Ontario users: +$200 for "upgraded machine" under ADP??

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ChrisC
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Ontario users: +$200 for "upgraded machine" under ADP??

Post by ChrisC » Wed Jul 30, 2014 6:25 pm

Just got back from a new DME who claims that I have to pay $200 more for an s9 elite or REMstar pro 60 series. Claimed that the basic ADP amount only applied to a REMstar SE or s9 escape.

What the heck?? I feel like I'm totally getting scammed. Are they allowed to charge an upgrade fee for machines?? I know they can charge for masks and services.. But I thought going above the ADP approved price was a big no no..

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ShelaghDB
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ShelaghDB » Wed Jul 30, 2014 6:36 pm

Where in Ontario are you?

I am in Toronto and can point you to a guy, a doctor selling machines on the side. I bought a S9 AutoSet, with everything, the SD Card, the carrying case, brand new in a box, PLUS he throws in one brand new Phillips mask so in my case i took the SWIFT FX Nasal mask, still sealed, for only $650

You can get the S9 Elite, same deal with everything and the mask for $420

Now IF you won't use the mask, you could sell it on Kijiji which is Ontarios version of Craigslist and for some reason where everyone puts up their CPAP stuff rather than Craigslist here so if you sold it, my quick guess, for about $125, your ELITE brand new machine only costs $300

You have to pick up from the guy right beside Square One in Mississauga.
If you can do that, or want to do it, PM me and i will give you his email address and phone number.

I bought the S9 AutoSet and know he's legit 100%

For some reasons though, I did ask for future reference about the S9 VPAP machines but they run about $1800 so I don't think he gets deals on those ones

What the heck?? I feel like I'm totally getting scammed. Are they allowed to charge an upgrade fee for machines?? I know they can charge for masks and services.. But I thought going above the ADP approved price was a big no no..
Most insurance companies will pay 75% and you pay 25% so I am guessing thats the deal you have. In my case I WAS NOT allowed to pay for an AutoSet for some bizarre reason I still cannot figure out other than the fact that i had a real prick of a doctor.
When I told him I wanted to pay the difference, 25% he got really mad and ranted on a bout how the S9 Autoset was all bullshit, and that the ESCAPE was as good, yadda yadda yadda which we all know is not true.........and he decided to be a real mensch and wrote across the prescription S9 ESCAPE and if patient wants the S9 Autoset she can pay 100% herself for it....... LOL

Yeha, he had a real attitude problem............I have since signed up on line on EVERY place for his name and warned everyone NOT to go to him + why and i hope he remembers me clearly when he starts to lose patients

Everyones case is different, as is their insurance so in my case, and many others, its easier to just buy it online and not have to deal with all the bullshit.
Not everyone I understand has that ability and has to go through the DMEs so if you only have to pay $200 and can afford it, Id buy it over the ESCAPE if that is offered for free for its crap. The other one mentioned I cannot comment on as i am not familiar with so someone else where will have to do so.

There is also another Canadian or two that will very likely chime in with a better explanation of the insurance prices than I have............
Claimed that the basic ADP amount only applied to a REMstar SE or s9 escape.
Yup, same as me.
Whatever you do, beg, borrow, or steal but DO NOT accept the ESCAPE.
Please come up with the $200 however you have to do it

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Pugsy
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by Pugsy » Wed Jul 30, 2014 6:46 pm

You might find this discussion useful
viewtopic.php?f=1&t=95962&st=0&sk=t&sd=a&hilit=Ontario

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ShelaghDB
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ShelaghDB » Wed Jul 30, 2014 6:46 pm

Sorry I just realized you are not a newbie but have been at this since 2009. Weren't you made familiar with this the first time are around? How did you pay for your last machine?

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ChrisC
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ChrisC » Wed Jul 30, 2014 8:10 pm

Pugsy wrote:You might find this discussion useful
viewtopic.php?f=1&t=95962&st=0&sk=t&sd=a&hilit=Ontario
Thanks for the link! Read through there first and it did have plenty to say about the new funding model. Mostly dealt with the 'packages' DMEs are pushing.. mine had a bronze/silver/gold package (including gems like 3 filters for $350) that I was up front about not wanting at all.

My main concern is that the rep specifically said they would charge ADP the full $860 and then I'd be responsible for my 25% PLUS an additional $200 on top of that for a data-capable machine. Was blown away: did not think this was even legal under the policies of ADP.

