Newbie Help

Hello,

I have been "lurking" in this forum for a while and have finally joined. I am newly diagnosed with sleep apnea. On Monday I will be going to my doctor to see about getting a machine. The sleep lab I am using has informed me that they are contracted with my insurance (blue cross blue shield) to act as the dme. They only have two machines to choose from: Resmed S9 Escape and a Fisher Paykel machine. I don't really want either of those machines. I was looking at getting the Resmed S9 Autoset or the Devilbiss Intellipap Autoadjust.

Has anyone ever dealt with the doctor as the dme? Do I have to get one of the machines that they have? Can I get a prescription and get my own equipment? I have to meet my deductible which will cost me $1,500 out of pocket. Based on my research I can get something for less than that online.

Any advise, comments or suggestions will be greatly appreciated.

Thanks!

You need to contact your insurance to see just what they will cover. If they allow you get your own machine find out exactly what you need to do to get reimbursed.

Brenda

needmoresleep616 wrote:The sleep lab I am using has informed me that they are contracted with my insurance (blue cross blue shield) to act as the dme.

You need to call your insurance company and talk directly to them. And you need to do this BEFORE you meet with the sleep lab-DME on Monday. It seems highly unlikely that a BCBS insurance company would have only one in-network DME in your area. Chances are the sleep lab is indeed in-network, but chances are they are NOT the only in-network DME in your area. In other words, the sleep lab is indeed "contracted" with BCBS to act as a DME, but my guess is they are misleading you into believing that they are the only DME that is contracted with BCBS.

My advice? On Monday morning, call the sleep lab and cancel your appointment to pick up the equipment----politely inform them that you now realize you need more time before you make any decisions about where you plan on obtaining your equipment. Tell them that you plan to contact BCBS yourself to find out exactly what your benefits are and to obtain a list of DMEs that are in-network. And tell them that the two machines they propose to sell you are unacceptable to you and that you intend to shop around after you know exactly what conditions your insurance company imposes on you concerning in-network DMEs.

And an important note: Please realize that regardless of what they say, the sleep lab/DME is NOT giving you a machine. They are selling you and your insurance company a CPAP machine under a rent-to-own contract. So when talking about the machine(s) they intend to set you up with, do NOT use the word give to describe the transaction.

They only have two machines to choose from: Resmed S9 Escape and a Fisher Paykel machine. I don't really want either of those machines. I was looking at getting the Resmed S9 Autoset or the Devilbiss Intellipap Autoadjust.

All the more reason for canceling the appointment with the DME side of the sleep lab on Monday morning.

Has anyone ever dealt with the doctor as the dme?

Yes, there are folks here who have gotten equipment from a doctor/sleep lab/dme. But I don't think it's the norm. And my gut impression is that satisfaction with doctor-DMEs ranges all over the board and is directly tied to the equipment provided. The folks with doctor-DMEs who insist on selling their patients bricks (like yours does) tend to be very, very unsatisfied with the DME end of things.

Do I have to get one of the machines that they have? Can I get a prescription and get my own equipment? I have to meet my deductible which will cost me $1,500 out of pocket. Based on my research I can get something for less than that online.

No, you don't have to get one of the two machines they are willing to sell you, but it will take some time and work on your part to not get stuck with one of these two machines.

Yes you can get a copy of your prescription. You may have to insist and you need to be prepared to play some hardball and be prepared to honestly tell the doctor's office that given your high deductible you intend on going out of network and purchasing your equipment on line if need be. If the doc's office still will not provide you with a copy of the prescription, call your insurance company and report the problem to them. Doctors are legally obligated to give you copies of your prescriptions in the states.

And from the sound of it, you will have to spend a pretty hefty chunk of your own money on the machine. All the more reason to NOT buy the S9 Escape or the F&P machine (most likely an ICON Novo?) from the sleep lab-DME.

It sounds as though you think they are asking you to spend $1500 OOP on a brick that costs around $750 + $250 for the humidifier on-line. $1500 will easily buy you the S9 AutoSet plus it's humidifier if you buy on-line.

It's true that you won't have a brick and mortar store to go to if you need the machine's settings to be adjusted, but that's not difficult. More problematic perhaps is whether you will be able to find a DME that is willing to service the machine---as in checking it out annually to make sure that it continues to blow pressure at the correct level and to provide repair service should it be necessary.

A question for your insurance company is what buying the CPAP totally OOP does to your benefits concerning CPAP supplies. In other words, would the insurance continue to pay its share of the ongoing supplies.

So---reiterating the most important thing: Cancel the appointment to pick up the overpriced brick and call your insurance company on Monday morning to find out what the real story is from them concerning (1) what DMEs are in network, (2) whether they pay for CPAPs by code, and(3) exactly how they pay for equipment and how it factors into your deductible and copays.[/i] After you have armed yourself with that knowledge, start calling DMEs and asking questions.

Thanks for your input. Your information is very useful. I plan to contact the insurance company. I plan to ask all sorts of questions on Monday and make an informed decision. If I am going to spend that much money I am going to be smart about it. Reading on this forum will help me even more on Monday.