The adventure is about to begin....

Hello all,

I had a sleep study 10 years ago with no major problems found. However, over the last few years, my wife has become more and more concerned. Finally, when I saw my primary care doc (great doctor), I mentioned her concern, the fact that my mother snored horribly and that my brother is on CPAP. He got me hooked up with a sleep doc and got a sleep study scheduled. I went with a bit of trepidation, half expecting the same result I had 10 years ago. The tech told me that they might, but probably would not, wake me up and put a mask on me, so I really wasn't expecting anything. Well, at 1 am, they woke me up and stuck a hose on my face. I won't say it was the best experience as it took me about 2 hours go get back to sleep, but maybe, just maybe I did feel a bit better the next morning. The tech said I was stopping breathing about 40 times an hour. Fortunately, I did get enough sleep with the mask on that they were able to determine my pressure level. Maybe it was the CPAP, maybe it was just having concrete data that something was going on.

That was a week ago. This afternoon, the sleep doc's office calls to schedule an appointment to get me set up with a machine. I had expected them to let me borrow a machine before I sat down with the Dr. and I would have had more time to research the particular equipment. The machine they want to give me is the Resmed S9 Elite. From what I've read, this should do nicely. They said my insurance required me to rent-to-own over a 10 month period and the cost of the humidifier would not be covered. I asked the cost of the machine and they said $1660! Well, before you look, cpap.com sells it for just over $800. With that markup, I was really concerned about the cost of the humidifier, especially if it comes out of my pocket. I called my insurance company, and since I've already met my deductible for the year they will cover 90% of the cost. They also said they would do the same for the humidifier. They also said it will be a purchase, just spread out over many months.

I follow up with the doc next week and I'm supposed to bring my machine. I asked about software that will let me read the datacard, but got the usual "you wouldn't understand" it spiel. That's just not going to fly.

I just found this site a few days ago, but I'm impressed by the advice that is freely given. I plan on studying a bit more tonight. I know this is a tough road, but I plan to stick it out. The only real question is how forceful I will have to be on the humidifier. If I get the humidifier, should I really get the heated hose? If insurance picks it up, my cost will be minimal, and even if it doesn't, the cost may be worth it if it keeps me on treatment. Armed with my prescription, I suppose I could just order it rather than deal with the DME.

Any other thoughts or hints would be appreciated.

snoreguy, hopefully for not much longer

Hey here is a video that goes over the top three machines it may help you make a decision.
Good Luck, also if you have any questions my family owns a DME so I know the ins and outs feel free to email me or ask on the site. http://www.sleepnation.tv
sleepnationtv@gmail.com

Snoreguy, welcome to the forum! Get the humidifier, it can really help you stay comfortable. If your insurance pays 90% you're luckier than many of us! Even with great insurance, be sure to get the Rx in your hand, because you just never know. Read all you can here, you'll learn so much. And ask whatever you need to, we're here to help!

I have a few suggestions you may wish to consider:

1. Ask your doctor to write the prescription to include the heated humidifier.
2. Take the prescription yourself and make a copy to give/fax to the DME. Or ask the Dr. to give you a copy of your Rx if he is dealing directly with the DME. You may need the prescription later.
3. Ask your doctor to write "mask of patient's choice." Take your time with the DME selecting a mask, and understand the return policy. They generally let you exchange the mask within 30 days.
4. If you live in a climate where the winters are chilly, get the heated hose. Have the Dr. write that in the prescription.
5. Ask the doctor for a copy of the sleep study report.


As for the data, don't deal with the doctor on that. You're just creating a negative tone with him that you don't need to have, so why even discuss it with him? He probably can't help you acquire it, anyway. You can't get insurance to pay for it, either. You'll have to get a card reader and the software. I'm sure people here will help you figure out how to do that.


Somebody here will know, is the S9 Elite capable of auto? Is there an S9 that is? If so, you should ask for that machine. Unless you need BiPAP, and I take it you don't, you should be able to get either a straight CPAP or an auto off of the same Rx. You can remove all doubt if you can get the doctor to write the prescription for an auto in the first place. Otherwise, you should find out what the S9 auto is called, and insist on that when you get to the DME and they try to give you the Elite. However, if your doctor writes the Rx for "S9 Elite" you may not be able to get anything else.


This is where a doctor who is fully supportive can be a BIG help.....like a doctor who says, "I'll write the prescription any way you want it." Loves those docs.

