DME Bovine excrement

Lyn · Post by **Lyn** » Thu Sep 21, 2006 6:00 pm

apria wrote: apria healthcare follows procedures that are enforced by the government. being that mask are prescriptive items. we need to have a rx for a new mask

The 2 DMEs that I have purchased from & BC/BS must be doing business illegally because none of them have ever required a prescription for me to get a new mask.

Guest · Post by **Guest** » Thu Sep 21, 2006 6:39 pm

Lyn wrote:
apria wrote: apria healthcare follows procedures that are enforced by the government. being that mask are prescriptive items. we need to have a rx for a new mask
The 2 DMEs that I have purchased from & BC/BS must be doing business illegally because none of them have ever required a prescription for me to get a new mask.

Like most things when insurance is involved - it all varies. There is not one pat answer that covers all cases. Sometimes a provider will be required to have a new prescription on file, sometimes they won't. Many times even if they do need a new Rx, you will never know it because they simply call the doc themselves and get it without mentioning it to you.

Patrick A · Post by **Patrick A** » Thu Sep 21, 2006 11:48 pm

All I know is you call Apria, it seems to me you get different answers everytime you call them. Because you never seem to beable to talk to the same person. But god forbid if you owe them money they call you everyday. Some times up to three and four times a day.
Even I you have called and tried to set up a payment schedule with them.
And good lord willing and the creek don't i hope you don't have an emergency and NEED to speak to an R/T

SelfSeeker · Post by **SelfSeeker** » Fri Sep 22, 2006 8:25 am

From what I understand, Ontario residents are lucky in that provincial insurance will pay a machine for someone that does not have private insurance. In many provinces if you do not have private insurance you may need to pay for the machine on your own.

For US residents, I do not understand how the private insurance wants you to get a script for a mask. This would cost more money because would the Drs not need to get paid to be seen and give a sript?

My insurance has not told me how long I need to wait for a new mask, when needed. Whatever that means.

They did tell me to shop around for the best machine, since in would benefit me as well to get a lower price. They will cover the cost of buying on internet. Now waiting for the letter of confirmation, before I order it. (Not auto would need a script for that.)

Guest · Post by **Guest** » Fri Sep 22, 2006 8:54 am

SelfSeeker wrote:For US residents, I do not understand how the private insurance wants you to get a script for a mask. This would cost more money because would the Drs not need to get paid to be seen and give a sript?

No. In a rare case a doctor might want to see you prior to writing such a prescription, but in most all cases they will just do it over the phone. The doctor has already seen you obviously since they wrote the prescription in the first place so it will usually just be a matter of calling the office - telling them what you want a prescription to say and the fax number to send it to.
It's all pretty rare to start with though since also in the vast majority of cases we don't need new prescriptions to get a mask.

SelfSeeker wrote:My insurance has not told me how long I need to wait for a new mask, when needed. Whatever that means.

That will actually be the basic rule of thumb for everything - machines, masks, hose whatever. Insurance will pay for the items whenever you need them. You just have to be able to document why you need it. In most cases, Insurance will determine the standard length of time a given item will last. Therefore, they expect to pay for a new mask maybe every 6 months. As long as you are still using the equipment you can routinely still order a mask that often without doing anything extra. However, if you have a need for a mask in say, 2 months, you can still get it and have it covered - the need just has to be documented. Say for example you have a Swift and suddenly you get into a car accident and bruise your nose badly to the point that you can't use the Swift. The DME would then contact the doctors office and get a new script for say a Full Face Mask and also obtain a letter of medical neccessity from the doctor explaining your injury. Depending on insurance they may also have to obtain a copy of the hospital notes and/or accident notes. They would submit all this to the Insurance along with a claim for the mask and it would (usually) get covered.
Does that clear it up or make things more confusing than ever?

Wulfman · Post by **Wulfman** » Fri Sep 22, 2006 10:35 am

.....Insurance will pay for the items whenever you need them. .....
Therefore, they expect to pay for a new mask maybe every 6 months.

