Insurance and DME

[exersize_freak]

If your insurance company requires an authorization then the insurance company is also required to send you a letter saying that the authorization has been approved the day that the insurance company approves the DME's request for authorization.

Your insurance company's online provider search tool will let you know if the DME is "in network".

[Cardsfan]

Ask the insurance co these questions:
1- Do I have a separate deductible for Out-of-network providers? How much is it?

2- If I use an out-of-network provider, does it apply to my deductible?

[ThisGuy]

I got an approval letter from insurance. More confusion. Says I am approved for Continuous airway pressure device, start date 4/26/16 to end date 7/24/16, 6 units, code E0601. Also approved for tubing with heating element, start date 4/26/16 to end date 7/24/16, 1 unit, code A4604.

So, it seems that they have approved use of cpap for 2 months? I suppose this means they will review compliance in 2 months and re authorize? This appears to support the rental option, not a purchase option.

Why can't they just explain this in plain english?

[amenite]

...

Why can't they just explain this in plain english?

When my insurance changed mid-way through a 10 month rent to own contract I did my due diligence and made every attempt to get some kind of transfer or whatever. By the time I got someone from the new carrier to explain that they basically contract a third party to manage all the administration of CPAP benefits and the third party works with whatever DME you wind up with, I cut my losses, took my prescription and went rogue.

I got a different answer form everyone I spoke to and in the end it seemed to me that's how they want it to go. Because for every beneficiary that's forced to jump through all the hoops and succeeds there are probably 2 that say screw it and just go buy their own, and another one or two that fail altogether and suffer the consequences.

[Cardsfan]

(that's 3 months)
What does your prescription say for length of time? If it says 99 Months use, that means lifetime. And that is what is common for the prescription to be written as.

Just get on the phone with your Dr office and insurance co. and ask them to explain it. And then send it to you in writing. If your prescription is written for "lifetime" why is your approval only for 3 months? Or, is your prescription for some reason, only good for 3 months?
It's ridiculous we have to jump through these hoops, but that is the way it is.

[Jay Aitchsee]

I'm only guessing here, as others have said, your insurance company is the authority, but I think, some rental coverages are continued contingent upon compliance and a face to face with the prescribing physician after some period of time to ensure that the treatment is beneficial to you. Perhaps your approval is to allow the contingencies to be carried out during an initial 90 day rental period.

[Cardsfan]

Can you go back and check exactly what that letter says again?

[Okie bipap]

Some insurance companies follow Medicare guidelines which require a 90 day rental in which you must prove compliance and have a followup face-to-face meeting with the doctor to verify the treatment is effective. This meeting takes place sometime between day 31 and day 90 in your treatment.

[ThisGuy]

I talked to the DME adjuster and she pulled up the insurance policy and went through it with me. It is a rent to own policy. The initial payment covers all supplies and the first months rent. My insurance approval is for 90 days as stated in the letter from Anthem. During 60-90 days a compliance report is sent to insurance to get approval for the remaining 7 months. 70% compliance is required. If I am compliant, then insurance approves coverage of the remaining rental fees and the equipment is mine to keep at the end of the rental period. Additional supplies are covered at 80%.

My initial payment of $350 will cover 1st month rent and all supplies ( apap, heated hose, mask, filters....) This will pretty much finish off my deductible. Then I am responsible for $9\mth (20% of $45) for the remaining 9 months. I believe I have to pay the full $45 for Jan\Feb next yr when the deductible starts over. This works out to $503. This seems reasonable and about the cost of buying a unit second hand, so I am planning to go with the DME option. Plus it goes towards my deductible and I get the advantage of having a local DME to work with as I figure out what mask works for me.

Thanks for listening to my rambling about insurance. It's new and awkward to me, and just wanted to make sure I wasn't getting taken or find out later that I should have just bought it on my own. Maybe someone else going through the same situation can get some help from it. Wish I'd looked into the home sleep study more before going through that. Simple at home study is costing me almost $800 out of pocket. Seems ridiculous to pay that much to rent a system that someone plugs into a computer and generates a report. Now, I've seen where you can get an at home sleep study done through an online source for $250. They even provide an Rx if you have sleep apena.

BTW, I meet with my DME tomorrow to get fit and pick up my equipment. Ready to get started, it's been a month since my sleep study.

[Janknitz]

You did your homework and it all sounds good.

Now the next hurdle is to get a decent machine, and to make sure it's a new machine. Did you request a particular make and model? Do you know how to check run hours on the machine you requested?

[ThisGuy]

You did your homework and it all sounds good.

Now the next hurdle is to get a decent machine, and to make sure it's a new machine. Did you request a particular make and model? Do you know how to check run hours on the machine you requested?

It is my intention to get an Airsense 10 Autoset. I expect it to be new, but will check the hours. I believe they are in the "about" menu.

[chunkyfrog]

You are correct. Look for "run hours".
Usage can be reset. If they show you that, grab the knob and go for the truth.

[ThisGuy]

I met with DME and got fit for a dreamwearer mask and received an Airsense 10 Autoset. The unit is new - no hours.

I was finally able to get a sheet showing my insurance company's allowed prices and it looks reasonable. I have not met my deductible, so I have to pay the full amount, $314.95.

A7034 Mask $60
A7035 Headgear $18.93
E0562 Humidifier $139.44
A7038 Filter $6.03
E0601 Apap $45.80 (10 payments)
A4604 Heated Tubing $46.77

After paying the initial fees, my deductible will be met and the additional rental will be covered 80%, so 9 payments at $9.35. Total cost will be ~$400 for apap with heated tube and mask. I have 30 days exchange on all masks.

Looking forward to my first night as a hose head.

[grayghost4]

I would tell them I don't want the Humidifier

[VikesFan]

Seems to be a lot of confusion going on here.

I manage a DME company, so I know a little about this. The first thing anyone needs to know, is that insurance companies are evil. Period. Premiums, copays, out of pockets, have done nothing but increase over the years. Meanwhile, reimbursements for providers (all types) have dropped. Since UnitedHealthcare took on the Tricare contract, average DME reimbursement has dropped %30 for most providers. Now tell me, have any of you seen a 30% reduction in your direct insurance charges? I'm betting no. Insurance is not in the business of making less money, ever. Also, you do not have the choice of picking any provider you want. That is dependent on insurance contracting. Some insurances are exclusive with certain providers in each city, and by law if the DME provider did not win the bid or get the contract, they CANNOT help you.

When your DME provider tells you compliance is required, 99% of the time they are right. There are exceptions, (if your insurance allows for purchase) but typically most insurances will only AUTHORIZE lease-to-own machines. They might claim to offer other methods, but the reality is they can approve and deny any request they want for any reason, and from a financial standpoint, lease-to-own and requiring compliance is the logical option for insurance, as they are most likely not to lose on the deal. Reimbursement is universal for all billing codes, i.e a full face mask will ALWAYS get reimbursed to the DME provider for the same amount regardless of the type/brand/etc. Same goes for PAP devices, and everything else. This is true 100% of the time. So when they tell you they cover 80% of the cost, they mean 80% of the allowable, which is ALWAYS the same. Example: An unnamed insurance company reimburses $60 for any full face mask, which when used in the case of the Amara View, roughly...1/2 of the cost for the company to buy them. Do you see the problem?

Perhaps I'm being naive about DME companies, (I pride myself on how our company operates in regards to putting patients first), but trust me when I say any decision a DME provider makes is because financially, insurance companies are breaking our kneecaps and the government is letting them.