Insurance, my DME, and S9

[ecocyber]

Larry, I used to own a DME and am real familiar with insurance billing issues. You are correct in you suspicion that the DME is looking primarily at his bottom line. He has to make a reasonable profit in order to pay the bills and service his clients. My guess is that the insurance hasn't enough codes to cover the breadth of devices available. That is not the DME company's fault, it is the fault of the manufacturers not going to the insurance company and lobbying for a new code to cover the added features (and cost) of their newer devices. The DME only has the established codes to work with. I don't want to debate what a reasonable profit is because that is another issue all together. Lets not open up that hornets nest.

Let me explain how you might be able to get around this problem. I would talk to your sleep specialist and your DME company and see if they would agree to put the necessary written justification together for the newer device. Then the DME company can petition the insurance company to pay using a non-specific miscellaneous code (usually something like E9999 or something like that). Every insurance company has such a code to permit the DME to justify payment for something that doesn't fit into the established codes. Assuming your sleep specialist really feels that the S9 has some feature or capability that the other device doesn't, he could put a case for it in writing. It will take some extra time by your doc and by the DME, but it is a legitimate way to get the more expensive device paid for.

Another way you might pursue this is to have the DME investigate exactly how much more it would cost him above and beyond what the usual allowable is from the insurance company. Your DME could bill your insurance on an unassigned basis and then send you a monthly bill to cover the co-payment and the extra cost of the device divided into 13 payments. Essentially, the DME would then be passing along the extra cost to you. Not as appealing, but it is a possible avenue to explore. The extra cost to you on a monthly basis might only be $10 or $20.....it all depends on how much extra the S9 costs the DME. The only caution with this approach is that your insurance may not pay the DME as much when billing unassigned as if the DME billed taking assignment. You would have to check into that with your insurance company.

I hope this gives you some perspective on what might be possible. Good luck. I hope you end up getting the device that will give you the best therapy.

[dtsm]

dtsm
I am hoping there will be a few S8 Autoset IIs
available at unheard of low prices soon
DSM

I think many of us hoping for same

[Slinky]

I've only been around since 2006 but I think I'm seeing a trend here. I was around when the M Series was introduced, I was around when the S8 series was introduced, and the S8 II series and then the SystemOne series and now the S9 series - ooops plus the introduction of the IntelliPAPs and the new HC fully data capables - and the Sandmans for that matter tho I've heard little promotion of them.

The trend I am seeing is the introduction of a new series of xPAPs, the manufacturer Reps get really busy making the rounds of the DMEs and a lot of new users start showing up in the forums w/the new series xPAPs. That tells me that when the manufacturers are introducing a new series they give their sales Reps the ability to offer some really good bulk prices to the local DME suppliers.

[Satsleep]

Thank you Ecocyber for the information regarding how to deal with the DME and the insurance company. I was hoping someone with experience in the area would provide insight in to how this all works. I have some follow up questions which I hope you or someone else can address. I understand there is just one insurance code for CPAP and APAP. I also understand there is a wide range of costs to a DME for machines. I have been told that the insurance will pay the same irregardless of the cost of the machine to the DME. Is this true?

If true, then the insurance company does not care which machine the DME furnishes, correct?

As I believe Ecocyber states the machine to be furnished is a business decision by the DME (as long as it meets the prescription), correct?

If all of this is correct, then Ecocyber your suggestions are ways the DME might get more money from the insurance company and thus make the machine fit within the DME's business plan for profit off each machine, correct?

If all of this is correct it also implies that shopping DME's might be a good idea as each one might have a different profit margin. It also means the focus of negotiation in the first instance should be with the DME to see if they will accept less profit.

Finally, is Medicare's position on this the same as the insurance position outlined above or is it different?

Thanks again for helping me understand this relationship between insurance and a DME.

Larry

[dtsm]

The trend I am seeing is the introduction of a new series of xPAPs, the manufacturer Reps get really busy making the rounds of the DMEs and a lot of new users start showing up in the forums w/the new series xPAPs. That tells me that when the manufacturers are introducing a new series they give their sales Reps the ability to offer some really good bulk prices to the local DME suppliers.

In the human health care industry, eg pharmaceuticals sector in particular, we call it 'sampling'. Give the docs a ton of samples to give away free to their patients, tell them it's the latest new drug (when it's usually not a break-through but merely a reformulation), and a couple of months down the road, 'paid subscriptions' are being filled like crazy at the pharmacies. That's how the generic business was built, and that's how we'll get 'older models' at heavily discounted prices.

[BlackSpinner]

I would never buy the latest mechanical or electronic toy on the market. Let others find the problems first. Models go out for sale when the sales staff want it to hit the market - not when the designers/ developers feel they have totally debugged the item. I have been in this boat so many times with software I wouldn't want to be on the receiving end.

Never buy the newest of a product line whether it is cars, phones, computers, software or medical equipment - let some else be the beta tester.

[Slinky]

Your assumptions are correct, Larry, and, yes, it applies to Medicare as well. Medicare is my primary and then I'm fortunate to have a good secondary health insurance as well.

[rested gal]

Rested Gal and DTSM, Why would you choose the S8 over the S9? Is it because you do not like the features or is there a therapeutic reason?

Larry

For me, it would be the features. I expect I would get just as good therapy with an S9 as with the S8's I've used.

I already have a separate heated hose I can use with any brand/model of machine. And a separate humidifier I can use with any brand/model machine. Both of those work great for me. I prefer those as separate, as opposed to integrated and proprietary.

My main reason for not liking the design of the S9 is the knob to go through the S9 menu, instead of using buttons (S8.)
I also don't like having the air hose connection on the back instead of the front.
Don't like the shape as well as I like the S8's.

As others have mentioned, I like "tried and true." Others are welcome to work out the bugs, if any. I don't know that there will be any glitches that will turn up in the S9's -- but if there are, they won't be plaguing me!

[ecocyber]

OK Larry, I think you have it pretty much nailed now as to how to approach the DME's. I have BS of CA PPO and they currently allow two codes for xPAPs as I understand it. The first is for anything but a Servo Ventilation type and the second is for only the Servo Ventilation types (like my BiPAPautoSV Advanced). This is way too few codes for the breadth of devices on the market imho.

And, you are correct in saying that Medicare operates pretty much the same way and has the same rules. In fact it is the other way around with most private insurances....they adopt the codes and sometimes the allowables set by Medicare.

The insurance companies don't care what device you are issued under each separate code. But I am sure they would rather you not get the Servo Ventilator types because the costs are over twice the other types of xPAPs. They will pay a percentage of the allowed amount for that code. Not a penny more. No mater which device you get.

And yes, I think you would be wise to "shop around" for a DME provider. See which of them will get you the device you want and need no matter what the cost is. Some DME's are very flexible about this if the order for a device comes directly from your Sleep Specialist. You see, the DME lives and dies by referrals. And to keep a good referral source (like your Sleep Specialist) happy and sending lots of referrals to him; he will sometimes provide something at a loss, just to keep the specialist happy. Believe me, this happens a lot with busy Sleep Specialists that see a lot of patients and make a lot of referrals. So, try having your Sleep Specialist call up the DME and place the order for the more expensive device for you. And tell your Sleep Specialist beforehand that you really need his or her help to get you the more expensive device. If the specialist really believes you need the more expensive device, they will go to bat for you.

Please let us all know how this all turns out. Best of luck to you.