Trying to upgrade machine

This is frustrating. I picked up my CPAP, a REMstar Plus C-Flex and System One humidifier several days ago. After getting it home, I found this site and started reading about all the excellent self-help (or at least self-information) that goes on when people have access to their own data and learn about their own condition. So I resolved to find a way to return the REMstar Plus and get instead a REMstar Pro, which will capture the data and allow me to become a sort of apnea nerd, as is my nature.

Well, I just got off the phone with the main office of Global Sleep in Houston. They operate the sleep clinic where both my initial PSG and titration study were done -- look at me! It's almost like I'm learning some of the lingo! hehe -- and they are the DME supplier as well. When I went in last week to get the machine, there was never any talk of options...they just brought out the carrying case and said, "$160 please." I wasn't even clear whether this was a rental or purchase. (It's a purchase. The $160 is my part of the 85/15 insurance coverage I have.) So anyway, when I talked to the nice lady at Global Sleep she (predictably) asked, "Why do you want a different model that records data?" I told her, "I want to be able to monitor my own progress on this therapy and I need to be able to access the data in order to do that." She then asked, "Did your doctor ask for this?" "No," I said, "I haven't spoken to the doctor yet. "Oh," she said, "we'd need a request from your doctor for that."

Now, I don't have a copy of the prescription for the CPAP, but I kinda doubt that the DME supplier has to hold on to the machines with more features as if they were Schedule 3 drugs or something. I'd like to hear your advice about this. My inclination at this point is to call them back and say, "I'd like to return this equipment, please." And then go find another supplier online that will sell me the machine I want. Lots of you guys and gals have this capability, and it pisses me off a little to have people act as though people aren't allowed access to their own health information.

Thoughts?

I bet the RX to DME said cpap with heated humidifier and mask.
I doubt very seriously if it specified a machine, make or model or data capable or not.

Tell them you will be returning the machine if they won't supply a data capable machine then you won't be using their services. I will be surprised if they don't start back peddling but they might stick to their guns.

In the meantime you can check with your insurance company to find out if there are other DME providers that can be used and call them up and ask them if you can get so and so machine.

Humidifier may or may not be returnable. If not, see if you can find DME that will supply the PR System One Machine that you want so it will be compatible with the humidifier you have. The PR System One Pro CPAP with CFlex Plus is data capable and will work. Also the PR System one CPAP Auto with AFlex is the APAP model and it also is data capable.

Online purchase is an option. A little more out of pocket. Check with your insurance company to see if their are other DME choices available.
It can be used in cpap and apap modes.

If I manage to work things out where I can get whatever machine I want under my insurance, is there some potential future benefit to having the System One APAP machine versus the CPAP machine?

Potentially, yes some benefit.
The APAP machine can be used in CPAP mode if desired. So 2 machines in one. The straight CPAP machine (Pro) only does cpap.
There are times when variable pressures of the APAP can come in handy. It is nice to have the choice and the overall price is not hugely different. Some people do fine with APAP and some people don't like the variations in pressure. They can be disturbing to sleep.

Yup, you fell right into that trap they set for you--don't blame yourself, they are as slick as oil!

Unfortunately, with an outright purchase, you don't have the best leverage--with a rental you could return it and say you're done renting from them unless they want to switch you out to a data capable machine. With a purchase, you don't have that same clout.

First you need to know what your insurance will cover. Take a look at my blog link below for what you need to know BEFORE you meet your DME. Call your insurance company and ask--never take the DME's word for what is covered and what is not. If your insurance will cover any CPAP/APAP machine, then you have a stance to take with this DME. Also find out whether you need to go to only particular DME's or can go anywhere. So, just like buying a car, if you aren't happy with this dealer, you can walk out and go to the next one on your list.

NOTE: If you have an HMO, the insurer may very well negotiate with the providers about what specific machines they will pay for and you may be limited in what DME you can use. In that case you may be SOL unless you want to pay out of pocket for what you want.

It's very important to make sure you won't get stuck with NO machine in the end. You want to be sure that if you can't work it out with this DME , you CAN go elsewhere, or--if necessary--pay out of pocket (there are ways to save) for exactly what you want. If you can't afford to pay out of pocket and you're not sure you can go to another DME or get something else covered by your insurer, then don't cut of you nose to spite your face and end up with NO treatment!

IF you are assured that you are not stuck with this DME and machine, ASAP, take your machine back. As already pointed out, expect that they will not agree to take back the supplies (filters, hose, mask) and probably not the humidifier either. But they should accept the main unit back if it's within 30 days--this may even be required by your state consumer laws, if it's not on their written policy (which should be on the receipt you got when you signed for this equipment). IF you return it, be sure to contact your insurer to make sure your insurer doesn't pay for it because getting money back will be next to impossible.

Now, the next step in this process is getting the machine you want. You do NOT need a prescription in order to get a data capable machine, but DME’s tell you this to stall you and give you cheaper machines (so they can pocket the difference). Therefore, it’s easiest if your rx says something like “with patient access to AHI and leak data”. But if your prescription doesn’t say that, it does not mean that they can’t give you a data capable machine—no matter how much they try to convince you otherwise.

Respironics System One machines are very good machines, and a data capable Pro or Auto will do fine. If you can somehow return the humidifier, then you can look at other brands (a lot of people prefer the S9 auto because it has better display/onboard data capabilities) but if you’re stuck with the humidifier you might as well stick with PR’s so you can use the humidifier with your new machine and save yourself a few hundred dollars to purchase a new humidifier.