Isn't this mask replacement thing still subject to deductibles?
Let say I have a $750 deductible (and a 20% copay after that) and it's just rolled over into a new year and I'm "due" for a new mask and have had no other medical expenses..... If I go to a B&M DME and they want to charge my insurance $250 for that mask.....wouldn't I (really) have to pay the full price?

If so, I can't imagine why I'd want to go to a B&M DME shop just to burn up my deductible. I would have to buy at least 3 of those masks before my insurance would pay 80%......which means I could buy 5 UMFF masks from CPAP.COM and have money left over (at least until ResMed initiates their price hikes to Internet sellers) for the same amount of money that would have only got me 3 from the DME.

Den

snoregirl · Post by **snoregirl** » Fri Sep 22, 2006 11:08 am

I am wondering the same thing on deductable for the new year.

I plan to wait and ask this during my company timeframe for insurance signup (annually in NOV) since it doesn't apply this year (my sleep study made sure I paid the full deductable) and who knows if it will be the same next year.

If masks and parts (hoses, filters etc) are subject to deductable, then I will be buying them all online and ignoring insurance...

Only thing so far that amazed me was that a new swift pillow from my B&M DME was less than from Cpap.com (total price $22.xx my cost $4.xx I think CPAP.com was just under $30.). This item is the ONLY time so far that my DME has beat Cpap.com. I just find it interesting. Hoses are 3x cost of Cpap.com as are other items. WHy so cheap on the pillow. Maybe they made a mistake and will try to bill more later.....

Wulfman · Post by **Wulfman** » Fri Sep 22, 2006 11:28 am

snoregirl wrote:If masks and parts (hoses, filters etc) are subject to deductable, then I will be buying them all online and ignoring insurance...

And I don't know why they wouldn't be. It should be just like other medical expenses.....YOU pay for the first $$$ until the deductible has been met and then the co-pay after that.
Other than the original purchases last year, I've bought all of my items out-of-pocket from CPAP.COM because I haven't had any medical expenses this year (insurance is on a calendar year).
I just get frustrated when I keep seeing these statements that "insurance will pay" come up in the threads. Unless a person has FULL coverage insurance with no deductibles or co-pays, (it seems to me) they would be paying full price up to the deducitble limit.
And people wonder why their insurance is so expensive.......

Den

Guest · Post by **Guest** » Fri Sep 22, 2006 11:49 am

Wulfman wrote:I just get frustrated when I keep seeing these statements that "insurance will pay" come up in the threads.

Well obviously I was speaking in generalities. None of us can possibly even begin to try and answer questions with an answer that will absolutely apply to each and every single person who might come and read this message board.
Insurance will cover these items in most cases that fit within the scenario I mentioned. If it will or not for any specific individual who may or may not read this particular message on this particular board cannot be answered with any certainty.
By the way, this is exactly why I firmly believe so many of the people within the brick and mortar DME companies refuse to answer questions about this stuff. The second they try and give a general answer someone will come back with exactly this sort of response and say "Well, you told me insurance pays for it. So I'm not paying anything now".
I also think this is why the answers people get when they call insurance companies serve only to confuse the issue rather than clearing it up. They will tell you nasal pillows are covered. Come to find out though, just as you described above you haven't met your deductible. Suddenly someone gets a bill for the pillows and they come here and post a message about how the DME company is trying to rip them off charging them for pillows when the insurance company TOLD THEM THEY WERE COVERED!! Sound familiar?

