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Insurance, DME's, getting the data-capable machine you need (slinky) (Insurance and the CPAP Industry)
Dealing with Insurance and DME's and getting the data-capable xPAP machine you need Author: 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 knowledgeablechanges 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. Fully data capable CPAPs I am aware of: a] Resmed S8 II Elite w/EPR b] Resmed S8 Elite w/EPR c] Respironics M Series Pro w/C-Flex Fully data capable autoPAPs I am aware of: a] Resmed S8 II AutoSet b] Resmed S8 AutoSet Vantage c] Respironics M Series Auto w/A-Flex d] Respironics M Series Auto w/C-Flex e] Puritan Bennett GoodKnight 420E You will get just as good therapy w/the CPAPs as you will w/the autoPAPs - but the autoPAPs are like two in one as they can be used in CPAP mode as well as auto mode. The DATA CAPABILITY is THE important issue, more so than auto or not. When shopping the local DME suppliers they most likely are going to whip out a bare bone, compliance data capable only device. You can counter by asking for one of the autos. Most likely they aren't gonna wanna provide one. But if you mention the importance of the data capabilities to you that gives them the negotiating room to offer you a fully data capable CPAP. Voila! You should both be happy! Understand that most all insurances pay by HCPCS code, NOT by brand or model. And when insurances contract w/local DME suppliers they agree on one set reimbursement fee for that HCPCS code E0601 CPAP. AND autoPAPs are coded as HCPCS E0601 (as well as the CPAPs). The catch is that, of course, the bare bone, compliance data only CPAP "costs" the DME supplier less to buy than the fully data capable autoPAPs. So most protect their profit margin by foisting off as many bare bones, compliance data only CPAPs as they can on unsuspecting new CPAP clients. When shopping the local DME suppliers be sure to inquire about their mask exchange policy. You will want one that has a lenient mask exchange policy. And another little secret most local DME suppliers would prefer you not know: Resmed, Respironics and Fisher & Paykel all provide FREE mask exchanges to the local DME suppliers most all of their masks that a client has tried and not been successful w/IF the DME fills out a form and returns that mask W/IN 30 DAYS. Now, just because so many of us in the forums have encountered lousy local DME suppliers (the reason many of us are here), there ARE GOOD local DME suppliers out there. DON'T go in w/a chip on your shoulder EXPECTING them to try to take advantage of you. Keep an open mind, but be prepared. Be FIRM, be DIPLOMATIC, be TACTFUL, but be FIRM. YOU are the one paying for this equipment, whether thru insurance OR out of pocket. No difference. W/o YOU they miss out on a lucrative sale. YOU are going to be sleeping w/this device for the next 5 years. If you have problems getting the machine you want and/or you are trying to upgrade your machine and/or your doctor isn't interested in your therapy: There IS the possibility that your insurance is only contracted w/this one local DME supplier and your sleep lab MAY have checked w/your insurance and THAT is why your equipment order was sent to that particular DME supplier. When - and IF - you see this doctor again be sure to diplomatically express your disappointment that she isn't interested enough in your therapy to want that data from a fully data capable CPAP to assist her in monitoring your CPAP therapy. Meanwhile, call your insurance company and ask THEM what local DME CPAP suppliers they are contracted with. Hopefully, you have the option of more than just this one. And ask what local sleep labs/clinics they are contracted with. Again, hopefully you will have the option of more than just this one. 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 instance, the script from your doctor should contain: 1] Resmed S8 Elite w/EPR (w/integrated humidifier if you prefer) 2] Pressure ---- cms (whatever your pressure is) 3] EPR setting 3 (or whatever your doctor suggests) 4] Ramp off (unless you prefer it on) 5] Efficacy & Usage Data access 6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifier. If so just add "w/integrated humidifier" to the Resmed S8 Elite) 7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice. Or: 1] Respironics REMstar M Series Auto w/A-Flex (w/integrated humidifier if you prefer) 2a] Minimum pressure (whatever your doctor has determined) 2b] Maximum pressure (whatever your doctor has determined) 3] A-Flex setting 3 (or whatever your doctor suggests) 4] Ramp off (unless you prefer it on) 5] Show AHI/Leak feature On 6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifier. If so just add "w/integrated humidifier" to the REMstar Auto w/A-Flex) 7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice. 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 specifying full face if the script just says mask, or will only provide the exact mask mentioned in the equipment order). 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 w/o.
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Insurance, DME's, getting the data-capable machine you need (slinky) (Insurance and the CPAP Industry)

Dealing with Insurance and DME's and getting the data-capable xPAP machine you need
Author: 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 knowledgeablechanges 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.

