Upgrading Machine Cost?

Sleepqueen · Post by **Sleepqueen** » Tue Aug 01, 2017 11:28 am

Can someone please explain to me the difference between CPAP and APAP in terms of how insurance handles when they are the same code? How does this affect the billing process and how do DMEs handle? Thanks in advance.

ChicagoGranny · Post by **ChicagoGranny** » Tue Aug 01, 2017 11:36 am

Sleepqueen wrote:Can someone please explain to me the difference between CPAP and APAP in terms of how insurance handles when they are the same code? How does this affect the billing process and how do DMEs handle? Thanks in advance.

There is no difference. The amount the insurance will pay and the amount you are required to pay in copays or deductibles is the same for an APAP as a CPAP.

Exception: Check if your insurance allows balance billing. Most policies do not.

Sleepqueen · Post by **Sleepqueen** » Tue Aug 01, 2017 12:26 pm

I am hoping to trade in my CPAP for an APAP and was advised there is an upcharge of $160.

WearyOne · Post by **WearyOne** » Tue Aug 01, 2017 12:37 pm

I have really bad insurance, but didn't have any trouble getting a new machine in 2015. Now, mine was written up by the sleep doc as needing to be replaced because of a problem (it was making an odd noise, but still working at over eight years old). That machine was a CPAP. The new machine is a great APAP. Sleep doc asked me what machine I wanted, made a suggestion, which is what I wanted anyway, and wrote the script for exactly that machine. Had no trouble at all with insurance or the DME.

If you're just trading up and there's nothing wrong with your current machine, that may be treated differently. I've always heard that the insurance coding for CPAP versus APAP is the same.

Pugsy · Post by **Pugsy** » Tue Aug 01, 2017 12:45 pm

WearyOne wrote:If you're just trading up and there's nothing wrong with your current machine, that may be treated differently. I've always heard that the insurance coding for CPAP versus APAP is the same.

Nope. Only treated differently by the DME because they make more money on a cpap only vs an apap capable machine.

Billing codes are the same for either the brick or the full data machines. E0601 when talking about cpap/apap single pressure machines.

The upcharge thing is called "balanced billing" and is illegal with most insurances and that includes Medicare.

They aren't happy with the contracted allowable amount for E0601 machine and want to charge more for the other machines because those other machines don't offer the same profit margin.

ChicagoGranny · Post by **ChicagoGranny** » Tue Aug 01, 2017 3:28 pm

Sleepqueen wrote:I am hoping to trade in my CPAP for an APAP and was advised there is an upcharge of $160.

How old is your CPAP? Will your insurance policy cover a new machine at this time?

Most insurance policies will not cover a new machine if you have a machine that is less than five years old. If this is your case, you are at the mercy of your DMEs policy on trade-ins.

Which model APAP are you considering?

WearyOne · Post by **WearyOne** » Tue Aug 01, 2017 3:35 pm

Pugsy wrote:
WearyOne wrote:If you're just trading up and there's nothing wrong with your current machine, that may be treated differently. I've always heard that the insurance coding for CPAP versus APAP is the same.
Nope. Only treated differently by the DME because they make more money on a cpap only vs an apap capable machine.

Billing codes are the same for either the brick or the full data machines. E0601 when talking about cpap/apap single pressure machines.

The upcharge thing is called "balanced billing" and is illegal with most insurances and that includes Medicare.

They aren't happy with the contracted allowable amount for E0601 machine and want to charge more for the other machines because those other machines don't offer the same profit margin.

Good to know!

Pugsy · Post by **Pugsy** » Tue Aug 01, 2017 3:42 pm

ChicagoGranny wrote: How old is your CPAP? Will your insurance policy cover a new machine at this time?

Couple of months but it's a tad complicated.
See past thread
viewtopic.php?f=1&t=155438&p=1182355#p1182355
She was given a half assed brick....and wants full data plus she got to trial an apap and did better with it. Getting some run around about there "not being a code for the apap".

Granddaddy · Post by **Granddaddy** » Tue Aug 01, 2017 3:43 pm

ChicagoGranny wrote:
Sleepqueen wrote:I am hoping to trade in my CPAP for an APAP and was advised there is an upcharge of $160.
How old is your CPAP? Will your insurance policy cover a new machine at this time?

Most insurance policies will not cover a new machine if you have a machine that is less than five years old. If this is your case, you are at the mercy of your DMEs policy on trade-ins.

Which model APAP are you considering?

Fair question but IF (it is older) and the machine is broken as in it fell off the car (or night stand) and spilled water inside and no longer works the DME will (must) replace it. A loaner should be provided while this unit is sent out for repair estimate.

This is why having a spare cpap is always recommended cuz things like this do happen on long holiday weekends and the DME may take a week or more to even get to checking on you.

IF it is newer be sure to contact your insurance to ask exactly what they cover and how but it will be as mentioned above - the point is you will know exactly what your insurance has to say and can relay that to your DME.

btw - which DME is pulling this?

Granddaddy · Post by **Granddaddy** » Tue Aug 01, 2017 3:49 pm

Can also get the doc to write a make & model specific order saying "Do NOT Substitute" if you are not sleeping well. The DME may act slowly but they have to act.

D.H. · Post by **D.H.** » Tue Aug 01, 2017 4:52 pm

My insurance (back in 2005) said they would pay for a replacement machine only if the old one could not be repaired or such a repair would cost more than a new one. Fortunately, the old one was not supported by the manufacturer, so it was not possible to get an authorized repair.

Another stupidity was that I could buy it from the "preferred" supplier for a co-payment of 10% on their $1500 price tag, or for a 30% co-pay form an off-plan provider who was selling the identical machine for $500.

ChicagoGranny · Post by **ChicagoGranny** » Tue Aug 01, 2017 6:51 pm

Pugsy wrote:
ChicagoGranny wrote: How old is your CPAP? Will your insurance policy cover a new machine at this time?
Couple of months but it's a tad complicated.
See past thread
viewtopic.php?f=1&t=155438&p=1182355#p1182355
She was given a half assed brick....and wants full data plus she got to trial an apap and did better with it. Getting some run around about there "not being a code for the apap".

+1

I don't want to read that long thread, but this was encouraging -

I went back the next week and they gave me an APAP test machine to figure out what my numbers needed to be. It was the best week of sleep in my entire life! I slept deep every night and hardly woke up at all.

For sleep like that, I would pay the $160 upgrade in a flash.

Upgrading Machine Cost?

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