Working with Physicians Insurance and DMEs
Contents
Physician Help[edit]
Getting into a Sleep Specialist/Sleep Lab Quickly[edit]
author unknown
This might seem like a no-brainer, but I'm going to mention this anyway just in case someone out there needs this info.
Anyone who has been into see a sleep specialist / neurologist as a new patient and then has booked a night at a sleep lab knows all too well how even in first rate medical cities (ie. Boston; Philly; Cleveland) it can easily take 1-3 months to get an appointment with a good Neurologist / Sleep Specialist. And then you're at the back of the line again to get into a sleep lab. AND THEN you're at the back of the line AGAIN to get back into see your Neurologist for the results of the sleep study. And if your results are inconclusive as they often are, add another 1-3 months for a repeat night at a sleep lab etc etc. When you're suffering from Sleep Apnea, nothing is more painfull than knowing it might take 6-8 months to finally be treated for the disorder.
So here are my tactics for getting into Sleep Specialist, Sleep Lab, and most importantly getting treatment ASAP or well within 6-12 weeks.
1. After you book your first appointment with your Neurologist / Sleep Specialist, call the scheduling desk and quickly convey that you are available on short notice if anyone else should cancel their appointment. If they say they have a long list, then pull out the "friendliness card" and make sure you're well known to the office staff.
2. After your first night at the sleep lab is booked, get on the phone to the sleep lab and do the exact same thing. Sleep Labs bill $1,000-$4,000/night so they are always eager to book empty beds, and people cancel their sleep lab nights left and right.
3. After your night in the sleep lab, you have no choice but to wait for your results to be compiled and sent to your neurologist. But once you\'re able to get into see your Neurologist for follow up, get on the phone and request that the office call you for cancelled appointments.
Hope this helps! I've been into 5 sleep studies and this always works for me.
Suggested Specific CPAP Equipment Rx/Scripts[edit]
by CPAPtalk member Slinky
(Editor's note: a doctor's prescription is required for a PAP machine and mask whether through a local DME or online. Online, a generic CPAP prescription will work for either a CPAP or APAP. At a local DME, a prescription specific for APAP will probably be required. See prescription advice and requirements at https://www.cpap.com/cpap-faq/Prescriptions.html#FGID-130 )
If your equipment order (Rx/script) will be for "just" a straight CPAP and not one of the more sophisticated bi-levels (Bi-PAP) or SV, etc. most doctors write a fairly genetic script and then most DMEs will take advantage and provide you with a bare-bones CPAP.
I would suggest that you ask your doctor to write a very explicit equipment order so that you get EXACTLY what you want and really need. The following are some suggested orders (not that I am recommending one machine over the other, just to give you and your doctor an idea).
You will notice the similarities to each suggestion.
1] Exact brand and model of machine
2] Scripted pressure (the autoPAPs have a pressure range rather than a set pressure)
3] Scripted amount for lower pressure at exhalation
4] Starts w/4 cms of pressure and ramps up to your set pressure after you get to sleep
5] Allows you to access your nightly data via the LCD screen
6] While the integrated humidifiers are most convenient for travel and take up less space on your nightstand, in really dry situations sometimes they can't provide as much humidity as you might need or want. For many the integrated humidifiers are more than satisfactory.
7] This ensures that you can try several masks, including a Full Face mask (sometimes they insist on a script specifiying full face if the script just says mask, or will only provide the exact mask mentioned in the equipment order).
Rx Sample 1
Rx Sample 2
Rx Sample 3
Rx Sample 4
To the best of my knowledge the only other fully data capable CPAPs (as of January 2008) are the Puritan Bennet GoodKnight 420E autoPAP and one other Puritan Bennet GoodKnight straight CPAP. I'm not sure of the correct model. Nor do I know the specifics for those Puritan Bennet's or I would have included them. Those who have the 420E really like them so hopefully further information can be included by someone who knows the Puritan Bennet devices.
Glossary for PSG (Sleep Study) Terms[edit]
The PSG Glossary is the first section of the CPAP Definitions page.
