Remember the RT I was bragging on??....

[Guest]

KansasRT,

Call (Respironics, Resmed, etc) and ask them directly who your Rep is for your area. If they can't give you a name and number, hopefully they can let the Rep know and she/he can initiate contact with you.

If you can't get a response let me know here and I will find out for you. I am good friends with all of my Reps, they can findout for me if you give me a location.

[rested gal]

Michelle’s script was for “BiPAP ST,” with pressures and rate specified. The Adapt SV is clearly not a cheapo substitute on the part of the DME. They could have provided a less expensive machine meeting this script.

Our experience with this DME has been a pleasant surprise. Wish they were all that way!

Wayne

Well, I'm amazed. Amazed that a DME would take it upon themselves to substitute a COMPLETELY different type of machine from the one on the Rx. Hopefully, the DME called the doctor first to get his approval !! And hopefully the doctor fully understands the difference between a bilevel ST and an Adapt Servo Ventilator.

I'm not saying that the Adapt SV might not even give far better treatment for your wife, Wayne. And I agree that the RT's candor in telling you she was not familiar with an ASV machine was wonderful.

However, setting up the ResMed ASV machine properly, with its Learn Circuit and Learn Patient routines, and using a mask compatible with that machine is sooooo important. I can hardly imagine just deciding to give out that machine to someone who had not undergone a sleep study titration ON that particular Adaptive Servo Ventilator.

Hope all goes well. I think I'd be asking the RT or the doctor to contact both the sleep lab and ResMed to see if it would be a good idea for your wife to go back in to the lab WITH that machine, for a specific titration using it. If possible.

[J-Mac]

Problem is, the DME does NOT have to supply any particular machine, whether it is stated on the scrip or not. Most health insurance plans have cost containment measures written in to them, with a standard one - for all Rx's, not just CPAP-related - stating that the provider is to fill the scrip with the lowest cost product that meets the criteria for the medicine, equipment, etc. So as long as they supply a CPAP that performs the same medical function as the one the doctor specified, they are to supply the most inexpensive available. The only way around such contract provisions is for the doctor to state very specifically that the particular brand/model/style, etc. of CPAP equipment is medically necessary for your condition; basically saying that no other CPAP equipment can help you. And that is pretty much impossible to prove, so your doctor cannot state that without showing clearly that he or she is not being honest - and no doctor will risk that.

Which is why I purchase all of my own CPAP equipment, supplies, etc. myself. I do not want a DME being held to strict economic rules to decide what cheap crap they want to supply to me!! I want to choose exactly what type, brand, model, etc. of each piece of equipment I wish to use.

Of course this costs me quite a bit of money each year, but I feel it is justified personally so that I get what I feel is best, and not some bean counters at the insurance company.

Good luck!

Jim

[TossinNTurnin]

Problem is, the DME does NOT have to supply any particular machine, whether it is stated on the scrip or not. Most health insurance plans have cost containment measures written in to them, with a standard one - for all Rx's, not just CPAP-related - stating that the provider is to fill the scrip with the lowest cost product that meets the criteria for the medicine, equipment, etc.

I don't think that's true, I could be wrong. Perhaps someone else can clarify?

IF a doctor writes a specific script that says Do Not Substitute on it, I don't believe a pharmacist or DME can .... substitute.

Now with drugs, I think that generic prescriptions have a different "code" than a brand name drug.

But with CPAP machines, be it bare bones, or a more featured machine... they're all billed under the same code, E0601.

[WNJ]

Rested Gal,

The DME in this instance manages “sleep services” for my wife’s health insurer. I get the impression that they control everything from pre-approving the initial sleep study, to choosing the doctor, to providing the equipment and supplies.

Michelle, my wife, has complex sleep apnea, with more central apneas than obstructive. I spoke to the DME at length before Michelle got her machine. They told me this machine gives better treatment for the kind of complex apnea that Michelle has compared to a BiPAP. (Michelle only later got a copy of her script and sleep study reports.)