Fully data capable CPAPs I am aware of:
a] Resmed S8 II Elite w/EPR
b] Resmed S8 Elite w/EPR
c] Respironics M Series Pro w/C-Flex

Fully data capable autoPAPs I am aware of:
a] Resmed S8 II AutoSet
b] Resmed S8 AutoSet Vantage
c] Respironics M Series Auto w/A-Flex
d] Respironics M Series Auto w/C-Flex
e] Puritan Bennett GoodKnight 420E

You will get just as good therapy w/the CPAPs as you will w/the autoPAPs - but the autoPAPs are like two in one as they can be used in CPAP mode as well as auto mode. The DATA CAPABILITY is THE important issue, more so than auto or not.

When shopping the local DME suppliers they most likely are going to whip out a bare bone, compliance data capable only device. You can counter by asking for one of the autos. Most likely they aren't gonna wanna provide one. But if you mention the importance of the data capabilities to you that gives them the negotiating room to offer you a fully data capable CPAP. Voila! You should both be happy!

Understand that most all insurances pay by HCPCS code, NOT by brand or model. And when insurances contract w/local DME suppliers they agree on one set reimbursement fee for that HCPCS code E0601 CPAP. AND autoPAPs are coded as HCPCS E0601 (as well as the CPAPs). The catch is that, of course, the bare bone, compliance data only CPAP "costs" the DME supplier less to buy than the fully data capable autoPAPs. So most protect their profit margin by foisting off as many bare bones, compliance data only CPAPs as they can on unsuspecting new CPAP clients.

When shopping the local DME suppliers be sure to inquire about their mask exchange policy. You will want one that has a lenient mask exchange policy.

And another little secret most local DME suppliers would prefer you not know: Resmed, Respironics and Fisher & Paykel all provide FREE mask exchanges to the local DME suppliers most all of their masks that a client has tried and not been successful w/IF the DME fills out a form and returns that mask W/IN 30 DAYS.

Now, just because so many of us in the forums have encountered lousy local DME suppliers (the reason many of us are here), there ARE GOOD local DME suppliers out there. DON'T go in w/a chip on your shoulder EXPECTING them to try to take advantage of you. Keep an open mind, but be prepared.

Be FIRM, be DIPLOMATIC, be TACTFUL, but be FIRM. YOU are the one paying for this equipment, whether thru insurance OR out of pocket. No difference. W/o YOU they miss out on a lucrative sale. YOU are going to be sleeping w/this device for the next 5 years.

If you have problems getting the machine you want and/or you are trying to upgrade your machine and/or your doctor isn't interested in your therapy:

There IS the possibility that your insurance is only contracted w/this one local DME supplier and your sleep lab MAY have checked w/your insurance and THAT is why your equipment order was sent to that particular DME supplier.

When - and IF - you see this doctor again be sure to diplomatically express your disappointment that she isn't interested enough in your therapy to want that data from a fully data capable CPAP to assist her in monitoring your CPAP therapy.

Meanwhile, call your insurance company and ask THEM what local DME CPAP suppliers they are contracted with. Hopefully, you have the option of more than just this one. And ask what local sleep labs/clinics they are contracted with. Again, hopefully you will have the option of more than just this one.

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 instance, the script from your doctor should contain:

1] Resmed S8 Elite w/EPR (w/integrated humidifier if you prefer)
2] Pressure ---- cms (whatever your pressure is)
3] EPR setting 3 (or whatever your doctor suggests)
4] Ramp off (unless you prefer it on)
5] Efficacy & Usage Data access
6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifier. If so just add "w/integrated humidifier" to the Resmed S8 Elite)
7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

Or:

1] Respironics REMstar M Series Auto w/A-Flex (w/integrated humidifier if you prefer)
2a] Minimum pressure (whatever your doctor has determined)
2b] Maximum pressure (whatever your doctor has determined)
3] A-Flex setting 3 (or whatever your doctor suggests)
4] Ramp off (unless you prefer it on)
5] Show AHI/Leak feature On
6] Fisher & Paykel HC 150 heated humidifier (unless you prefer the integrated heated humidifier. If so just add "w/integrated humidifier" to the REMstar Auto w/A-Flex)
7] Nasal mask, Full Face mask, or Nasal Pillows mask of patient's choice.

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 specifying full face if the script just says mask, or will only provide the exact mask mentioned in the equipment order).

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 w/o.

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