Get a copy of your sleep study report. You can refer to it from time to time as you learn more about your treatment. If you visit a specialist (sleep doctor, Ear/Nose/Throat doctor, pulmonologist, cardiologist, eye specialist, allergist, surgeon, dentist, etc.), give them a copy of your sleep study.
Insurance and DME Help[edit]
Getting the data-capable xPAP machine you need[edit]
by slinky (compilation of various posts)
Often beginners to CPAP end up with the low-end, non-data capable xPAP's. However, we know that the ability to monitor your own progress (AHI, leaks, etc) greatly increases compliance and allows you to make knowledgeable changes to your therapy (hopefully with the help of your sleep doctor).
Insurances WILL cover data capable machines. DME's WILL supply you with data capable machines, and here's how to ensure that you end up with a data-capable machine (or the machine and mask you want) when dealing with un-helpful Insurance, DME's, and doctors:
1] Call your insurance company.
a] Ask them what local DME CPAP suppliers they are contracted with
b] Ask them what your DME CPAP benefits are: copays? deductibles?
2] Since you found this forum I can guarantee you that you are NOT going to be satisfied w/anything LESS than a FULLY DATA CAPABLE CPAP.
a] Start checking out CPAPs at cpap.com. Never mind price at this point. Just check out the features. You can choose those CPAPs that interest you and cpap.com offers the opportunity to run a comparison of features of those that interest you.
b] Check out autoPAPs separate from "just" CPAPs. You might well get "auto fever" before you are done reading here.
3] Prepare a WRITTEN request for:
a] The doctor's dictated results of BOTH your sleep evaluation AND your titration studies
b] The full scored data summary report w/condensed graphs for BOTH your evaluation AND your titration studies
c] The script (equipment order) so that you may "shop" your local DME options
d]If you will not be seeing the sleep doctor for a consultation again FAX this above request to him and keep the proof of FAX. If you will be seeing him BEFORE you receive your equipment then you can just GIVE the request to him TO BE PUT IN YOUR RECORDS as well as discuss the results w/him.
WRITE, don't call[edit]
WRITE, don't call, this sleep lab/clinic and request a copy of the doctor's dictated results of both your sleep evaluation AND titration studies (about 1-2 pages each), AS WELL AS the scored report (full data summary report w/condensed graphs - about 5-7 or more pages each) from both studies AND your equipment order (script). This might also be a good time to diplomatically express your disappointment that doctor isn't interested enough in your therapy to want to monitor your data from a fully data capable CPAP.
That letter just MIGHT get you another appointment w/that doctor, your reports AND the script you want for a fully data capable CPAP. Maybe not an autoPAP, but at least a fully data capable CPAP.
It might even be a good idea to send that letter CERTIFIED MAIL, RETURN RECEIPT REQUESTED as PROOF that you HAVE requested those copies which you have a legal right to under HIPAA if you are in the USA. It also signals to the lab and doctor that you ARE serious about wanting them. Keep a copy AND all your receipts of having sent it.
With those copies you have almost all you need. The only other thing you will need is your family doctor to write the equipment order YOU WANT.
For examples of how scripts should be written see the section Suggested Specific CPAP Equipment Rx.
Don't get your heart set on an autoPAP. That can be a tough one to get, especially if you are stuck w/this same DME supplier which you might well be depending on how long you've had your current CPAP.
Also give consideration (if you already have a non-data-capable CPAP) that you will be better off getting the same brand of CPAP, just a fully data capable model, so that the humidifier doesn't have to be replaced as well. The more equipment this DME supplier has to exchange the harder they are going to fight providing it. AND your insurance is NOT going to be happy if they have to purchase another humidifier, all they know is they purchased A humidifier, not which one nor that a Respironics integrated isn't going to fit on a Resmed or vice versa. They most likely would refuse to do so and you'd end up buying the humidifier out of pocket - or going without.
Insurance Denied[edit]
This CPAPtalk thread offers advice to those who are given the following notice: DENIED: BiPAP Asv labeled experimental treatment. BiPAP is no longer experimental and are FDA approved SDB therapy machines. Recipients of this notice are encouraged to appeal or purchase online at wholesale prices.