As you know, I am seeing my MD next week and will discuss with her that I think an apap will better suit me. So I called my ins. which really couldn't give me definitive answers about whether or not they will cover an apap. I explained that I am still in the rental stage of my cpap. She said that the DME should do a courtesy pre-authorization to find out. I explained to them that I understand the billing code is the same as cpap. But she really didn't have anything info in front of her to tell her yes or no. She did say that if its medically necessary, she didn't see it to be a problem. Next I called my DME and explained the same, that my MD may be ordering me an apap. They said to have the MD fax the script and maybe include a letter of medical necessity to them and they would try to process it. I'm taking this as the same as a courtesy pre-authorization. He also made a comment that he wasn't sure if my insurance would pay for another machine since they already are now. I said to him, as long as my insurance doesn't have a problem with it, you shouldn't either, right? Then I went on to talk about replacement parts, which again my insurance explained that there is no limit on masks or parts that she could see and as long as it was necessary, she thought it would be covered. The DME stated that most people need replacement parts every 2-3 months. I said, no, that would explaine getting a new mask, but not just a part. I said some people need new nose pillows 1-2 times a month. He answered by saying, well I could order it and try to process it. Well I'm not paying 1005 for it, I'll pay my 20%. So how do you find out without being stuck with it? Why can't these types of things be clearer. Why can't my insurance just say yes or no to my questions. THey are very good insurance and never had trouble before, but that's b/c everything else is covered 100%. Medical, dental, physical therapy, chiropractor, everything else but DME 80/20%. Well I guess I'll get the script (hopefully, still not sure if the MD will do this) and try to find out if its covered.
Spoke with DME and insurance today
Spoke with DME and insurance today
~Melissa~
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
replacement masks follow medicare replacement schedules (you might want to look that up). Your insurance company also follows those guidelines for replacements.
your insurance isn't really going to provide you with much information on autopaps, they will try/avoid paying for anything if at all possible.
Your insurance hasn't paid for any machine at this point, you should still be in the "trial" phase which means your DME is billing them on a month-by-month basis (usually lasting from 30-90 days). Then it will convert to a 10-month rent to own. The appointment you have is probably the post 30-day followup. If you are unhappy with therapy/machine now is the time to voice it with your doctor and obtain a decision.
It is easier to pursuade your doctor for an autopap use if you sleep in different positions during the night, have difficulty tolerating cpap therapy or have aerophagia or have high cpap pressure requirements.
But as mentioned before, if you want to get an autopap and have your insurance pay for it, it requires the cooperation of your doctor and DME to acomplish that. As you know, the autopap and cpap share the same medicare billing code. That means the DME is going to bill insurance using that same code and they are going to receive back a negotiated fee for that machine (the avg. used to be around $1700). If they can give you a lower cost plain jane machine, they make more profit then if they gave you a more expensive autopap machine. Some people have negotiated with DME for a recording autopap and paid the difference in cost. You can see the difference in cost from cpap.com between the machines. You might make an offer to the DME to pay the difference.
you can also use your existing cpap prescription to purchase an autopap of choice on-line, but getting insurance to pay for it is another question. Most of the time you are better off just buying the autopap wanted out of pocket and using the DME machine as backup.
your insurance isn't really going to provide you with much information on autopaps, they will try/avoid paying for anything if at all possible.
Your insurance hasn't paid for any machine at this point, you should still be in the "trial" phase which means your DME is billing them on a month-by-month basis (usually lasting from 30-90 days). Then it will convert to a 10-month rent to own. The appointment you have is probably the post 30-day followup. If you are unhappy with therapy/machine now is the time to voice it with your doctor and obtain a decision.
It is easier to pursuade your doctor for an autopap use if you sleep in different positions during the night, have difficulty tolerating cpap therapy or have aerophagia or have high cpap pressure requirements.
