Newbie Navigating the Medical/DME system

[eljorgito]

Hi everyone -

I'm new to CPAP but, like many others here, have found this forum and all of you to be simultaneously brilliantly helpful and wicked inspiring. Many thanks already, and more in advance. I have a few questions that I'd love ideas on below.

First, some context...

I don't have my CPAP yet - just did titration study about 10 days ago, so I'm hoping to get the Rx and DME referral this coming week (diagnosed with mild apnea). I'm excited to get on the machine - the one night on CPAP in the lab, with about 5 hours of sleep with the leads hanging everywhere, left me more energetic the next day than I remember being in years). I haven't actually seen the results of the sleep study yet... more on that below.

The tech summary report from my initial study showed:
- Resp. Events: mild to moderate OH and OSA
- AHI: mild to moderate
- severe snoring (my wife could have answered that one easily enough)

From everything I've read here and lots of research, I have a pretty good idea of what I want in terms of equipment (data capable, preferably APAP, travel friendly) I want. I travel extensively and internationally for work, primarily to developing world countries, and getting something that travels well is super important. I'm also a tech geek, so getting something data capable is super important.

My top priority is to get onto the CPAP therapy as soon as possible, though. It seems that I *might* be able to get more of what I want if I get the Rx from the sleep clinic and buy the equipment myself and work with insurance to get reimbursed, but it seems that would take longer than going through the standard process of having the Rx written and faxed to a DME, and getting set up with the DME.

I did call the clinic last week and spoke with the Patient care coordinator, and told her I wanted to be involved in the discussion about what to prescribe, the type of equipment I get, etc. She was friendly enough, but not super helpful. Here's what I got:
- they don't specify anything more than "CPAP, heated humidifier" on the Rx. everything else is between me and DME and insurance
- specifically, anything beyond standard CPAP (such as data capable, etc.) is beyond the scope of the prescription unless changing to BiPap or ASV
- what's "medically necessary" is what I'll get
- things like battery packs for travel don't fall under "medically necessary"
- the DMEs they work with provide only "quality" equipment the sleep clinic drs like (specifically either respironics or resmed)
- they send you to DME first and then schedule follow-up to discuss results. they do this to expedite getting you on therapy ASAP (which seems reasonable)
- she offered to set me up with an appt with the nurse practitioner I saw on my first visit before they send the Rx to the DME if I want, but the first available appt isn't for several weeks

So. Blah. This notion that maybe I should be a part of the conversation about my healthcare seems to be alien to her. Not surprising, and I'm not out to fix the system. If it comes down to it and I have to spend my own money to buy the system I want, I'll do that once I get the Rx.

Talked to an insurance company agent last week and she said CPAP is 100% covered, no deductible, both rental and purchase, in-network and out. I will have a list of approved DMEs from the insurance provider handy when I go to the "recommended" provider.

So here are my questions:
1. it seems that going with the flow and getting to the DME as quickly as possible is the fastest way to get to CPAP therapy. It's possible the DME won't suck and I'll get what I want, and if I don't I'll at least get on therapy and then can sort out what to do next. Does that sound like the best approach?
2. Does anyone have tips for getting what they want from their DME (assuming you can't get your dr to write a specific Rx)?
3. What questions should I ask the DME? (planning to have detailed conversation about returns etc.)
4. If I end up hating the sleep clinic my PCP sent me to and want to find a good sleep dr that will actually talk to me, are there any resources for finding a locally reviewed sleep dr? (other than asking my PCP, which I will also do)
5. Assuming out of network insurance coverage is 100%/no-deductible (which implies they'll reimburse me for buying myself) would it be just as fast to go to cpap.com or similar with my Rx and skip the DME altogether? If so, are there any downsides to that route?
6. what am I not asking/doing that I should be?

Again, many many thanks for any help anyone can provide... hoping to be on CPAP soon and able to help others here as I learn more!

Cheers,
-george

[jules]

and maybe out of network coverage is 0 % reimbursed

will they let you actually have the Rx in hand or are you going to have to fight for that?

is this an HMO?

[eljorgito]

and maybe out of network coverage is 0 % reimbursed

Actually the claim from the insurance CSR was that out of network is 100% covered as well. I've asked insurance co to clarify on that.

will they let you actually have the Rx in hand or are you going to have to fight for that?

Unclear so far, but that's a line in the sand for me. I will get the Rx in the end.

is this an HMO?