If they take the humidifier back or you’re willing to shell out some money for exactly what you want, the possibilities are endless. You can find a better DME that will supply what you want, you can order new online, you can seek bargains on Cpap.auction.com, secondwind.com, Craig’s list, etc. Note that most insurers will not cover online and private purchases.

Hint: When looking for a new DME, it’s my understanding that our hoses, cpap.com, have a brick and mortar store in Houston, and if they are anything like their mail order business you will be treated well by them.

Awesome information from everyone. I'm very likely to pop by my doctor's office tomorrow. I called today to get them to make copies of all my sleep study paperwork, so I'll probably just ask them if I can see the Rx for the CPAP as well so I know what was ordered. And then I'll get back to work on getting a different machine. I'll keep this updated in case my progress can help anyone later.

Ask your doctor for a new Rx specifically stating "CPAP fully data-capable."

If you get a CPAP you will never know whether an APAP would be advantageous for you. Go with an APAP. As has already been stated, an APAP can be run in CPAP mode but a CPAP cannot be run in APAP mode.

Ask the doctor to specify APAP on your prescription as well to ensure you don't have to fight with a DME over that.

Some will insist that they don't have to provide an APAP unless the doctor specifies a range of pressures--not true, but it's another little argument they like to make. Usually they say something like "your insurance will not pay for an APAP unless your doctor prescribes a range of pressures. If you've already called the insurance company and know that they don't care if you get an APAP or a CPAP (because they are the SAME billing code) then you can nip that little lie in the bud with the DME.

Breathe Jimbo wrote:Ask your doctor for a new Rx specifically stating "CPAP fully data-capable."

Ask him for an "auto-CPAP" prescription. Get an original of the prescription on paper. Don't simply let him fax it to his favorite DME. Don't give the prescription to the DME until you agree on a machine. Keep a copy of the prescription. Heck, "forget" to bring the original and give the DME the copy. If they kvetch, tell them to call the doctor to fax a copy.

By the way, you should say "Philips Respironics System One REMstar Plus" or "PR System one REMstar plus." There are at least two other, older series of "Remstar Plus CFLEX" machines.

If you get a Respironics, get a PR System one Auto machine. It has full data capability, CFLEX, SD memory card, and most of the other stuff you want.

The machine they charged your insurance $1000+ for can be bought for $400 online including humidifier. The "correct" PR Sys One Auto CPAP can be bought for $550 or so online without the humidifier. The humidifier you have will work with it. Or buy the whole thing with humidifier for $650 or so.

Specify the auto because you can always use the Auto machine in manual CPAP mode. The Philips Respironics System One Auto CPAP machines all do full data recording. If you get a ResMed machine, I THINK, data may be a problem if you get an S8 machine because the card readers aren't available any more. A ResMed S9 Auto machine uses a standard SD card reader, so that won't be a problem. The Respironics humidifier won't work with a ResMed machine, of course.

So let us know how this goes with your DME.

Always remember, a DME provider is a business. The APAP and the data-capable machines all cost more wholesale than the "standard" one they gave you, but the insurance companies have a set rate for "CPAP hardware" that they pay out. Some DME/Insurance combos have settled on slightly more for the advanced machines, but the profit margin to the DME still shrinks.

Hit them where it hurts. Tell them (with the doctor's RX in hand) that if they try to pull this kind of stunt EVER again with you; not only will you stop using them, but you will recommend to everyone you know that this DME is not to be trusted. If the don't believe you, show them this board and the no doubt dozens of folks in your area who are potential customers for them.

Be nice - such as by telling them it's going to be very easy to shut you up =) but be firm. Just like you don't accept the first car the dealer shows you unless it's EXACTLY what you want, don't settle on the first machine the DME gives you unless it's the one you're willing to shell out that 160 bucks for.

Also remember that if your out-of-network costs for DME are not too high (mine is 70/30 out of network, 80/20 in) then buying a machine with cash and getting reimbursed may be an option. Remind the DME provider of that fact when you go in. Hearing that it was only a 10% difference for me to buy on my own from another DME gave me a LOT of bargaining power!

I got my GP to write my APAP prescription for me while there on a routine visit. He was already aware of the apnea of course, and I just had a little conversation about wanting to be proactive about my treatment. He was all for that.

OK, I checked with Cigna and got details on my coverage using the very helpful questions in Janknitz's article. Cigna does not discriminate between machines -- "Whichever machine the doctor orders." Do you read this to mean that if the original Rx says only "CPAP machine, hose, mask, humidifier" that I should be able to get any machine I want? They use a company called CareCentrics to handle the DME end of things, so I'll have to call them to find out which in-network DMEs I can use to get certain equipment.

In the meantime, I'm going to drop by the doctor's office this afternoon -- my PCP...I don't have a separate sleep doctor -- and pick up the copies of my sleep study records. While I'm there, I'll ask for a copy of the Rx or at least what the exact wording of the Rx was. That should be the last bit I need to know before confronting Global Sleep again, right?

Actually, that's the issue. Cigna tells the DME, "We will pay X amount for ANY XPAP MACHINE" - so the DME tries to give you the cheapest one (wholesale) so they can get the most profit margin.

It does mean that with the right Rx, you CAN get the DME to give up a better one, or demand a refund for all returnable parts and take your business elsewhere. They would rather have some profit than a net loss when they have to give the insurance money back =)