But as mentioned before, if you want to get an autopap and have your insurance pay for it, it requires the cooperation of your doctor and DME to acomplish that. As you know, the autopap and cpap share the same medicare billing code. That means the DME is going to bill insurance using that same code and they are going to receive back a negotiated fee for that machine (the avg. used to be around $1700). If they can give you a lower cost plain jane machine, they make more profit then if they gave you a more expensive autopap machine. Some people have negotiated with DME for a recording autopap and paid the difference in cost. You can see the difference in cost from cpap.com between the machines. You might make an offer to the DME to pay the difference.
you can also use your existing cpap prescription to purchase an autopap of choice on-line, but getting insurance to pay for it is another question. Most of the time you are better off just buying the autopap wanted out of pocket and using the DME machine as backup.
I am not familiar with NY, but most of the insurance companies we work with in Kansas follow medicare replacement schedule. Which is as follows...\
Monthly---- 2 disposable filters
1 mask seal
2 sets of nasal pillows
1 CPAP tubing
Quarterly--- A mask system
Every 6 months --- Headgear
Chin Strap
Our most of the insurance that we work with has the stipulation that when you need supplies more often than that you can submit an order from a physician and they will take it into consideration. I have never had to push that issue. I think that the replacement schedule is very generous and as far as masks go I let my patients try as many masks as they need to before deciding on a certain mask, so them not having what they need is not really an issue. I am not sure that this schedule goes throughout the US. It is really unbelievable to me that the DME company cannot tell you exactly what your insurance will cover. It also seems fishy that your insurance will not tell you exactly what they will cover. As far as switching our the CPAP for an APAP, if you have a script from your DR and you are still renting the machine the DME has no choice(Although they may say they do.) Also, if they are a decent DME company they should have gotten an order for replacement supplies when they filled your original script. It saves you the hassle of all of this when you need supplies. I am sorry to ramble, but it really irks me when DME companies jerk peoples chains.
Monthly---- 2 disposable filters
1 mask seal
2 sets of nasal pillows
1 CPAP tubing
Quarterly--- A mask system
Every 6 months --- Headgear
Chin Strap
Our most of the insurance that we work with has the stipulation that when you need supplies more often than that you can submit an order from a physician and they will take it into consideration. I have never had to push that issue. I think that the replacement schedule is very generous and as far as masks go I let my patients try as many masks as they need to before deciding on a certain mask, so them not having what they need is not really an issue. I am not sure that this schedule goes throughout the US. It is really unbelievable to me that the DME company cannot tell you exactly what your insurance will cover. It also seems fishy that your insurance will not tell you exactly what they will cover. As far as switching our the CPAP for an APAP, if you have a script from your DR and you are still renting the machine the DME has no choice(Although they may say they do.) Also, if they are a decent DME company they should have gotten an order for replacement supplies when they filled your original script. It saves you the hassle of all of this when you need supplies. I am sorry to ramble, but it really irks me when DME companies jerk peoples chains.
KansasRT wrote:I am not familiar with NY, but most of the insurance companies we work with in Kansas follow medicare replacement schedule. Which is as follows...\
Monthly---- 2 disposable filters
1 mask seal
2 sets of nasal pillows
1 CPAP tubing
Quarterly--- A mask system
Every 6 months --- Headgear
Chin Strap
KansaRT, this has always been a bit confusing to me. What's the difference between a mask system and the headgear? I know what the headgear is, but is the mask system just the mask without the headgear? What if at 3 months you're entitled to a new mask system, and you want to try something different than what you already have; how can you if you won't get the new headgear to go with it? (assuming that the mask system is the mask without the headgear) And lets' take the Activa for example. Is the cushion considered the mask seal? Does one have to get the same size when getting a replacement?
You and everyone else too.....I am sorry to ramble, but it really irks me when DME companies jerk peoples chains.
The key to the APAP and getting insurance to agree is that THEY deem it medically necessary. My experience is that their doc (insurance co doc) looks at documentation (sleep study, pressure, letter from your doc...) and they and they alone seem to decide if you "need" it or not.
