can i get dr. to order resmed for me

[dankc]

i have one of the major insurers, nothing great, through work.

my doctor said he is "ordering me" a unit. i told him to hold off. i wanted to first ask here for tips on how i will be able to get a resmed.

i took a look at some posts and learned about renting? can they force you to rent, or will it be my choice?

also, if i buy a cpap on my own outside of insurance, will they still pay for supplies? i have cigna HDHP

thanks

[CPAP-A-MUST]

I believe all the doc has to do is to specify the make and model of the machine. This is what my sleep institute did when initially diagnosed and placed on CPAP therapy. They also wrote to mask script that stated “patient’s choice” or something similar.

[robysue1]

i have one of the major insurers, nothing great, through work.

my doctor said he is "ordering me" a unit. i told him to hold off. i wanted to first ask here for tips on how i will be able to get a resmed.

The first critical thing to find out is who is the DME your doc wants to "order" the CPAP from? You don't want the doctor choosing your DME for you. Call your insurance company and get a list of DMEs that are in-network.

Then start calling the DMEs and asking them if they sell Resmed machines and if they will set you up with a Resmed APAP if the doctor's script simply says CPAP @ n cm.

If you find a DME that is willing to set you with a Resmed APAP even if the script says CPAP @ n cm, then you've found your DME and you then tell the doctor where to send the script.

Alternatively, you can also ask the doctor to prescribe the machine by brand name and model and add dispense as written to the script. If the phrase "Dispense as written" is NOT part of the script, then the DME can legally substitute an alternate brand/model of machine that can deliver the pressure specified in the script.

It's also important to keep in mind that you are under no obligation to accept a machine that you do not want. So if you go to the DME having told them in advance that you want a Resmed and they try to switch brands to you, you have the right to say, no I'm not accepting this machine and then walk out without the machine. The machine is still brand new, so they can sell it to the next customer. You will, however, need to watch your credit card statements like a hawk for a few months to make sure they're not trying to charge your credit card for a machine you for which refused to accept delivery.

i took a look at some posts and learned about renting? can they force you to rent, or will it be my choice?

That depends on your insurance and whether you want the insurance company to pay for (part) of your machine.

If you are willing to buy the machine out-of-pocket and not use insurance at all, then you can tell the doctor to write you a physical copy of the script, scan the script in as a pdf and submit it to whatever DME you want, including on-line DMEs like our host CPAP.com.

But if you want your insurance company to pay their share of the cost of them machine, you have to follow their rules.

also, if i buy a cpap on my own outside of insurance, will they still pay for supplies? i have cigna HDHP

That's something you would need to check with the insurance company. Some will and some won't. You need to get in writing what your insurance companies policies are about paying for supplies if you buy the machine yourself.

[Sheriff Buford]

As what was mentioned above, TELL the doctor to write on the prescription:

-Resmed Airsense 11 (or whatever machine you want)
- Your settings

Get a copy. If he doesn't give you a copy, tell the doctor you need one because you may want to shop for a machine. Hopefully, the Doc will send it to the DME and you'll get a copy.

Sheriff

[chunkyfrog]

Resmed Airsense 11 (or 10) AUTOSET.
Don't give them any wiggle room.
If you do, you WILL regret it.

[Janknitz]

If you are on Medicare, you will be stuck renting the machine. On traditional Medicare (Part B) it will be a 13 month rental and then you own the machine--this is called a "capped rental". You will have to meet your part B deductible ($226) this year and next. Your supplemental insurance may or may not pay all or part of the deductible and usually you must pay at least something toward the monthly rental,

If you are on a Part C advantage plan, most of them have gone to perpetual rentals. That means you pay the rental co-pay forever.

Private Insurers may have different rules. Some of them follow Medicare Part B guidelines for capped rentals, others require a shorter rental period before purchase, and some simply purchase it outright at the beginning.

So you need to contact your INSURER to find out what your situation is. The question to ask is "What are my out of pocket expenses for CPAP"? You want to know if you have to pay a deductible, what your co-pay is for rental or purchase, if you can purchase outright. Don't bother with the insurer about what model of machine they will cover. ALL APAP/CPAP machines have the same billing code, so they don't care what machine you get. They will pay exactly the same amount no matter which machine, and your DME in most cases (by contract with your insurer and usually also by state law) is prohibited from charging you more than your deductible and co-pay set by your insurance company. Charging you more than that is called balanced billing, and it's not allowed.

With that information, you can calculate your out of pocket costs and decide for yourself if it's worth it to have help from your insurer or buy outright yourself--you can buy a brand new ResMed 10 AUTOSET for $695 and no hassle from our hosts at cpap.com. They have them in stock (DME's may tell you it will take months to get a ResMed 10 or 11 Autoset), or buy a good quality used one--Look for our member LSAT who can help you find one.

NEVER rely on the DME to tell you what your insurance will cover and what your out of pocket expenses will be. ALWAYS check with your insurance company. Be aware that if you want to purchase outright from most DME's they will take you to the cleaners price-wise. Check the prices on our host at cpap.com before agreeing to purchase retail from a local DME, so you know what a reasonable price is for a new unit. And learn how to check the "run hours" to make sure what you're getting (rental or purchase) is brand new.

[dankc]

Thanks to everyone. I will proceed as you guided me. Will let you know

[dankc]

I got around to making a couple calls today. Called my insurance asking them for a cost for a particular machine, and they said i have to go to DME for that. I called one, Apria, who told me i have to go to my insurance for that. Figures.

My insurer said the following DME are in network. Any recommendations based on the DME? (i will still call them and see if they have no problem giving the resmed)

aerocare
aeroflow
apria
edgepark
lincare
rotech
usmed

[atab]

dankc, Can you please update on what happened with your order. I am having an appt with Dr. to get a new CPAP. I called my insurance (Medicare Advantage). They say whether I rent or buy (with a 20% copay) will depend on DME. According to the insurance person, DMEs bill them in different ways. Any one having experience?

[Janknitz]

I called my insurance (Medicare Advantage). They say whether I rent or buy (with a 20% copay) will depend on DME. According to the insurance person, DMEs bill them in different ways. Any one having experience?

The person you spoke to at your insurance company doesn't sound like they know what they were talking about. Advantage plans still have to follow Medicare guidelines and Medicare does not allow outright purchases. Traditional Medicare requires a 13 month capped rental and then it's considered a purchase, Advantage plans have the option of a perpetual rental instead of a capped rental. But AFAIK (I could be wrong) Advantage plans won't cover an outright purchase. Traditional Medicare won't for certain.

You can ask for the Evidence of Coverage (EOC) which will have a section on DME that explains how CPAP machines are covered. It won't tell you the out of pocket cost, though.