Prescription?

[joey777]

I have been having a time obtaining my medical records but tomorrow they are supposed to have them ready for me to pick up. (I did have to threaten them with HIPAA and a medical board complaint to get them) Here's my question which I think I know the answer already but I need your input. I switched from a Resmed S8 Elite to a Autoset II. I asked them for an update prescription for the Autoset and was told that I didn't need it, the original prescription for the S8 was the same thing. Now if this works like any other medical prescription that's not true. You couldn't have a scrip for an antibiotic and switch it to a controlled substance could you. I think not. In the end I just told her that I wanted to have my records as up to date as possible so I needed the Autoset one to match my current machine instead of arguing with her. At the end of the call she wanted to know if I was going to switch doctors. Of coarse I said I have no intention to do so. I have canceled the last two appointments already. I guess she don't get the point or maybe her intent was to send or not send my records to another doctor. Seen that one before

[GumbyCT]

I asked them for an update prescription for the Autoset and was told that I didn't need it, the original prescription for the S8 was the same thing. Now if this works like any other medical prescription that's not true.

The answer is both Yes & No. It really depends on how your DME wants to handle it, using the current prescription or just yank you around. I'll guess you'd get different answers from different DME's.

You would certainly be better off if the script stated exactly what you want.

[Slinky]

Insurances pay by code, not brand or model. All CPAPs and autoPAPs are considered CPAPs and HCPCS code E0601. (Bi-levels, SVs, etc are NOT this same code).

So, yes, technically, the desk dragon was correct, your Resmed S8 II AutoSet is an HCPCS code E0601. HOWEVER, many local DME suppliers will give you grief or try not or absolutely refuse to provide the higher priced autoPAPs and some even fight providing you w/a fully data capable CPAP such as the Resmed S8 Elite w/EPR, preferring to provide a bare bone CPAP or at most a compliance data only capable CPAP.

To avoid the hassles it is much easier on you as the patient if your equipment order (script) clearly states which brand, model, pressure settings and humidifier as well as "full face, nasal cushion, nasal pillows or "hybrid" mask of patient's choice".

That gives the local DME supplier NO WIGGLE ROOM on what equipment you are to be provided with AND gives you, the patient, the opportunity to try the various style masks and select the one YOU want.

[GumbyCT]

Cliff Notes provided by Gumby

and that Slinky sure knows her stuff. Think I'm a pain to deal with? ha

So - Yes or No what's it gonna be? (Meatloaf)

[joey777]

My main concern is if I wanted to purchase another unit online or from a different DME they would give me only what was written on the scrip which right now is a straight S8 elite not AUTO. Not so much for insurance codes. So the question is ...when I pick up my medical records tomorrow and if the new scrip is not present should I make a stink about it. I'm ready to do so if need be.


BTW.. My DME is my doctor.
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CPAPopedia Keywords Contained In This Post (Click For Definition): DME, auto

[Wulfman]

My main concern is if I wanted to purchase another unit online or from a different DME they would give me only what was written on the scrip which right now is a straight S8 elite not AUTO. Not so much for insurance codes. So the question is ...when I pick up my medical records tomorrow and if the new scrip is not present should I make a stink about it. I'm ready to do so if need be.


BTW.. My DME is my doctor.

Now THAT is scary!

When purchasing machines from an online seller (like CPAP.COM), you can get either a straight CPAP or an Auto (APAP) with a plain CPAP prescription.
On the other hand, if your prescription says APAP/Auto, you can only buy an APAP/Auto with it. (this could be a disadvantage if you already had an Auto and wanted to get a straight CPAP for a backup or travel machine)

With local, brick & mortar DMEs, you're probably not going to get much beyond what your prescription says. You MIGHT be able to upgrade from a "dumb" CPAP to one that is data-capable, but getting an Auto without it being on the prescription might not happen. Just depends on the DME and your insurance provider.

Den

[mikesteg]

That is scary...

I'm a bit confused/curious: why would the DME not want to sell you the most expensive machine the insurance company will pay for? I'm sure profit margins vary, but it seems like a higher price tag would generally result in more profit. (For that matter, it seems like they'd be willing to sell you more than insurance would cover as long as you're willing pay the difference.)

BTW, I'm a newbie here. My wife has an S7 Lightweight and a Breeze w/nasal pillows.

[GumbyCT]

BTW.. My DME is my doctor.

So the plot thickens...
What do YOU think he is interested in selling to you? At an overinflated price!!!

[Wulfman]

Not only is it scary, but it might be a problem for some in the future. I finally found the thread (from a few days back) that brought up the proposed rules.

viewtopic/t32613/Medicare-proposes-not- ... -xPAP.html


Den

[jnk]

Just as an example of how a DME can try to misuse a prescription . . .