That is the problem.
I experienced an insurance doc deciding that even though my doc prescribed it, and wrote the letter for all the reasons people have mentioned her (sleep position, weight change, questionable titration...) I did not NEED it.
So by all means go that direction and try to get the insurance to approve, but remember that they may not. Then your other option is pressure the DME with returning their machine and them losing your business if they don't honor your prescription.
I would be very careful about offering to pay the difference or pay for an "upgrade". Can easily hike you above cash online cost. Then why support an uncooperative DME when you could spend your money online without hassle.
That is the problem.
I experienced an insurance doc deciding that even though my doc prescribed it, and wrote the letter for all the reasons people have mentioned her (sleep position, weight change, questionable titration...) I did not NEED it.
So by all means go that direction and try to get the insurance to approve, but remember that they may not. Then your other option is pressure the DME with returning their machine and them losing your business if they don't honor your prescription.
I would be very careful about offering to pay the difference or pay for an "upgrade". Can easily hike you above cash online cost. Then why support an uncooperative DME when you could spend your money online without hassle.
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whatrdreamsmadeof
- Posts: 421
- Joined: Sat Aug 19, 2006 2:12 pm
- Location: vA. BEACH, VA.
Does anyone know if your insurance co. only has 1 dme for you to deal with, and you are experiencing difficulty, if there is any other recourse besides out of pocket.......I do know that the insurance comapanies have a complaint package you can fill out on the dme that is being difficult, but that does not help the patient.........do the dme's have someone they are accountable to? It seems to me, unless each dme is on a commission only, to save the medical company money.....they shouldn't try to stiff the patient. If the patient has no recourse or source then, it seems as if the system is failing us.............My dme gave me a used mask, by his own admission,after going to him due to face swelling, also he said he could not test the machine as it was an auto type, what is up with this????????
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Guest
I'm glad to hear that the dme is being helpful and obviously working with you to get the autopap. Not sure where some of the other folks are getting that they are being difficult and to fill complaints out on them.
It sounds like you have good insurance. I think a lot of these problems stem from the people at the insurance companies having something like a list that says "Item X - Covered - Yes. Item Y - Covered - NO". So they look up a certain item and tell you it's covered. The problem being what exactly is involved in getting it covered. Some companies aren't willing to jump through the 47 hoops involved in getting it. So yes, they may cover new pillows every Wednesday for all we know. However, what they aren't telling us is that to get them covered every Wednesday someone has to submit a new claim each time along with an updated prescription with each order and a fresh copy of a sleep study and a Letter of Medical Neccessity. Yeah guess what, I aint gonna go through all that for a pair of nasal pillows!!!
By the way, I of course have no NYNURSE actually put it when speaking to someone, but for what it's worth if someone said to me in the same words she put in her message 'They don't have a problem with it so you shouldn't either'. That COULD come across really really snide. I know if someone said it to me I can only see a very few ways where it wouldn't come across as snide and basically end any desire I had to be helpful to that person. Just a thought - not an accusation so please don't take it that way!
It sounds like you have good insurance. I think a lot of these problems stem from the people at the insurance companies having something like a list that says "Item X - Covered - Yes. Item Y - Covered - NO". So they look up a certain item and tell you it's covered. The problem being what exactly is involved in getting it covered. Some companies aren't willing to jump through the 47 hoops involved in getting it. So yes, they may cover new pillows every Wednesday for all we know. However, what they aren't telling us is that to get them covered every Wednesday someone has to submit a new claim each time along with an updated prescription with each order and a fresh copy of a sleep study and a Letter of Medical Neccessity. Yeah guess what, I aint gonna go through all that for a pair of nasal pillows!!!
