Yet Another DME struggle

[Llama]

Hi everyone, I am a new user to the board and trying to be a new user of a CPAP. It's long and I am sorry.

I had my sleep study about a month ago and got my summary results last week. My dr prescribed a CPAP requesting therapy and compliance data to the local DME and it has been nothing but a PITA since.

The DME guy set up an appointment on Tuesday to pick up my machine and I should have known to just walk away then. He insisted over and over again that the REMstar Plus M Series with C-Flex with SmartCard would capture the therapy data that my dr requested. I questioned his about it over and over again and he kept assuring me that I was mistaken when I said it was compliance only. Like a dummy, I submit and we ring up the order and I head home. I immediately hop online and confirm that I have indeed been saddled with a machine I do not want. I don't even bother unpacking it and just continue to use the ResMed Escape my folks handed down to me.

I call Wednesday morning and leave a message asking them to call me ASAP so I can swap out the machine. I call again in the afternoon and leave another message. I call Thursday morning and leave another message and this time he calls me back. He again assures me that I am wrong about the capabilities of the machine because "he's a sleep therapist and he's been using a CPAP for 10 years so he knows what he's talking about". I then tell him that I am looking for a specific list of machines (ResMed Elite II or Autoset II) then and he tells me that he will need a new script because the doctor listed "CFlex at 3" in the exhalation relief box so he is "forced to use the Respironics".

I call my doctor and she tells me that she has no problem writing exactly what I want down to the machine and that she'll contact him directly. I get another call from him 30 minutes later telling me that he'll put it together but now I'll need to drop off the machine, go through the pre auth with the insurance and wait for it to arrive. I agree with that course and leave to head home for the day.

During dinner he calls back and tells me that, despite the fact that the machine I have will capture the data I am looking for, he's worked it all out and we'll just do it as a swap out tomorrow morning. I ask him which machine we're getting this time and he says "ResMes S8 Escape II"... I tell him that we're getting closer, but that still won't do the trick. He again assures me otherwise and asks me which models again I will accept. He declines the Autoset II since "it is only for people that need titrating" and then says the SAME THING for the Elite II! When I assure him that that is not the case for the Elite II he finally gets to the heart of the problem -

I'm sorry, we don't sell those models because they cost too much.

I'm all for business people making money, but don't cloak your profit motive with some "Aw, shucks, I'm just trying to help you out" while flat out misleading patients, banking on patient ignorance/frustration to move inventory and flat out not knowing product lines.

Unless I hear differently from the board, I guess I'll be dropping off the Respironics tomorrow and ensuring that he files the paperwork to correct the billing.

1. Should I be asking him for the copy of my prescription or not sweat it and get my doctor to write me another one?
2. Am I right to return the "REMstar Plus M Series with C-Flex with SmartCard" and also pass on the "ResMed Escape II"?
3. Should I expect a similar runaround from other local DME's?
4. Is there a chance that my insurance carrier (United Healthcare) will reimburse at any rate from an online purchase? If so, what do I do to ensure that they hold up their end of the bargain when I submit?
5. Is it normal for a patient to walk away from the DME with no particular insight on how much I will be billed for? He wrote down the prices he was submitting to insurance ($1305.00 USD) and put my estimate as 20% as I expected, but he said my amount would be lower since my 20% would be only against what the insurance actually pays. Why doesn't he KNOW what my plan pays? Heck, how do I find out what my plan will pay ahead of time?

If I'm just wrong about the machines and my impression of the scenario I am more than willing to apologize to him (and to DME's in general) and have little doubt that someone here will set me straight.

[carbonman]

I call my doctor and she tells me that she has no problem writing exactly what I want down to the machine and that she'll contact him directly.

Llama, this is so sad.

Have your Dr. write a Rx for a Resmed S8 Autoset II or Apap of patients choice.
You get the Rx in your hand and take your business else where.
I have UHC. They paid rent on mine for 10mths, now I own it.
Be sure you know exactly what they will and will not pay for.
It is standard practice for a brain dead patient to walk into a DME and be fleeced.
Fight the fight now.....and get it over with. It will be worth it in the future.
I know.