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ChrisC
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ChrisC » Wed Jul 30, 2014 8:14 pm

ShelaghDB wrote:Sorry I just realized you are not a newbie but have been at this since 2009. Weren't you made familiar with this the first time are around? How did you pay for your last machine?
Yep: was very familiar with the process. I had accessed ADP for my first machine. My humidifier is now on the fritz, so I qualify for a replacement machine (it's been 5 years). My first kick at the can was with Medigas, who tried (in vain) to give me an S8 Escape. I put up a bit of a fuss and, no problem. They gave me an S8 Elite II.

I actually manage a HHC store as an ADP vendor (mobility) and I know firsthand that I couldn't bill a patient for more than their 25% copay on the device itself. Accessories, sure: they're fair game since they're not covered by the program.. but if I bumped a walker two hundred bucks above the ADP-listed price, we'd be in big trouble..

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Additional Comments: 10CM pressure. Started CPAP March 26, 2009. Humidifer is actually a H4i
"Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so."
-- Douglas Adams

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SleepWrangler
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by SleepWrangler » Wed Jul 30, 2014 10:06 pm

ChrisC wrote:I actually manage a HHC store as an ADP vendor (mobility) and I know firsthand that I couldn't bill a patient for more than their 25% copay on the device itself. Accessories, sure: they're fair game since they're not covered by the program ... but if I bumped a walker two hundred bucks above the ADP-listed price, we'd be in big trouble..
I agree with you. I don't know about legal vs. illegal but certainly there must be a qualification or certification process for vendor inclusion in the ADP program. Seems that the price you've been quoted is not compliant and would cause an OHIP ADP administrator to get involved. Now you have to decide to force this vendor to comply or move on to a different vendor.

BTW, there are rules regarding replacement too. As I understand it, five year replacement isn't part of the program any longer. Instead the Respiratory Equipment Policy and Administration Manual, September 2012 says: damage due to normal use and wear, and the Client confirms that the respiratory Device is no longer under warranty and the cost of the repair is more than one third of the original purchase price.

Whatever you learn it would be really helpful to update the thread Pugsy referenced. That thread has become the unofficial FAQ, of sorts, for dealing with Ontario ADP. This topic would be an excellent contribution.

Respiratory Equipment Policy and Administration Manual, September 2012
http://www.health.gov.on.ca/en/pro/prog ... manual.pdf

Changes to How the ADP Funds Positive Airway Pressures Systems
http://www.health.gov.on.ca/en/pro/prog ... 131218.pdf

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ChrisC
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ChrisC » Thu Jul 31, 2014 11:37 am

Will definitely update when I get a response from the vendor. Being an ADP vendor myself, I do have some contacts that I could raise a you-know-what storm with. Like you say, it's all about whether I want to force this vendor to bend and abide by ADP policy.. Or whether I should just go elsewhere.

I have a feeling they deal a lot with people who are simply submitting to a drug plan..

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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by Hose_Head » Thu Jul 31, 2014 6:52 pm

ChrisC wrote: Yep: was very familiar with the process. I had accessed ADP for my first machine. My humidifier is now on the fritz, so I qualify for a replacement machine (it's been 5 years). My first kick at the can was with Medigas, who tried (in vain) to give me an S8 Escape. I put up a bit of a fuss and, no problem. They gave me an S8 Elite II.
To get a replacement machine under ADP, did you also have to do a new sleep test?

I'm now at 6+ years since starting on apap. My machine is still working OK but who knows for how much longer. I am wondering what's required to get a newer machine. I'm aware that so long as my current machine is working, I won't qualify under ADP. This seems to be a strange requirement to me because the system, as currently set up, puts patients through a period without a machine while waiting to get a replacement machine. Maybe there is a work-around for this (old, non-working machines now have a market value! )

I'm also worried that I may no longer qualify for an apap because I don't think I meet their new requirements to get one. If that is the case, I may just say screw it and buy a machine on my own using my old Rx. A PR System One auto from our host is not all that expensive (there are ways to get it delivered to you in Canada). Heck, it's worth a couple hundred dollars to me just to avoid that miserable sleep test!
I'm workin' on it.

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ChrisC
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ChrisC » Thu Jul 31, 2014 8:32 pm

Nope! My doc just wrote a new script, citing "inadequate hunidification". The vendor will have to submit that my machine is too expensive to repair on the new application for funding.

I'm just going straight cpap.. You might need a study to indeed qualify for APAP under the horrible requirements.

