Insurance and CPAP question

KarenAZ · Post by **KarenAZ** » Fri Mar 21, 2008 6:55 pm

Does anyone know if you have a choice of machines with insurance? I specifically switched to BC/BS HMO to have the benifit of autodelivery of supplies every 3 weeks that I don't pay for plus they paid 100% for my machine. I don't know if the sleep study place recommends the machine or if it's the only one the insurance company will pay for. I'm single and on a limited income so I don't have the $$ to purchase my own outright.

Does anyone know how that works? I looked in the light bulb and couldn't find an answer. Thank you for your time.

Karen

Slinky · Post by **Slinky** » Fri Mar 21, 2008 7:47 pm

Well, the BIG question is HOW LONG have you had your Respironics M Series Plus?

IF you've had it less than 30 days your chances are pretty good for getting it exchanged for a fully data capable CPAP and quite likely an auto PAP.

IF you've had it less than 60 days your chances are so-so that you can get it exchanged for a fully data capable CPAP and slimmer for an auto PAP.

IF you've had it more than 60 days and less than 5 years - your chances are pretty much nil.

Insurances pay for CPAPs by HCPCS code, not by brand or model. All bare bones straight CPAPs thru fully data capable straight CPAPs thru auto PAPs are all billed and reimbursed at that one HCPCS code: E0601. The local DME supplier's profit margin is greater if they can slip by w/providing a bare bones or a compliance data only straight CPAP.

KarenAZ · Post by **KarenAZ** » Fri Mar 21, 2008 7:50 pm

Well I fall into the 'nill' category LOL. I've had it less than a year but more than 60 days. It will be a year in July. I'm going back again cuz I feel like I am smoothering. Maybe if the sleep study place recommended to the doctor an autopap.... I'll have to ask the sleep study guy.

RiverDave · Post by **RiverDave** » Fri Mar 21, 2008 8:26 pm

Karen,

What is your machine set at pressure-wise? That may explain the "smothered" feeling you are getting. When I started, my minimum pressure was way,way too low for me to feel comfortable. matter of fact, that's how I found this forum.

TR · Post by TR » Fri Mar 21, 2008 10:34 pm

with BCBS you rent to own...ergo if you need to switch to a new machine APAP you can. APAP therapy is only if you failed on CPAP...read the Sleep Apnea medical guidelines. When I called, it is all based on medical necessity.....no caps, just necessity.

ozij · Post by **ozij** » Sat Mar 22, 2008 6:13 am

Hello Irena,
Please tell your assistant about cpaptalk - he will be able to help far more people.

You are misusing this forum - please do not do this again.

We have had posts by helpfule DMEs, you are not one of them.

O.

(3rd copy of my message).

KarenAZ · Post by **KarenAZ** » Sat Mar 22, 2008 3:29 pm

Ummm Who is Irena??? I don't even see a post by that person? *confused* OMG I did when I hit reply - LOL nothing like drumming up business in a forum?!

TR - I will check into maybe getting another machine when I go back for the study in a few weeks.

River Dave - I haven't a clue as to what my machine is set at. I know it ramps after 30 mins. And I've been using it fine until recently but then I've also recently lost nearly 50 lbs so that could make a difference. I've noticed a difference in my overall breathing, etc. so I would imagine that would affect my pressures. Hence - the new sleep study.

Will keep advised of what happens.

ozij · Post by **ozij** » Sat Mar 22, 2008 4:14 pm

Someone probably deleted her posts as spam - something I intend to do in the future - though I hope the lady got the message and will go away..

O.

TR · Post by TR » Sat Mar 22, 2008 4:58 pm

WHat dme do you use here in PHX? I've been using US Med....they have been OK.......who is your sleep doc and all that jazz.......pm me so we can compare notes.....BCBS is pretty good to work with.....

Capri · Post by **Capri** » Sat Mar 22, 2008 7:50 pm

KarenAZ wrote:Does anyone know if you have a choice of machines with insurance?

It would seem, with all respect, that you are putting the cart before the hose ... I mean horse!

You should first become familiar with the world of Durable Medical Equipment (DME) suppliers and insurance. Until then, you may want to ask for a loaner or rental machine or buy an older one cheap on the auction site because this is going to take some time. Now get out your health insurance certificate booklet and read about your DME benefits. Find our your coverage for this type of equipment, along with your deductible, copays, coinsurance, necessity of physician referrals and annual/lifetime maximums.

1. Ask your prescribing physician to write a prescription that is as specific as possible, specifying what your xPAP and supplies need to do for you, e.g. a full-faced mask or a heated humidifier. Do not bother with brands at this step.
2. Get a referral to a good DME provider. Your visit there should be free. Interview them, identifying your expectations and any special needs. Now you will need to provide them with your Rx and a copy of your sleep study results. At this point you can get into such issues as brands and accessories.
3. This is important and takes some time. With your DME representative, submit the list of equipment you want to your insurance company for Precertification.. You don't want to have any surprises or get burned when buying xPAP equipment from a DME dealer. You could get stuck for literally THOUSANDS of dollars! Do not proceed until you receive precertification IN WRITING back from your insurance company. I called Blue Cross and asked to speak with an agent who is familiar with CPAP. They referred me to one who was on CPAP herself! She understood the importance and urgency of my request, and walked the paperwork through precertification. She was very excited and proud when she called me to let me know she had just faxed the precertification to my DME rep.
4. Now you're ready to get your xPAP and supplies. Now simmer down and don't go wild. Assuming you have to pay a portion of the expenses, buy a machine that has features you will use or anticipate doing so. Ultimately they all blow air, some quieter, some louder. When you can get an entire setup for around $500, your 20% coinsurance will be significantly less than if you go for a setup for 2 grand - and more!
5. Like any major purchase, ask about their return policy. It's an electronic device - get a good surge protector before you go out and get a snuggy hose with kittens printed on it. Finally, use common sense setting up your equipment so you don't step on your mask or worse.
6. Now, if you have any money left, go ahead and accessorize.