The DME just requested the data from the machine. (I just mailed them the data card a couple of days ago.) I spoke to them about the data card, the information it contains, and how they were going to use it. They said it contains very detailed information, which they will analyze, above and beyond compliance information, which Michelle’s insurer requires.

We will be asking them for a hard copy of the data from the card. I may even buy the software to read the data myself.

I was very skeptical of Michelle getting good service from this DME. So far, I’m satisfied that they’re providing good service. Out of concern for Michelle’s welfare, I will continue to keep an eye on things.

Wayne

[J-Mac]

TossinNTurnIn:

If you don't believe it, read the plan documents of your health insurance provider, or ask your doc or pharmacist. They do have to power to substitute with approved products, unless the physician states that what is prescribed is medically necessary - that is the key term. E.g., they cannot refuse to provide a humidifier with a CPAP machine IF the doctor claims that a humidifier is medically necessary for your condition. However it is difficult for any doc to prove that a particular brand of CPAP machine is the only one that can help you.

A long fight over this is exactly why I buy my own. Otherwise I would never willingly pay approximately $1,200 to 1,500 yearly for all my own equipment, accessories, and supplies! (Grr.. - I hate even thinking about it!)

Jim

[rested gal]

Michelle, my wife, has complex sleep apnea, with more central apneas than obstructive. I spoke to the DME at length before Michelle got her machine. They told me this machine gives better treatment for the kind of complex apnea that Michelle has compared to a BiPAP. (Michelle only later got a copy of her script and sleep study reports.)

I agree that an ASV machine is more suited to treat centrals than a BiPAP S/T which used to be the machine of choice for centrals. I applaud any DME who knows that and would suggest to a doctor that Michelle's Rx be switched to a totally different type of machine...an ASV.

My astonishment was because I thought the DME had substituted a different type of machine on their own initiative.... "Michelle’s script was for “BiPAP ST,” with pressures and rate specified. The Adapt SV is clearly not a cheapo substitute on the part of the DME."

However, since you said this:

The DME in this instance manages “sleep services” for my wife’s health insurer. I get the impression that they control everything from pre-approving the initial sleep study, to choosing the doctor, to providing the equipment and supplies.

If the DME does have complete control of everything, you're fortunate that they do seem to be "up" on treatment for CSDB. More so than the doctor who wrote BiPAP S/T on the Rx in the first place.

That's an interesting arrangement.

[TossinNTurnin]

TossinNTurnIn:

If you don't believe it, read the plan documents of your health insurance provider, or ask your doc or pharmacist. They do have to power to substitute with approved products, unless the physician states that what is prescribed is medically necessary - that is the key term. E.g., they cannot refuse to provide a humidifier with a CPAP machine IF the doctor claims that a humidifier is medically necessary for your condition. However it is difficult for any doc to prove that a particular brand of CPAP machine is the only one that can help you.

A long fight over this is exactly why I buy my own. Otherwise I would never willingly pay approximately $1,200 to 1,500 yearly for all my own equipment, accessories, and supplies! (Grr.. - I hate even thinking about it!)

Jim

Interesting. Thank you Jim for the information. I will have to re-think things.

[darthlucy]

IF a doctor writes a specific script that says Do Not Substitute on it, I don't believe a pharmacist or DME can .... substitute.

In the case of drugs, it is true that if the doc writes the scrip with the notation Dispense as Written (or do not substitute), the pharmacist does have to fill it as written and not substitute a generic. However, that does not mean that the patient will not pay a higher co-pay as a result. Example: Let's say the generic of a drug costs $10, and the brand costs $100 (cash price, not co-pay). With a DAW Rx, the insurance could make the patient pay not only the normal co-pay for the brand (which is typically the highest tier co-pay when there's a generic available) PLUS the difference in the cost. So in this example, you would have to pay the highest tier co-pay plus $90. Not all insurances work this way, but some do.