Nope. Insurance is CareFirst BCBS (I think Maryland - it's out of DC metro area and I'm out of state in Seattle).

[jules]

ah raining there yet today? it has been raining on the coast but then it rains here all the time (more than Seattle)

just this whole DME / internet vendor issue can be tricky with insurance

if you get permission to buy from a place such as cpap.com, then get that in writing - it is different than labs or doctors tests

[eljorgito]

68 and sunny in Seattle today. don't tell anyone...

yeah, whole insurance/DME thing seems tricky, annoyingly so.

[jules]

well if I can get the message out to the Seattle folks that it ALWAYS rains here, then we will have 5 weekends from hell in the summer that might be semi tolerable - but if they think they want to come to the beach anyhow, well, we still have 5 weekends from hell in the summer where we stay home and hide

I live in a tourist trap town out here, Ocean Shores. Pretty nice many months of the year but forget it during tourist season.

Do you have a PCP you can contact and have them write you the script for a machine? If you are buying from cpap.com (I do) you need a cpap script to buy an APAP for example. Read their statements about prescription requirements. You will get a receipt with the insurance codes on it as an attachment to an email but they will not help process your claim.

[GumbyCT]

1. it seems that going with the flow and getting to the DME as quickly as possible is the fastest way to get to CPAP therapy.

It typically takes a month....I know but that's what it seems to take. When you call the lab - they'll say they faxed it 3 days ago. You call the DME they'll say they haven't got it yet. Yep that's typical too.

Get the script "IN YOUR HAND", period! Then YOU can do what you want.

It's possible the DME won't suck and I'll get what I want,...

This is just a fantasy, my friend. Have you heard about the Smart Blonde?? She is the best RT in town....lmao

Does that sound like the best approach?

NO. see above.

2. Does anyone have tips for getting what they want from their DME (assuming you can't get your dr to write a specific Rx)?

A make/model specific prescription is THE best if you can't convince your DME to give you "the make/model" you want. Else, Try your PCP he "can write you the script". He may need coaching from you tho -so educate yourself here.

Get the list of DME's in your hand before you speak to the first one, so YOU know what your options are. If you don't get a warm feeling that means they are not p*ss*ng on your leg
What I'm trying to say is learn to trust your instincts here and if you even think things are rough in the used car business, well this is much worse. Go with your feelings here. Knowing you have other options WILL give you incredible leverage here. May I ask which Ins. Co. covers 100%?

5. Assuming out of network insurance coverage is 100%/no-deductible (which implies they'll reimburse me for buying myself) would it be just as fast to go to cpap.com or similar with my Rx and skip the DME altogether? If so, are there any downsides to that route?

The down side is mask fittings. You can usu. get that done at a sleep lab tho yours doesn't sound too friendly. Maybe there is another lab? Or DME where you can lay down with mask at FULL pressure. If you can't lay down while trying the mask, try another place, period. Your face WILL change shapes when you lay down "in your sleeping postion" - I don't care what the DME says.

Oh you better ask about buying online first. If they will that is a powerful option.

4. If I end up hating the sleep clinic my PCP sent me to and want to find a good sleep dr that will actually talk to me, are there any resources for finding a locally reviewed sleep dr? (other than asking my PCP, which I will also do)

At the top of every forum page there are icons - learn them. One is local Services. I think that might list some. If not, you do have Google, right? Google IS your friend!!

6. what am I not asking/doing that I should be?

"If this mask doesn't work for me - what is your policy?" ALL mask manufacturers allow the DME to exhange the mask within 30 days if it doesn't work for you. The DME has to do paperwork and the replacement doesn't have to be from the same manufacturer. IF your DME tells you they can't/won't do this for you....excuse yourself and take your money elsewhere.

Yes, your Ins. Co is paying with YOUR money.

You sound savvy enuff to be able to check if the machine will run on 12volts. Most will. And learn the data models so when they tell you "Oh this has data" it's Advanced Data you want - with AHI, leaks, etc. NOT just how many hours it was powered on. Search for links by Rested Gal - who has an extensive listing of data capable machines.

by George I think that That should keep you busty for awhile

Wishing you and everyone starting out the very best.

