Please help with DME "negotiations"

sleepyinO · Post by **sleepyinO** » Wed Jul 16, 2008 9:46 am

Hello,

I'll try to make this long story as short as possible...

I had a sleep study (I posted it previously) and my doctor ordered a CPAP machine.

The DME had me use an S8 Vantage for two weeks to see what pressure I needed. After that, they told me that my insurance would not pay for a CPAP machine (before they even submitted anything to my insurance). I asked them to attempt to get authorization from my insurance company anyway, and they gave me a Sleep Easy machine to use in the meantime.

Now I have learned that my insurance company did approve the CPAP machine for $1700, which is the amount the DME requested. Obviously, $1700 is a ridiculous price for a Sleep Easy. So, I told the DME that I am going to return the machine and take my business elsewhere unless they will give me the S8 Vantage with humidifier, software and card reader.

I definitely will not get a machine from them unless it is the S8 Vantage (or something better), but I am curious about the software and card reader. Do DMEs usually even sell these items? If so, I am assuming that insurance won't pay for them, but is it ridiculous for me to ask for them to be included with the machine?

If they refuse to include the software and card reader, what machine would you suggest that I tell them I want, if not the S8 Vantage?

On cpap.com, I can get the S8 Vantage, software and card reader for $995. I'm sure the DME can get it all for much less and still make plenty of profit at $1700.

Let me know what you think....

Thanks!

Brian

Guest · Post by **Guest** » Wed Jul 16, 2008 10:04 am

Call your insurance, find out the rules for getting reimbursed if you pay out of pocket, and if it works for you, then buy it yourself on CPAP.com.

That's what I do. I don't get reimbursed 100% when I do that, but I have a FSA (pre tax dollars I can use for medical expenses) so I just write the rest off to the FSA.

I'm lucky I can afford to operate this way. Other people simply can't, and they are at the mercy of the DME's.

No offense to the very GOOD DME's and RT's on this board.

Cheers,
Babs

dllfo · Post by **dllfo** » Wed Jul 16, 2008 10:07 am

First, is your DME a National Chain (Apria, etc.) or is it a local store only?

Second, you did the right thing. TELL THEM what you want but go get a prescription for the exact machine you want. Give your doctor a brochure if you can (downloaded from the internet perhaps??).

When you have a specific prescription from you doctor, you should get that machine.

I did that. The DME offered my wife an entry level machine and I trumped the DME with about 3 months of printed data from the Respironics BiPap Auto. Plus a brochure so my doctor could spell the name correctly. Their sleep study doctor titrated her with 6 cmH2O and her IPAP was around 12, with an EPAP around 8 I think....been a few years.... I asked their doctor to revisit his findings and he refused. He also quit them shortly thereafter. They have a new doctor now. Our doctor, who sent her there had all the data I gave him and their 2 page report. If nothing else, the "gross weight" test won it for us.

Never give up. Pro-Active people get the treatment they need. I was told by a friend (OB-GYN doctor) that he felt like people who push the hardest probably really need the treatment most of the time. Keep trying.

You came to the right place, this forum you will get the best non-medical advice anywhere.

sleepyinO · Post by **sleepyinO** » Wed Jul 16, 2008 10:22 am

It is a local DME (Frontier Home Medical).

If I do end up going the cash route, I will probably go through Walgreens - OptionCare. I work at Walgreens, so I get a 25% discount if i pay cash...

Slinky · Post by **Slinky** » Wed Jul 16, 2008 11:27 am

Call your insurance company and ask them what local DME CPAP suppliers they are contracted with. Hopefully, you will have the option of more than just this one.

Also ask what your DME benefits, copays and/or deductables are.

Ask if they would consider you "in network" if you purchase elsewhere out of pocket and submit a PAID INVOICE W/HCPCS codes and if so what your reimbursement percentage would be.

As far as dealing w/this particular DME supplier: be FIRM, be DIPLOMATIC, be TACTFUL, but make it clear you will NOT accept this SleepEasy device. You got much more comfortable and effective therapy w/the Resmed S8 AutoSet Vantage and are NOT getting comfortable, effective therapy w/the SleepEasy device.

You might also let them know that you are aware that a Resmed S8 AutoSet Vantage is billed and reimbursed as HCPCS code E0601 as is the SleepEasy and thus the Vantage DOES fit your script.

I know of NO insurance company that reimburses for the software and cable reader. The software ware is intended for PROFESSIONAL use ONLY. Even if the local DME were willing to provide it to you at your expense they would need a script to do so just to protect themselves. You can get them cheaper online anyway and w/o a script.

You make no mention of any type of humidifier. You might want to take that in to consideration as well. The humidifier is billed separately from the CPAP device. I can't use a CPAP w/o heated humidity. I tried w/o any humidifier and w/a passover humidifier and just couldn't tolerate it. I had to have a heated humidifier.