billing code machine you get....single vs bilevel pressure.
Assuming your OSA is plain jane vanilla OSA and your pressure needs don't support the need for a bilevel...you will get an E0601 billing code machine.

This guest never said any of that.

I have plain old Medicare as my primary insurance and a state health plan (former employer) for secondary. There is no "Advantage" in my plan so do you still think I can contact Medicare and get the same guidance that you mention?

Most certainly. I think you are better off with the traditional as in most cases it really is more flexible. If your secondary is like mine it will cover anything that Medicare does not as long as Medicare pays they will - no fussing about things.

Unless and until you call Medicare you can get all kinds of stories. They are open I believe more than 12/15 hrs/day - I don't recall exactly but I was impressed - and because they cover soo many different things they do have people who specialize in specific areas.

So write down your questions and call them.

OR Find your State's State Health Insurance Assistance Program (SHIP). State Health Insurance Assistance Program (SHIP or SHIIP) is a state program that has been providing free Medicare Help for Seniors.

afaik each state has a SHIP.

[Comfortably Numb]

Pugsy, since the day I joined this forum, your insight and responses have been outstanding and much appreciated. thank you