Wulfman · Post by **Wulfman** » Fri Sep 22, 2006 12:15 pm

Anonymous wrote:
Wulfman wrote:I just get frustrated when I keep seeing these statements that "insurance will pay" come up in the threads.
Well obviously I was speaking in generalities. None of us can possibly even begin to try and answer questions with an answer that will absolutely apply to each and every single person who might come and read this message board.
Insurance will cover these items in most cases that fit within the scenario I mentioned. If it will or not for any specific individual who may or may not read this particular message on this particular board cannot be answered with any certainty.
By the way, this is exactly why I firmly believe so many of the people within the brick and mortar DME companies refuse to answer questions about this stuff. The second they try and give a general answer someone will come back with exactly this sort of response and say "Well, you told me insurance pays for it. So I'm not paying anything now".
I also think this is why the answers people get when they call insurance companies serve only to confuse the issue rather than clearing it up. They will tell you nasal pillows are covered. Come to find out though, just as you described above you haven't met your deductible. Suddenly someone gets a bill for the pillows and they come here and post a message about how the DME company is trying to rip them off charging them for pillows when the insurance company TOLD THEM THEY WERE COVERED!! Sound familiar?

Absolutely!
And then you have ResMed doing a "survey" and stating that XPAP users aren't replacing their masks often enough..... Like was discussed some time back after that survey came out, why replace the WHOLE mask when (on many of them) you can just replace the seals, pillows or whatever for a much smaller cost.

Den (who's still using the SAME mask, SAME seals and SAME headgear after 16 months)

KimberlyinMN · Post by **KimberlyinMN** » Fri Sep 22, 2006 12:20 pm

apria wrote:you cant put the entire blame on apria healthcare. working in the company, i will say that it's a great company. it has millions of dollars of great equipment and products and of course. it's # 1 in the nation.

It's #1 in the nation? For what? I've only heard about it via this website. Granted, I guess I've only worked in Minnesota, New Jersey, Colorado and Kansas.

Hmmmm...

Kimberly

Guest · Post by **Guest** » Fri Sep 22, 2006 12:43 pm

KimberlyinMN wrote:
apria wrote:you cant put the entire blame on apria healthcare. working in the company, i will say that it's a great company. it has millions of dollars of great equipment and products and of course. it's # 1 in the nation.

It's #1 in the nation? For what? I've only heard about it via this website. Granted, I guess I've only worked in Minnesota, New Jersey, Colorado and Kansas.

Hmmmm...

Kimberly

Oh they are. They have been for about 7 or 8 years once they passed American Homepatient and Lincare. Possibly even longer than that. They were already at the brink coming out of the Homedco days.

sleepyinsunnyvale · Post by **sleepyinsunnyvale** » Fri Sep 22, 2006 1:55 pm

In the Investor Relations area of the Apria web site there is a presentation that was given on 9/7/06. It states:
Apria is #1 in Home Medical Equipment with 9% market share
#2 in Respiratory Therapy with 13% share and
#3 in Infusion Therapy with 4% share.
Total revenue is $15.9B

http://www.apria.com/about_apria/0,2746,511,00.html

I too was a bit surprised. I'm not a big fan of Apria either. Two years ago I just returned their equipment, bought from cpap.com and took whatever my insurance would give me. It was worth not having to deal with them.

KansasRT · Post by **KansasRT** » Fri Sep 22, 2006 3:08 pm

Just because a company is big, it does not mean they are good to their customers. It means they negotiate the best contracts with insurance companies. Which also means that they use the plain jane equipment.

Lyn · Post by **Lyn** » Fri Sep 22, 2006 3:13 pm

Anonymous wrote:
Lyn wrote:
apria wrote: apria healthcare follows procedures that are enforced by the government. being that mask are prescriptive items. we need to have a rx for a new mask
The 2 DMEs that I have purchased from & BC/BS must be doing business illegally because none of them have ever required a prescription for me to get a new mask.
Like most things when insurance is involved - it all varies. There is not one pat answer that covers all cases. Sometimes a provider will be required to have a new prescription on file, sometimes they won't. Many times even if they do need a new Rx, you will never know it because they simply call the doc themselves and get it without mentioning it to you.

I have correct something I said. I have purchased from 3 DME's. The first DME & BC/BS were involved with my original APAP equipment purchase. So yes, they did have a script. But the two other DMEs (one of those being out of state in Nevada) had no idea who either my DR or insurance co were as both were out of pocket purchases.

Lyn

Machine