Is this Normal? - DME Related

I have Anthem Blue Cross(used to be Blue Cross/Blue Shield) of California. It is an HMO plan through my employer. I am not sure if our situations are the same but I had no deductible. They have covered the cost, in full, for the sleep studies and the equipment. I was sent to a DME called SleepMed. They were okay but nothing to write home about. They kept trying to give me a machine and mask that I did not want and that my doctor had not prescribed. I am allowed new filters, mask, and hose every 6 months according to the DME.

I would suggest using your Flex Spending plan on CPAP.com and buy what you need. I was a little apprehensive about what I could use my Flex Spending account for but I purchased almost $500.00 worth of items and everything was allowed. I even bought the software and card reader. If my insurance would not have covered my machine, I would have bought that with Flex money too. I guess it depends how much money you have in your account for this year. I just attached a letter with my CPAP.com receipt, along with my prescription, and my authorization statements from my HMO clinic showing that they would cover only certain things. I explained to the Flex Spending company that XPAP therapy was difficult to use, that patients often need to try many masks before finding one that works, and that other items were needed for safety and comfort( hose cover, medical ID tag for my carrying case, chin straps, etc). And then I had no problem. They covered everything. I even noted that I would need to buy distilled water on a regular basis and they have said that I can use my Flex Spending card to purchase distilled water. I know it is not a big expense but it is still an ongoing, long-term expense.

I am worried that you may go a long time without the therapy you need if you wait until January, etc. If you have the flex money, go for it and start your therapy ASAP. Oh, check Craig's list too. In my area, I found top of line models, many new, that were being sold at very low prices. I even saw my machine on there for $350.00 and CPAP.com sells if for over $700. It had never been used. Good luck. I have only been doing this is for about 2 months and things are slowly getting better. I especially love the Swift LT mask. It has made all the difference for me.

After reading all of this, I'm hoping I'm not totally screwed.

Today I saw the sleep doc and, although I've been having problems with tiredness and sudden awakenings using the straight CPAP, I convinced him to prescribe an APAP, which he did. I tried to get the actual prescription, which was right there, but he said he'd give me a card with my pressure on it, to carry if I travel. He was going to fax the prescription to the DME.

This is where it gets scary: He said the DME would give me the APAP for two or three weeks, read the data card, then find a new pressure number for me and bring back the regular ol' CPAP with the new pressure programmed in. Not what I wanted. He told me that he could only lower my pressure without doing another sleep study, not raise it. My pressure is 7.0. He said I did well during the titration at 6 and 7, except at 6, I snored. I told him, "Oh, great. Now I get to snore." That's when I talked to him about the Autopap and he agreed to the temporary trial.

I have good insurance and am concerned that the DME is controlling everything. He told me not to mention anything to them and maybe they'll just forget to swap me back to a CPAP (like they forgot to bill me for my mask. )

Hopefully, the APAP will come this week and I'll see what the DME says. Would it help to have my PCP pull rank on someone? She's the real advocate of the therapy and suggested the sleep study when I had no clue.

Lynne

Hey Murph -- I had a very similar issue with my DME.....telling me they don't "issue out" APAP machines so I went back to the doc and asked her to write a make, model specific script specifying a pressure range and fax it to the DME.....
I was titrated at 5.....I can't breathe at 5 so we tried 7 and that wasn't much better, so when I talked to the doc I had some data to give her.....When we talked I told her that I felt that a range of pressures would be more appropriate and that with the APAP I could self titrate occasionally (which I have done).....she also knew I had the software to read and change my card....
All that said -- if the doc prescribes a range they have no choice but to issue you an auto CPAP machine.....Go for it!!!!

The DME wasn't real happy about it, but I got my APAP machine as they couldn't program the CPAP machine for a range of pressures.....
Also -- they cannot keep you from acquiring a copy of the prescription and it's important that you get a valid copy of your script as you will need it to purchase equipment online and from other DME's if you choose. Remind the doctor that it is your legal right to have a copy of your prescription -- not just some nebulous card that really doesn't mean anything.....

Good luck!!!

Hey Goose,

Do you know if it's the patient's legal right to have a copy of the prescription in every state? I'm in Pennsylvania.

I have no idea what range, if any, the doctor put on the script because I never saw it close enough to read it. I should ask the DME what it said.

Another point is that you said your doc raised your pressure from 5 to 7. My doc said he couldn't raise it without doing another sleep study, only lower it. The way our sleep lab works is that she started at the lowest number and goes up until I didn't have apneas. So I'm stuck between 4 and 7 without another sleep study.

I'm seeing my PCP on Monday for an unrelated problem but I'm going to ask her about some of these things.

Thanks for your response. I'll continue to work to get this right.

Hey Murph,
I'd look into the legalities locally!!! I believe that the law is Federal having to do with HIPPA regs, but I'm not an expert in medical law. I know in California I have access to my entire medical records - and it's online, so it's even easier to access....I asked my doc for the script and was given an original copy -- I also got a copy from the DME to ensure they have the most up to date script!!! (which at the time they didn't!!)

I can't imagine needing another sleep study to adjust pressures -- that's what Auto machines are all about. Unless of course there's dollars involved one way or another.....I know the sleep center will get more $$$ if you have another study -- but again, that may be a state issue, but I've never heard that one before.....Those kinds of adjustments are much easier if the doc (or you) have data!!!! Be sure to get a data capable machine!!!! Then find the software and card reader to get the data so you can learn to interpret!!!