LoQ wrote:I have a few suggestions you may wish to consider:

1. Ask your doctor to write the prescription to include the heated humidifier.
2. Take the prescription yourself and make a copy to give/fax to the DME. Or ask the Dr. to give you a copy of your Rx if he is dealing directly with the DME. You may need the prescription later.
3. Ask your doctor to write "mask of patient's choice." Take your time with the DME selecting a mask, and understand the return policy. They generally let you exchange the mask within 30 days.
4. If you live in a climate where the winters are chilly, get the heated hose. Have the Dr. write that in the prescription.
5. Ask the doctor for a copy of the sleep study report.

As for the data, don't deal with the doctor on that. You're just creating a negative tone with him that you don't need to have, so why even discuss it with him? He probably can't help you acquire it, anyway. You can't get insurance to pay for it, either. You'll have to get a card reader and the software. I'm sure people here will help you figure out how to do that.

Somebody here will know, is the S9 Elite capable of auto? Is there an S9 that is? If so, you should ask for that machine. Unless you need BiPAP, and I take it you don't, you should be able to get either a straight CPAP or an auto off of the same Rx. You can remove all doubt if you can get the doctor to write the prescription for an auto in the first place. Otherwise, you should find out what the S9 auto is called, and insist on that when you get to the DME and they try to give you the Elite. However, if your doctor writes the Rx for "S9 Elite" you may not be able to get anything else.

This is where a doctor who is fully supportive can be a BIG help.....like a doctor who says, "I'll write the prescription any way you want it." Loves those docs.

I guess to me things seem a little backwards. After the sleep study the tech said they would call and set me up with a machine before I sat down with the doctor. I thought that would be a trial machine, not the one I'll be expected to live with. Instead I'll be getting the machine and then talking to the doctor. I'm going to ask for the humidifier and the heated hose. I don't want to argue with anyone, but I've already been sent a link to the software and it certainly does no harm seeing the numbers for myself. I'll ask for my prescription today, but I'd expect they will tell me I'll have to ask the doc directly, which I can understand. Next week, I'll definitely get all the paperwork.

The other question I have is why is the DME charging me and my insurance company $1600 for a $800 machine? All the talk about healthcare costs over the past two years and then you see something like this and it amazes me. Given that cpap.com must have some small margin, that means that the DME's mark up is well over 100%. Smells of collusion to me, and no doubt it is happening with every piece of medical equipment out there. Have we all been conditioned to just accept this stuff?

snoreguy wrote:The other question I have is why is the DME charging me and my insurance company $1600 for a $800 machine? All the talk about healthcare costs over the past two years and then you see something like this and it amazes me. Given that cpap.com must have some small margin, that means that the DME's mark up is well over 100%.

It is more expensive to run a shop like the DME runs than cpap.com. Hence, they must charge more.

Whether they need to charge double or not is up for debate. I have a small amount of sympathy for them because patients are typically allowed to exchange masks a few times in the first few weeks. cpap.com does not allow returns on used masks at all unless you buy the insurance. DMEs typically don't work that way, and they get the shorter end of the stick as a result. For both companies, the used mask can no longer be sold as new to another customer. This is a huge problem for both the company and the customer.

Snoreguy, your situation is exactly why we tell people to do the math BEFORE they accept any equipment or sign anything at the DME. Depending on your insurance contract (insurance varies tremendously) you might pay more out-of-pocket with a brick-and-mortar DME. There are valid reasons why a brick-and-mortar place has higher prices, but that doesn't mean you have to pay those prices. A good local DME is worth their weight in gold, but many of them just aren't worth your time to deal with. Stand your ground politely about what you want, and if they give you any difficulties about it take your money somewhere else.

LoQ wrote:

snoreguy wrote:The other question I have is why is the DME charging me and my insurance company $1600 for a $800 machine? All the talk about healthcare costs over the past two years and then you see something like this and it amazes me. Given that cpap.com must have some small margin, that means that the DME's mark up is well over 100%.

It is more expensive to run a shop like the DME runs than cpap.com. Hence, they must charge more.

Whether they need to charge double or not is up for debate. I have a small amount of sympathy for them because patients are typically allowed to exchange masks a few times in the first few weeks. cpap.com does not allow returns on used masks at all unless you buy the insurance. DMEs typically don't work that way, and they get the shorter end of the stick as a result. For both companies, the used mask can no longer be sold as new to another customer. This is a huge problem for both the company and the customer.

I thought most mask manufacturers allowed DMEs to return masks that were rejected by patients. Is this not true?

mamaguinnie wrote:I thought most mask manufacturers allowed DMEs to return masks that were rejected by patients. Is this not true?

I don't know. But the point remains, someone other than the patient is eating the cost in this case. cpap.com charges you for the ability to return a mask. That suggests that either they don't have that deal with the manufacturer, or it's another (small) revenue stream for them.