By the way, I of course have no NYNURSE actually put it when speaking to someone, but for what it's worth if someone said to me in the same words she put in her message 'They don't have a problem with it so you shouldn't either'. That COULD come across really really snide. I know if someone said it to me I can only see a very few ways where it wouldn't come across as snide and basically end any desire I had to be helpful to that person. Just a thought - not an accusation so please don't take it that way!
A mask system is the "Hard" part of the mask and the Cushion or seal. The headgear is the soft part that attaches to the mask. Masks generally come with headgear and if the patient is not up for new headgear we just eat the cost. Replacement seals or cushions or pillows do not have to be the same size.
When I said to the DME, "My insurance doesn't have a problem paying for another machine, so you shouldn't either" I was merely trying to show the DME that I am not going to let you tell me what my insurance will and will not pay for. I am learning quickly, that most DMEs will try to pull the wool over your eyes and I'm not going to tolerate it. I will be assertive, while still being polite and professional. I work in healthcare, believe me I know how to play the game. We had a civil conversation without any confrontation, but I did want them to know, that I am not stupid. By the way, I don't feel your comment was an accusation, but wanted to set the record straight, that I am not rude and don't come across as being so. Sometimes that is often mistaken for being assertive, especially in a women.By the way, I of course have no NYNURSE actually put it when speaking to someone, but for what it's worth if someone said to me in the same words she put in her message 'They don't have a problem with it so you shouldn't either'. That COULD come across really really snide. I know if someone said it to me I can only see a very few ways where it wouldn't come across as snide and basically end any desire I had to be helpful to that person. Just a thought - not an accusation so please don't take it that way!
On another note, my cold is getting better and I hope to put the cpap back on tonight. One of my residents where I work, recently diagnosed with cpap, just got his new machine yesterday, a Remstar c-flex pro 2 (I think), is it wrong to be jealous?!?
~Melissa~
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
Melissa, it might be helpful to tell us who your insurance company is. That way, perhaps others who have that same insurance company can chime in with their experiences.
Usually, as long as you are firm (but polite) to the doctor and DME, you will get the machine you want/need.
Also, with your insurance company - talk to a "representative" instead of a "claims person". Your insurance company should have a representative who can tell you what DME coverage you have, and how often you are entitled to get masks, etc.
Good Luck
Usually, as long as you are firm (but polite) to the doctor and DME, you will get the machine you want/need.
Also, with your insurance company - talk to a "representative" instead of a "claims person". Your insurance company should have a representative who can tell you what DME coverage you have, and how often you are entitled to get masks, etc.
Good Luck
_________________
| Machine: DreamStation Auto CPAP Machine |
| Humidifier: DreamStation Heated Humidifier |
| Additional Comments: Compliant since April 2003. (De-cap-itated Aura). |
And Melissa, others have had this same problem. You might want to read this link:
viewtopic.php?p=98351&highlight=apap+doctor#98351
viewtopic.php?p=98351&highlight=apap+doctor#98351
_________________
| Machine: DreamStation Auto CPAP Machine |
| Humidifier: DreamStation Heated Humidifier |
| Additional Comments: Compliant since April 2003. (De-cap-itated Aura). |
Thanks Linda I have excellus blue cross blue shield through teamsters health and hospital fund. But claims get processed through the local BC/BS. Anyone have a hard time getting the machine they wanted through NY BC/BS?
~Melissa~
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
The best bridge between despair and hope is a good night's sleep. ~E. Joseph Cossman
also i would see what the dme bills the insurance at.
mine was 2.5 time the price of just buying it so even with only a 50% co-pay it was better to just buy it from cpap.com
my 50% copay was gonna be around $2000. (and that was for a bad machine)
my just buying it outright was $950
might be better with a 20% copay cant hurt to ask
mine was 2.5 time the price of just buying it so even with only a 50% co-pay it was better to just buy it from cpap.com
my 50% copay was gonna be around $2000. (and that was for a bad machine)
my just buying it outright was $950
might be better with a 20% copay cant hurt to ask