So the bottom line is that just because the patient or doctor wants the most expensive product, the insurance company is not required to pay for it if there is a lower cost alternative available.

[Slinky]

HORSEPUCKIES! Not all insurances work in your described manner, nor does Medicare, when it comes to CPAP equipment. They lump masks by style into separate categories. They lump ALL straight bare bones CPAPs thru fully data capable autoPAPs in ONE category and ONE HCPCS code, E0601, and they PAY ONE SET AMOUNT for that ONE HCPCS code, E0601, regardless of which brand or style of CPAP or autoPAP. (Bi-levels, SVs, etc. fall into a different category and HCPCS code). MORE INSURANCES follow the Medicare practice than the practice you have described.

[TossinNTurnin]

IF a doctor writes a specific script that says Do Not Substitute on it, I don't believe a pharmacist or DME can .... substitute.

In the case of drugs, it is true that if the doc writes the scrip with the notation Dispense as Written (or do not substitute), the pharmacist does have to fill it as written and not substitute a generic. However, that does not mean that the patient will not pay a higher co-pay as a result. Example: Let's say the generic of a drug costs $10, and the brand costs $100 (cash price, not co-pay). With a DAW Rx, the insurance could make the patient pay not only the normal co-pay for the brand (which is typically the highest tier co-pay when there's a generic available) PLUS the difference in the cost. So in this example, you would have to pay the highest tier co-pay plus $90. Not all insurances work this way, but some do.

So the bottom line is that just because the patient or doctor wants the most expensive product, the insurance company is not required to pay for it if there is a lower cost alternative available.

That's not true. Actually most insurance companies don't even know which machine you're getting. All they know is that you got a CPAP machine, and they know that because they use CODE to identify what they are paying for the code for ALL cpap machines, including the APAP/Aflex machine is E0601.

Insurance companies contract with DME's and they have told them "We'll pay you "X" for a (any) cpap machine". ... and so that they can do business through the insurance companies, DME's agree to accept that amount. Period. So, the cheaper the machine the DME can pass off on you, the more profit margin for them.

There may be a few exceptions to the rule ... but, in general... if the DME's want to get business from the insurance companies, they agree to those terms.



Now BiPap is a different matter, because that is a different insurance code.

[TossinNTurnin]

TossinNTurnIn:

If you don't believe it, read the plan documents of your health insurance provider, or ask your doc or pharmacist. They do have to power to substitute with approved products, unless the physician states that what is prescribed is medically necessary - that is the key term. E.g., they cannot refuse to provide a humidifier with a CPAP machine IF the doctor claims that a humidifier is medically necessary for your condition. However it is difficult for any doc to prove that a particular brand of CPAP machine is the only one that can help you.

A long fight over this is exactly why I buy my own. Otherwise I would never willingly pay approximately $1,200 to 1,500 yearly for all my own equipment, accessories, and supplies! (Grr.. - I hate even thinking about it!)

Jim

I just wanted to clarify on this, because I didn't think of it the first time.

It looks like you're saying your INSURANCE can insist on only certain products... which would likely be true. Just like, on some "brand name" drugs, some insurance companies simply will not help pay for them. It's accept the generic or you pay out of pocket... or pay a higher co-pay.

But, if the doctor writes out a specific script, the Pharmacist can not substitute it for a generic if the doctor says "do not substitute". Now whether the insurance will help cover that for you, is a different matter.

But IF you have insurance that will pay for the machine, whether it's a bare bones CPAP, or a full featured CPAP... your DME has to follow the prescription of the doctor.

I don't think the DME's can substitute on their own. In otherwords, if the doctor has prescribed a specific machine (do not substitute), as long as the insurance doesn't object, the DME has to provide what was prescribed if he's contracted with the insurance company.

Typically the "deal" between the insurance and the DME is that the insurance has negotiated a flat price for ALL cpap machines.

It sounds like your insurance does not have this sort of arrangement with your DME.