There is a wealth of information on this site and others. If you get the right machine and then find out your insurance won't cover it, you're not going to sleep much better anyway!
Cheers
Settings: CPAP 12cm, heated humidity, AHI=29

Main unit: ResMed S8 Elite, ResMed Humidaire 3i
Backup: ResMed S6 Lightweight, ResMed Sullivan Humidaire
Mask: ResMed Ultra Mirage FF
Backup: ResMed Swift II
Health Tools: ResMed ResScan Data Card, CMS-50E Pulse Oximeter, OneTouch Ultra glucometer, Citrus II spray mask cleaner
Software: ResMed ResScan 3.3, OneTouch, SP O2 Manager/Review

Snooze_Blues · Post by **Snooze_Blues** » Sat Mar 29, 2008 12:51 pm

Capri wrote:... Do not proceed until you receive precertification IN WRITING back from your insurance company. ...

Capri: Wow, good idea. I don't know why I never thought of seeking an equipment pre-certification from my insurance. That would take the guesswork out of who will be paying for what if I go independent.

Do I read you correctly in that you went directly to your insurance company (BCBS), rather than having your DME contact them?

That is what I'm thinking to do myself, in order to buy from cpap.com rather than my incredibly frustrating and expensive local DME.

I contacted the cpap.com insurance folks. They only take Blue Cross Blue Shield, which I don't have. So I'll be in the middle of an expensive transaction (between the DME purchase and my insurance reimbursement), which typically results in a poor and/or anxiety producing outcome, essentially loaning money to an inefficient, massive, stumbling, barely accountable bureaucracy.

KarenAZ · Post by **KarenAZ** » Sat Mar 29, 2008 1:29 pm

Okay thank you for the tips.

My 'sleep' doctor is my PCP and he uses ART (Advanced Resp. Therapy) to do the sleep studies, etc.

Slinky · Post by **Slinky** » Sat Mar 29, 2008 1:32 pm

Read and re-read Capri's advice. Its great advice and quite detailed. If you need clarification, ask her. PM her if necessary.

And how nice that TR is right there in Phoenix w/you! You two can be your own support group! Maybe a town the size of Phoenix has one or more support groups the two of you (or two of you and your spouses) could try out for a pleasant evening out. (Maybe you can help educate the other members if they aren't really "up on things" themselves - like tell them all about cpaptalk.com, etc.).

goose · Post by **goose** » Sat Mar 29, 2008 7:49 pm

Wow Capri -- great post!!!
I hope that someone who knows how will move it to "our collective wisdom" .

I've been at this for nearly a year and I had no idea about the pre-certification of the equipment (knew about surgeries etc., but.....D'oh ). My DME equipment is 100% so I've had few issues -- at least not after I got them trained ......They pretty much do what I ask anymore.

KarenAZ, if your machine is not performing its task properly or if it is inadequate for your treatment I believe that it can be replaced with a new prescription -- but as Capri notes, validate any of that kind of info with your insurance company. The more you understand your coverage the better you will be dealing with the DME....
The DME is going to try to pass off on you the most basic of anything in the script -- their profits are higher. Plain and simple.
The generic basic CPAP machine has the same billing code as the Remstar Auto C-PAP w/A-flex, so the DME is going to be reimbursed the same amount for either. One costs them $200 the other costs them $400.....which one do you think you'll get??

I have to agree with others on the "choking for air"....the pressure isn't high enough....I had the same issue when mine was set to 5....I can't really breathe until it gets to 7 and my "magic number" is 10. And yes, losing weight will change your pressure requirements -- Congratulations on the weight loss by the way!!! That's a FANTASTIC accomplishment!!!!!

If you have a good doc, talk with him/her about what you'd like and ask them to write the script brand, model specific. I had my doc write me a specific mask script (it was originally "patient preference") after the DME argued with me about "We don't carry that mask".....
Ok....Order it!!!!
Once the doc scripted that specific mask, they had to order it....And she'll write me a script for pretty much any mask I want/need. I don't even need to see her -- I just phone in my request and in a couple days the DME calls and tells me they shipped me a box.....

Good luck
take care
cheers
goose

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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap machine, DME, Prescription, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap machine, DME, Prescription, auto

Slinky · Post by **Slinky** » Sun Mar 30, 2008 10:07 am

I second Goose's accolades for your post regarding CPAP and insurance as well, Capri, and also that someone who knows how does add it to "Our Collective Wisdom" under the yello light bulb at the top of the page!!!!

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