[brazospearl]

Welcome to the forum, and kudos for doing your research before you get your machine. If your wallet can stand it, just get the prescription and order from cpap.com--you'll get exactly what you want. Then you can deal with your insurance scoundrels, I mean representatives, at your leisure. This will probably be quicker and probably less expensive in the long run than trying to get your local DME to provide what you want instead of what they want to sell you. Mask fitting can be a little tricky when you're ordering online, but many of us make it work. You're off to a great start with your good attitude, the knowledge you've already gained from your research, and your willingness to ask for help. Let us know how things go!
Brazospearl

[eljorgito]

Awesome info, thanks. I found the "local services" icon pretty much immediately after posting... doh.

May I ask which Ins. Co. covers 100%?

it's CareFirst BCBS, but I'm not holding my breath on the 100% coverage bit. We'll see, but that's what the CSR said... I've now asked in writing, waiting to hear back from them.

You're right, plenty to keep me busy for a while getting ready to not get hosed. Thanks again!

[eljorgito]

Welcome to the forum, and kudos for doing your research before you get your machine. If your wallet can stand it, just get the prescription and order from cpap.com--you'll get exactly what you want. Then you can deal with your insurance scoundrels, I mean representatives, at your leisure. This will probably be quicker and probably less expensive in the long run than trying to get your local DME to provide what you want instead of what they want to sell you. Mask fitting can be a little tricky when you're ordering online, but many of us make it work. You're off to a great start with your good attitude, the knowledge you've already gained from your research, and your willingness to ask for help. Let us know how things go!
Brazospearl

Thanks! Good advice and if I can get confirmation from the insurance folks that they'll give me at least some of my money back, buying direct and getting them to reimburse me seems like a great way to go.

I used a nasal pillow rather than mask at the titration study and it seemed to work out, so less worried about fittings than for a mask.

[cpapqueen1]

some carefirst policies do cover 100%. Some of the carefirst policies also require preauth. Carefirst is a great insurance...you should not have any issues getting the equipment you want.

[rested gal]

Welcome to the message board, George.

You're doing your research great!!

My list of machines that record "full data" (AHI and leak info) and those that don't -- updated through March 2010:
viewtopic.php?p=307168#p307168

DME might not understand what "Full data" is.
viewtopic.php?p=344265#p344265

LinkC's conversation with his DME about data:
viewtopic.php?p=342111#p342111

[eljorgito]

Welcome to the message board, George.

You're doing your research great!!

Thanks!! You just answered another question I had before I even had searched for it (list of full data machines)... I have to say, I'm completely impressed by everyone here... the responsiveness and support is pretty awesome!

[mattman]

Howdy Howdy George -

You've already gotten a lot of great responses and information so far so I've not much to add except for a couple of things.

As you can imagine, there is a pretty wide range of experiences out there. For many people and many situations you are right - Sleep Lab/DME can be a very quick route. In a lot of cases it can be less than 24 hours after a Sleep Study that people have equipment in hand. In other cases sadly, it can take weeks. Of course this means it's impossible to say ahead of time what your specific situation will turn out to be.

The other major thing I'd want to suggest is to specifically ask your insurance company about reimbursing you for cash purchases you make yourself. Almost all insurance companies treat that VERY differently and don't consider that type of transaction as "out of network". I've only heard of 1 case where someone was able to purchase equipment online themselves and get reimbursed for it.

Also, be aware of another big difference. You spoke to your insurance company and found out they cover CPAP equipment 100%. This does NOT mean your insurance company will cover YOUR cpap. That's a big, big, big difference. Your insurance company will have guidelines that you have to meet to establish qualification for the device. Unfortunately just having a prescription is not enough. It varies a lot from Insurance to Insurance but it's things like having an AHI above 5, having specific diagnosis codes, etc etc.

The only other bit of advice I'd have is for your question about getting what you want from a provider would be to just talk to them. Simple as that. Talk to them. In many cases they can be a very helpful local partner. Obviously if you read around here there are certainly cases where they haven't been but there are also a lot of cases where they are. So if you find one that seems decent just go in there and have a conversation with them. Explain that you are very interested in being actively involved in your own treatment and so have some questions and some specific goals and see where it goes!

mattman

[Really]

If you find a local partner and go with a nasal pillows mask that comes with 3 sizes, for example. Beware that your local partner may just decide to remove 2 sizes before you get the package. Really!!

Some won't consider that stealing from you. Just because you paid for all of them. Really!!

The partner can rationalize it by thinking you don't need them and they could sell them again. So that makes it OK. Really!!

BEWARE