This is your therapy. You are in charge. These people work for you.
Time for you to take over.

Go the distance.

[SaltLakeJan]

Het Llama,
How could my DME have moved from Ut to Vt so fast?

In answer to your questions . . .

#1 Yes, it is legally yours.
#2 Yes
#3 There usually is a good one around somewhere.
#4 E-mail our host, Cpap.com. Ask for the delivery price of the unit you want. Then call your insurance, Explain the difference in cost between online purchase and DME. If they agree, I would ask for confirmation. When you get
it, I would buy.
#5 No, ask your insurance what they will pay.

IMHO your DME is a scam artist, and a very good one.

Best of luck to you. For a beginner, you were very sharp. There are some great DME's,, keep looking, You might get a recommendation from a sleep center. Jan

[Doze]

Since you mentioned United Healthcare by name, I'd recommend you check their website for other candidate DMEs nearby. Even if you haven't registered for it, or forgot your account, the publicly-accessible portion of the http://myuhc.com website allows for physician, hospital, and [durable] medical equipment (DME) supplier searches, and shows which are "In Network" as long as you know your plan name, which it lists in a drop-down. Here's the direct link for provider search from the top-right of that front page: https://www.geoaccess.com/uhc/po/. The phone numbers are listed for each DME; with very little effort you might find another in-network provider for CPAPs nearby. Unfortunately, DMEs aren't listed by specialty, but the company names they pick generally make it obvious for around half of them, what services they are likely to provide.

My DME experience was not without hiccup, but I got through it with the machine I wanted, in part because I first called to verify that they carried the "latest Respironics PR-Series", which was on my short list along with the S8 Autoset II. I recommend a quick call or two just to see if an easier path than your current route might exist. If another DME seems promising, verify with United on the phone before actually contracting with that DME, as the "In network" statuses can change faster than they bother to update that online database. That said, the database is a fine place to find leads on [probably] in-network DMEs.

Good luck!

[Llama]

My wife dropped off the CPAP at the DME today (he does not come in until 10 and I am at work by then). He was relatively pleasant, but also insisted that I return the mask and headgear that he fitted me for. I don't have any problem with the ones he fitted me for nor with being billed for them, so I guess he just wants to be a tool and be able to totally remove me from the books. He said that whatever DME I go to get the machine at will want to fit me with a mask as his justification for the request? Legit or just him being unhelpful?

I hate that I got sucked into this mess. I read here for a month before getting the machine to prevent this exact problem, but he was so certain that he was right and that I was wrong that I second guessed myself.

[cinco777]

I hate that I got sucked into this mess. I read here for a month before getting the machine to prevent this exact problem, but he was so certain that he was right and that I was wrong that I second guessed myself.

Don't kick yourself in the *ss for being misled. Your DME had misled so many others before you showed up at their door that he was an Expert in lying, deceit, misinformation, and a host of other evils. Remember the old saying that "Practice makes perfect". Well, he like many other DME evildoers, had lots of practice.

Just continue to learn the ropes here on CPAPTalk, persevere, and you'll get through these start-up obstacles and figure out what you need to successfully treat your sleep apnea.

[DJ_Boxer]

In August I started my therapy with an Auto machine w/o asking for one, fitted for a Flexifit 407 which was too big for me, but talked for an hour about my machine and everything. This past month: I had a really bad cold and couldn't use either my Opus 360 or HC407 and needed a Full-Face mask. I had to get in touch with my doctor to get a script and to get the mask from my DME but here's the rub: they would have to come and fit me for it or I wouldn't be re-imbursed. This is a FlexiFit 431 with a Small, Medium, and Large cushion in one package. I was able to get it shipped out to me this week and can now use it. There are various types of DME's and they are as follows:(bad DME's, good DME's, and great DME's). The difference between good and great can vary because great is more equal to perfect and no-one or thing is perfect. They are a business and in business it unfortunately ends up being(money first, people second), where it should be(money=people) where when you put people first you get money(as seen with various devices: vcr's, tv's, blu-ray/dvd's, ...).
Remember Health-Care reform is on the way, hopefully not like 10 years ago when they introduced HMO's.

