CPAP settings & costs

Hi,

I'm new here, and new to the whole CPAP thing... don't have my machine yet, but have some questions and concerns.

When it was suggested I needed to be tested for sleep apnea, I went to my doctor first. He's not an expert, but my copays are doubled for experts, and I'm going through a very rough financial time, so I went to him. ($20 copay #1)

He sent me to a sleep center, giving me the impression that my insurance should cover the whole thing. Okay, I went through test #1, and was diagnosed with sleep apnea.

Went back to the doctor for results ($20 copay # 2) and was told, now, I have to go back to the sleep center for a test to determine my setting.

Went back to the sleep center. Didn't sleep very well, kept waking up, had a lot of dry mouth, but when I did sleep I thought it seemed better than normal.

Went back to the doctor ($20 copay # 3) and he read the results: They started me at setting # 3 and worked it up to # 15. That wasn't high enough. They want me back for ANOTHER test!

The doctor said, he didn't think I should have to go through that again. That I should be able to get the machine at 15, and work it up myself until I thought it was a good level. Then, after I have the machine for a while, I could go back for another. He wrote the prescription.

Now, he and the CPAP machine people are going back and forth. I still don't have the machine, but... since he's not an expert... *CAN* I just start at 15 and work it up myself until I think the level suits me, as my doctor said he thinks I should be able to?

Now, the kicker.

I got a bill from the sleep center for $1,600. My wife called and argued with them, they said it's a mistake: with my insurance, it should have been around $560. That's for the FIRST test... I'm still waiting to find out what it will be for the SECOND test, and they really want me for a THIRD test.. and my doctor said it should be covered, which I took to mean, like my x-rays and blood tests, COMPLETELY covered. Frankly, I'm on the verge of foreclosure! All my medical copays went WAY up, my mortgage is high, I'm borrowing from Peter to pay Paul, AND, I'm tired ALL THE TIME! I need this sleep apnea to be treated!

If this is going to cost me thousands of dollars, and I'm going to need more and more tests... turns out, after all these costs for doctors and sleep tests, the MACHINE will be paid for 90% and I have to pay 10%, which, for all I know, could mean 90% of a zillion dollars so I'll only have to pay a billion... this is insane!

I don't know if my doctor is right, that I can get my machine without going for that third test... but frankly, I can't afford all these tests... But I can't afford to be falling asleep all day long and have a constant, pounding headache either.

Shouldn't this be fully covered by insurance? Why do I need so many tests? Why are the costs so insane?

And then, the setting question... can I just start at 15 and change the settings myself? Is there, like, a little dial on the side that I can move up to 16, 17, until I think it feels right? Or should I go back for the third test I can't afford, that the doctor thinks I shouldn't be forced to go through anyway?

Thanks,
Charlie

Ask your doctor to write the prescripton for a Resmed S8 AutoSet II w/EPR and w/integrated Humidaire 4i humidifer OR the Respironics M Series Auto w/A-Flex and integrated heated humidifier w/a pressure range which those in this forum more experienced than I will suggest. Since your finances are strained at this time, the Resmed would be the better choice just because of the ease of access to and the amount of data available via the LCD screen. Ideally you would be able to get the software and necessary cable reader. But insurances don't pay for the software and cable reader thus the only reason the Resmed becomes the better choice for you.

Insurances pay be HCPCS (insurance) code rather than by brand or model. The above APAPs are the same HCPCS code (e0601) as a bare bone, compliance data only capable CPAP altho the APAP is more expensive for the local DME supplier to purchase. Thus the supplier would prefer to provide a straight CPAP. Stick to your guns, have your doctor write the script
specifically for one of the APAPs I suggested above.

The local DME suppliers have a two-tier billing system; the billed amount and the "contracted" or "allowed" amount. That latter two terms are the actual amount your insurance has contracted w/your insurance company to accept in payment. I've heard of local DME suppliers trying to charge the patient's copay based on the billed amount. Uh uh. You would only be responsible for your copay based on the contracted or allowed amount. I had a 20% copy. My total copay was $548 up front plus $15 a month for 13 months (up front sale of accessories, 13 month capped rental for the xPAP). Your copay is 10% compared to my 20%. Just to give you some idea of what to expect and be prepared for.

Also be sure to check w/your insurance company about annual deductable and copays just to be sure AND ask them what local DME suppliers they are contracted with. Hopefully you will have the option of more than one so that you can shop your options and have more bargaining/negotiating room when doing so.

Keep in mind that many local DME suppliers buy a good share of the xPAPs they sell in bulk from one manufacturer and their costs are higher it they have to provide an xPAP from another manufacture and so will be less inclined to negotiate on your costs.

Also keep in mind that Respironics, Resmed and Fisher & Paykel will replace FREE to the local DME supplier most of their mask models patients have tried and been unsuccessful with IF the supplier fills out a form and returns that mask to the manufacturer W/IN 30 DAYS. Even so, some local DME suppliers have a more lenient mask exchange policy than others. Once the correct pressure you need has been established THE MASK becomes THE KEY to successful CPAP therapy.