Whether or not any of them are allowed to return the mask to the manufacturer, there is still a cost to the business associated with the return. Someone in the company must deal with the return.

LoQ wrote:...As for the data, don't deal with the doctor on that. You're just creating a negative tone with him that you don't need to have, so why even discuss it with him? He probably can't help you acquire it, anyway. You can't get insurance to pay for it, either. You'll have to get a card reader and the software. I'm sure people here will help you figure out how to do that.

I disagree about not trying to deal with the doctor about data. My initial sleep doc told me I was not qualified to have data. I'll never go back to that arrogant jerk again. I wound-up getting a prescription for a S9 with heated humidifier and climate line hose from my GP. He was supportive but knows little about Sleep Apnea.

I found another sleep doc who actually spent quite a bit of time looking over the reports I printed out, then suggested I make a small pressure change. I have an appointment with him at the end of the month to review the reports again. A couple of weeks ago I saw an ENT about turbinate reduction surgery. She had me to bring my sleep study and ResScan reports to the appointment.

Personally, if I had it to do over again, I would have asked the first doc his opinion about empowering his patients with a data capable APAP machine (that can be set to CPAP or APAP if my needs change) at my initial appointment (before I even did the sleep study). The same goes for DME companies. Don't just let the doc fax the prescription over to the one he chooses without checking-out what equipment they plan to give you, etc. I had to fire my first DME to wind up with the equipment I have now You will be in a better position to negotiate with them before they deliver equipment you don't want to be stuck with..

LoQ wrote: Somebody here will know, is the S9 Elite capable of auto? Is there an S9 that is?

The S9 Elite is a full data straight CPAP. The S9 AutoSet is the automatic (APAP).

snoreguy wrote:They said my insurance required me to rent-to-own over a 10 month period and the cost of the humidifier would not be covered. I asked the cost of the machine and they said $1660!

This is the way it worked with my insurance. You may want to see if yours works in a similar manner.

Amount DME billed the insurance company for CPAP machine (insurance code E0601): $1,400
Amount insurance company allowed for the machine: $842.10

My DME "wrote off" the difference between the billed and allowed amount. See if your DME has a similar agreement with your insurance company. Not all do. This is sometimes called "accepting assignment." You may have other "in-network" DME options to choose from. Your insurance company should be able to advise regarding that.

I pay 20% on durable medical equipment, so my out-of-pocket cost for the CPAP was $168.42 (20% of $842.10)

LoQ wrote:Somebody here will know, is the S9 Elite capable of auto? Is there an S9 that is?

No, the S9 Elite cannot be run in auto (APAP) mode. It is a CPAP machine, and can only be run at a single, set pressure. The S9 Autoset machine can be run in either CPAP or APAP (set to run within a specified pressure range) mode. Other than that difference, the two S9 machines have the same features. Because the S9 Autoset can be run in either mode it is more flexible. For that reason, I would get the Autoset machine if you can. Your local DME will probably require that your doctor specifically write that on your prescription. The DME bills the insurance company using the same E0601 code whether it's a CPAP or APAP machine. If you purchase online (at cpap.com, for example), you can purchase an APAP machine even if the prescription says "CPAP".

Well, I got the machine and all and we'll see how it goes. They did include the humidifier and were surprised when I said I thought I'd have to ask for that separately. They have a very liberal policy about making sure I am happy with things and said if I wanted something different, hose, mask, etc, just to call and they would write a new script and make sure I get what I need. They also gave me a sheet of paper saying they don't care where I get my equipment. Maybe that's required, I don't know. Anyway, they seemed very helpful, and gave me the current script as if it was standard practice.

I certainly understand the need of a brick and mortar business to charge more. No question about that. However, does it really take a 100% markup to be successful? Maybe it does, but maybe it doesn't. My insurance company didn't seem to care. It doesn't really matter to me, as my out of pocket expense is pretty darn low, but in the end it does drive up the cost of health care and we all pay for that. Looking outside the CPAP box, I wonder if every piece of medical equipment has the same markup, wheelchairs, crutches, bandaids, etc. It just appears to be a systemic problem that no one seems motivated to fix, while every couple of years my health insurance cost goes up and the coverage goes down.

I'll admit I don't have all the facts, but it does make me wonder...

Anyway, the journey has begun...

Snoreguy, I'm glad you're happy with how things went with the medical folks. Looking forward to hearing how well you sleep tonight.

It sounds like things went well with your DME. Sleep well tonight, snoreguy. Be sure to let us know if you have any questions, and let us know how you're doing. We've all been on this meandering journey too....