DJ

[Sleeprider]

Once again Carbonman hits the nail on the head. Get the prescription for an APAP. After that the machines have comparable pricing. The problem is all the scripts for CPAP, which seem very short-sighted to save a small amount on equipment cost, as they leave the patient and physician with no other recourse than to go to another expensive sleep study if the therapy is not working as desired. An APAP can be allowed to verify the titration and show the results. Anyone reading this forum who is in the prescription phase, and wants to take an active role in their therapy, needs to ensure they get an APAP script.

[carbonman]

I hate that I got sucked into this mess.

Not to worry. It is a Rite of Passage into the cpap world.

You have already discovered another similar experience to yours.
They appear here daily.

You're on the road now.
Get the machine YOU want.
Keep reading.
Keep asking questions.
Get educated.
Become your own best therapist.

[Llama]

My wife popped into another local DME (Lincare) and the rep there was very friendly, but said that UHC would not cover either the Elite II or Autoset II - no matter what the script said. I am changing group insurance at work in Jan to Anthem BC/BS and he said that they on the other hand do not have such restrictions.

She is off to try another this afternoon, but I guess worst case I can wait until Jan 4 and use the hand me down until then.

[Llama]

they leave the patient and physician with no other recourse than to go to another expensive sleep study if the therapy is not working as desired. An APAP can be allowed to verify the titration and show the results.

Indeed, and when I talked to the original DME about it when he questioned why I wanted the data I told him that with compliance only data I can tell my doctor whether or not I have been using the machine, but with compliance+AHI+leak data I would be able to tell my doctor if the treatment is actually working. I am pretty sure that there was an actual ZOOM sound as that notion flew over his head.

[BlackSpinner]

My wife popped into another local DME (Lincare) and the rep there was very friendly, but said that UHC would not cover either the Elite II or Autoset II - no matter what the script said. I am changing group insurance at work in Jan to Anthem BC/BS and he said that they on the other hand do not have such restrictions.

She is off to try another this afternoon, but I guess worst case I can wait until Jan 4 and use the hand me down until then.

As others have said there is one billing code for these machines only.

[Llama]

As others have said there is one billing code for these machines only.

Ah, so is this another way to phrase "UHC reimburses less than Anthem" so it sounds like he is helping me?

[Sleeprider]

The DME is obliged to fulfill a prescription. If you can get a doctor to prescribe a specific brand and model of unit, more power to you, but most will define performance characteristics, such as APAP with exhalation relief (settings) and humidifier with accessories. Whether it is a Respironics, F&P, Resmed or any other "brand" may not be something that the doctors will normally specify, just as most consider generics to be equivalent. The point is, get a script that comes as close to what you feel you need as possible. I am all for getting the doctor to write the most specific script possible, including brands and models. The problem is if those specific equipment devices are 'out of plan', it can delay fulfillment. If fulfillment is through a specific DME, you will have to deal with the limits on brands and models that comply with the prescription, and that may be why prescription are written with some flexibility.

At least if you get the prescription in-hand, you may have the option of buying it on your own, rather than through a DME and accepting the standard reimbursement (probably less money). In my case, the insurance rented the unit for about a year which more than paid for the unit, and it became mine when the doctor confirmed it was necessary and I was compliant on the unit. You may not get exactly what you want, but you can get pretty close, at least in features.

[Guest]

Contrary to popular belief there are insurance companies who request the make model and serial number of the PAP unit given to a patient for prior approval. Recently our State employee insurance changed from BC/BS to Wells Fargo (yeah I thought they were just a bank too), they require the make, model, and serial number of the PAP unit given to a patient at the time of billing. What we found out in a very short time is while an active employee can get any PAP machine they want a retired employee can only get a basic model PAP machine, no exhale relief, no data, no nothing extra. Anything above and beyond a basic machine requires an approval by their medical review board upon a letter of medical necessity from their doctor, this is a 4-6 week process mind you.

We used to only issue M-series Pro's and Auto's to patients, but this policy has forced us back into carrying a stock of regular M-series.

So YES different insurance companies can and do specify which models their patients get, even with patients who have the same insurance, but different plans.


AKCPAPGUY