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ShelaghDB
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by ShelaghDB » Thu Jul 31, 2014 10:54 pm

I actually manage a HHC store as an ADP vendor (mobility) and I know firsthand that I couldn't bill a patient for more than their 25% copay on the device itself. Accessories, sure: they're fair game since they're not covered by the program.. but if I bumped a walker two hundred bucks above the ADP-listed price, we'd be in big trouble..
Interesting. I understand your earlier comments better now.
'm also worried that I may no longer qualify for an apap because I don't think I meet their new requirements to get one.
My understanding, although likely ill informed on this, is that to get an APAP machine, one must not be compliant somehow. I believe that would be for those who swallow the air and have difficulties that way, which if i am correct happens more with severe sleep apnea patients due to higher pressure settings??!!

No need to explain that to me as i can look that up but wondering what it was that they considered you in need for an APAP then, but no longer?

Curious what the price of APAP machines work out to if ones insurance pays all but 25%? Or at least a rough area quote?
I emailed the seller of the S9 AutoSets and Elits I have mentioned here about the price of an APAP and he told me unfortunately they were much higher, $1800.
I don't know if they are just $3k machines and $1800 is still a good deal OR whether he is unable to get a deal on them and $1800 is the rough going rate for everyone wishing an APAP machine?

/just looking ahead at the possibility of needing an APAP machine at some point

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Additional Comments: Prescription: 13 Pressure
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by Ford Guy » Fri Aug 01, 2014 5:08 am

ShelaghDB wrote:



/just looking ahead at the possibility of needing an APAP machine at some point
Your profile says that you are already using an APAP
S8 Autoset II is back up

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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by Hose_Head » Fri Aug 01, 2014 8:15 am

ShelaghDB wrote:
I actually manage a HHC store as an ADP vendor (mobility) and I know firsthand that I couldn't bill a patient for more than their 25% copay on the device itself. Accessories, sure: they're fair game since they're not covered by the program.. but if I bumped a walker two hundred bucks above the ADP-listed price, we'd be in big trouble..
Interesting. I understand your earlier comments better now.
'm also worried that I may no longer qualify for an apap because I don't think I meet their new requirements to get one.
My understanding, although likely ill informed on this, is that to get an APAP machine, one must not be compliant somehow. I believe that would be for those who swallow the air and have difficulties that way, which if i am correct happens more with severe sleep apnea patients due to higher pressure settings??!!

No need to explain that to me as i can look that up but wondering what it was that they considered you in need for an APAP then, but no longer?

Curious what the price of APAP machines work out to if ones insurance pays all but 25%? Or at least a rough area quote?
I emailed the seller of the S9 AutoSets and Elits I have mentioned here about the price of an APAP and he told me unfortunately they were much higher, $1800.
I don't know if they are just $3k machines and $1800 is still a good deal OR whether he is unable to get a deal on them and $1800 is the rough going rate for everyone wishing an APAP machine?

/just looking ahead at the possibility of needing an APAP machine at some point
You've quoted different posters. I've highlighted the one that appears to be from a post that I made.

To explain point, the requirements for qualifying for an apap under ADP have recently changed and it is now harder to get one. I suspect that my needs fall into the gap between the old and new requirements, qualifying for apap in 2008 when I had my sleep studies but not qualifying for apap under today's rules.
I'm workin' on it.

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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by Hose_Head » Fri Aug 01, 2014 8:20 am

ChrisC wrote:Nope! My doc just wrote a new script, citing "inadequate hunidification". The vendor will have to submit that my machine is too expensive to repair on the new application for funding.

I'm just going straight cpap.. You might need a study to indeed qualify for APAP under the horrible requirements.
Let's just hope that they get you a complete new system and not just a new humidifier!
I'm workin' on it.

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SleepWrangler
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Re: Ontario users: +$200 for "upgraded machine" under ADP??

Post by SleepWrangler » Fri Aug 01, 2014 8:42 am

ShelaghDB wrote:Curious what the price of APAP machines work out to if ones insurance pays all but 25%? Or at least a rough area quote?
I emailed the seller of the S9 AutoSets and Elits I have mentioned here about the price of an APAP and he told me unfortunately they were much higher, $1800.
Have you gone through the Ontario process at all? Your posts come across as someone not familiar with apnea diagnosis, equipment choices, vendor selection, ADP and vendor billing but does contain a lot of information related to selling electronics and hawking equipment for a practicing doctor active in the medical field. In Ontario this is unethical and possibly illegal. Are you aware that your statements about this particular seller are so persistent that they come across as astroturfing?

My curiosity is piqued so I will ask directly "Are you astroturfing?". Astroturfing is the practice of masking the sponsors of a message or organization to make it appear as though it originates from and is supported by grassroots participant(s).

BTW, insurance does not pay "all but 25%". The ADP program pays all but 25%. Private employment or group insurance may pay all or a portion of the remaining 25%.