I'd still be trying to get an Auto CPAP and then through the forum learn how to do adjustments yourself -- that said, adjustments are not to be taken lightly!!!! I only adjust mine after reviewing the data and evaluating. If I have questions about it I'll either consult my doc (who retired recently to have an addition to her family and to take care of the others for a time -- I sure hope she comes back into practice because she's a great doc!!!!!! I have not seen the doc she referred me to...) or I'll run my data and evaluations through this bunch and see what the consensus is......There is great collective knowledge with this group -- but I always keep in mind that what I'm getting here is opinion!! Educated opinion for the most part, but opinion none the less!!!!

Good luck -- and be sure to let us know how you're coming along!!!!
take care
cheers
goose

You guys are the best! I never would have had the courage to pursue better therapy if it weren't for this board.

This morning I called the DME, who I never dealt with at all before, asking if they got the prescription from the doc and what it said. She offered to fax me a copy of the prescription, which I gladly accepted. She seemed surprised that I was asking about an APAP, not a CPAP, and if it was just a trial. Wednesday the doctor told me the DME would only give me it on a trial basis. I didn't say anything and she said, "He didn't write a trial, so I assume it's a switch-out." I said yes, he mentioned that I would be giving back my CPAP and getting the APAP. So it looks like I'm going to be getting the APAP! I'm also going to finally have data capability. This is exciting!

The odd thing is that the doc told me he couldn't raise my pressure at all without another sleep study, only lower it. Yet, the prescription for the APAP has the range from 6-12 and my current pressure is 7. That sounds like raising it to me.

By the way, Goose, you call me Murph. I lost that nickname when I got married. I sure do miss it!

Excellent, MurphysLaw!!

Far out!!!!! That's great news!!! If you're at 7 and it's comfortable then 6-12 should work ok for you -- be sure to get a card reader and the Encore Viewer or whatever reader/software is appropriate for your machine!!!! Gotta have that data!!!!
Once you get all of that together pull your data at least once a week (I keep losing some because I forget to pull it and the card only seems to hold 7 days of full data....my bad!!!!). I don't have any of the documentation with the software, so I don't know if it tells you how to read it or not, but we're here -- ask away!!!!

If Murph is ok with you , it's certainly ok by me I'm just too lazy to type out Murphyslaw........

take care
cheers
goose

goose wrote:be sure to get a card reader and the Encore Viewer or whatever reader/software is appropriate for your machine!!!! Gotta have that data!!!!

If Murph is ok with you , it's certainly ok by me I'm just too lazy to type out Murphyslaw........

At this point, I don't really know how the software works, but I plan to read about it before they show up with the machine. I believe I'll be getting the same machine that you have, the M Series Auto.

And yes, Murph is great.

Murph, when you ask the doc for a copy of your Rx, be sure and also ask for a copy of your sleep study (the full report, not just the 'summary'). As Goose suspected, it IS HIPPA that governs that -- Federal law, the same in all states. You have the right to copies of EVERYTHING in your medical file. The doctor or clinic can make a "reasonable" charge for copying, and they have 30 days to comply. HIPPA creates a 'floor' of medical privacy, portability and patient's rights, individual state laws may grant greater degrees of protection (as do California's laws, for example), but existing state laws that provide for LESS protection are superseded by HIPPA.

Sounds like you have a good doc now!

Yeah! You're going to have data! Congrats. Let us know which machine and how it went.

gasp wrote:Yeah! You're going to have data! Congrats. Let us know which machine and how it went.

I will let you know how it goes. Thanks. I believe I will get the M Series APAP with C-flex, but am not totally sure.

And Bookbear, thanks for your tips. I need all the help I can get.

I haven't researched anything about software and how it works, but this forum is filled with great people to help me.

MurphysLaw wrote:

gasp wrote:Yeah! You're going to have data! Congrats. Let us know which machine and how it went.

I will let you know how it goes. Thanks. I believe I will get the M Series APAP with C-flex, but am not totally sure.

And Bookbear, thanks for your tips. I need all the help I can get.

I haven't researched anything about software and how it works, but this forum is filled with great people to help me.

Don't forget that if you buy the A-Flex you can put it on settings that make it a C-Flex. If you buy a C-Flex, it can not be an A-Flex.

gasp wrote:

Don't forget that if you buy the A-Flex you can put it on settings that make it a C-Flex. If you buy a C-Flex, it can not be an A-Flex.

The DME supposedly shipped it to me today, saving a human from showing up at my door to set it up. Humans take longer, they said. I'm going to ship the old one back or drop it off at to them a few miles away.

Although I'm not familiar with A-Flex at all, I'm very happy with C-Flex, If that's what I get, it will be fine with me. I'll be shocked if they give me something better than C-Flex.

A copy of the prescription was faxed to me, but it says "Illegal" all over the thing, showing that it's not the original. Will I need that to buy a card reader and software? If I buy the software online, will they accept the copy that shows "Illegal"? Has anyone had any experience with that?

Murph, INSIST on a "legal" copy of your Rx. What they faxed you does not comply with the law. You might actually have to go to their (the doctor's) office and politely but persistently wait until they give it to you. Be prepared for them to tell you you will have to come back to pick it up another time, but do it. That Rx is yours by Federal law.