My DME once told me over the phone: "According to your prescription, you have been prescibed 'nasal bipap,' so you aren't allowed to use a full-face mask, only a nasal mask"! She said that, in spite of the fact that the sleep doc had listed one or two full-face masks as possibilities at the bottom of the scrip!

I said. as calmly as I could (not very; I'm a redhead): "You and I both know that 'nasal bipap' is medical wording for noninvasive PAP therapy, not specifying a kind of mask. If you'd like to me to call my sleep doctor to tell him what you just said to me, I'm sure he'd be glad to explain that to you in further detail."

I don't know whether it was greed, dishonesty, or mere incompetence that was the motivation for that DME person's words, but I tell that story just to show the wisdom of Slinky's words:

To avoid the hassles it is much easier on you as the patient if your equipment order (script) clearly states which brand, model, pressure settings and humidifier as well as "full face, nasal cushion, nasal pillows or "hybrid" mask of patient's choice".

That gives the local DME supplier NO WIGGLE ROOM on what equipment you are to be provided with AND gives you, the patient, the opportunity to try the various style masks and select the one YOU want.

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, humidifier, DME, Nasal Pillows, Prescription

[Wulfman]

I can see the point when dealing with a local DME, but the problem that may come back to haunt you is that if the prescription is TOO SPECIFIC, what happens when the manufacturers quit making a certain model of XPAP machine or mask? One would then have to go back to a prescribing doctor and get an updated one (read that....PAY for one) or the DME wouldn't be able to give you anything. And what happens if you no longer have a "relationship" with your sleep doctor or you've moved to a different location or the sleep doctor is gone, too?

Your XPAP prescription is (theoretically) good for your lifetime.

I prefer mine as "generic" as possible.


Den

[jnk]

Wow. I hadn't thought of that apect, Wulfman. Good point.

When I told the sleep doc about the conversation I had with the DME, he volunteered to solve the problem I was having by writing a seperate prescription for any specific mask I wanted, no charge for the scrip. He wrote one for the mask I wanted, even specifying the size I suggested, and volunteered to fax the scrip wherever I wanted it faxed.

Maybe the trick should be to get two versions of the scrip--one generic for the future and one specific for the present, if the doc is willing to give a twofer, just to cover all the bases.

[joey777]

Very interesting. But now I don't know which way to go! Well come to think of it I have the original scrip that states the S8 Elite model. If I get the new one written for the Auto I could get both but why would I want the Elite? My insurance pays the same for either and the autoset can also run in the CPAP mode. Good point about the availability of a specific machine though. That would be a problem if they stopped making it. I know in the eye field a generic type scrip would not do. It would be illegal to substitute a different lens for another.

I thought I could go into any DME and order a humidifier as well as "full face, nasal cushion, nasal pillows, hose anything but a CPAP machine without a scrip. Am I wrong about this? Do I need this scrip in addition to the other?




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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP, auto

[jnk]

joey777,

Please don't let my "hijack" posts throw you off. My problem was that the DME tried to use the wording of my scrip against me, so I needed to push back by getting my doc to prescribe some specifics. I only mentioned it as an example of problems with the wording of prescriptions and dealing with DMEs. If your DME is your doctor, you have a completely different set of problems, but perhaps some nice advantages, too, depending on how you work it.

In general, as I understand it, the prescription from the sleep doc is for the therapy. The specifics on which equipment you get are generally left up to the DME who gets its money from a person's insurance. But the insurance will often pay a certain price to the DME regardless of what equipment the DME gives you. That makes it the goal of some DMEs to give you whatever is cheapest for them, so that they maximize profit (just good business), or to give you whatever they happen to be overstocked with (just good inventory management). So it can be useful in some cases to have the doc mention specifics if you need ammunition to deal with a DME that is uncooperative in giving what you need. In your case, you can't play the same guy against himself, since apparently he is writing instructions to himself.

Humidifiers are often mentioned in the prescription by the doctor in order to keep an insurance company from refusing to pay for it. But you don't usually need a prescription to get a humidifier, hose, mask, or anything else. It's only a matter of getting the right stuff and having a way to pay for it.

The conflicts of interest of all the parties involved in any situation means that you as the patient have to have enough information to know what you need and how to get it and how to get it paid for. That means searching these forums and then figuring out what it all means as far as how you deal with your doctors, your sleep techs, your DME, your insurance, and your sanity.

This is the best place to get good suggestions along those lines. I just don't have any myself.

jnk

[Slinky]

Insurances don't contract w/local DME suppliers by brand and model. The contract by HCPCS code. They pay ONE PRICE for that HCPCS code.

You know, you can always have your family doctor write your equipment order. If you can get your sleep doctor to script the exact macihine you want - great! Then you can have your family doctor write you a generic CPAP script for use w/the online DME suppliers so you can get whatever you want from them.