trying to get my ducks in a row

[cul8rv8]

Hello all, I have been reading on this site for a few months now, and finally signed up to tell my story and see if there is any advice out there.

First off, I had my sleep study done back in April. The sleep center sent my information directly to a local DME, but that DME is not used by my insurance, so they then forwarded it on to one that does work with my insurance.

At this point, I had no idea who any of these companies were that were calling me to set up appointments, so I refused, with good reason. My PCP also referred me to an ENT specialist to see if there was anything that could be done surgically rather than sleeping on a machine. It took me 2 months to get in to see the ENT, at which point he basically said there's not much he could do. Short back story, I broke my nose 14 years ago playing basketball in college, and after that I snore when I sleep. Looking back after reading about the symptoms of sleep apnea, I realized that I have basically had it since then but never realized it. My hope was that my nose could be corrected, and help with the issues, however the ENT stated that he could perform surgery that could help, but it would not be permanent as the tissue would grow back.

So I called my insurance company, figured out who these two DME's were, and have been working with the one that works with my insurance.

The DME told me I would be receiving the REMstar DS150. I immediately told them that I had been researching machines, and I wanted one that had advanced data capabilities, and was interested in an APAP machine. I felt the APAP would be better for me because I found it was difficult for me to breathe when I was first trying to fall asleep at the sleep study, and I like the idea that the machine will adjust to what you need. The machine that I asked the DME about was the IntelliPAP AutoAdjust Travel CPAP Machine, as I found the reviews on cpap.com very helpful and encouraging. The DME advised that they only sell the Philips machines, and that I would need a new prescription to receive an APAP. I then asked about the cost, and for the DS150 they stated it is a 15 month rent-to-own contract, my insurance would be paying half of the cost, I would be responsible for the other half, my portion coming out to $40 and change per month. I then advised that I knew exactly what mask I wanted, because it was the mask I used in the study and I was very comfortable with it, the Mirage Quattro Full Face Mask. They said it was a special order, but that was no problem. When I asked about the cost, it was covered 100% by my insurance. They also mentioned that I would need to pay $140 and change when I went in, this was the "setup fee." the "and change" was the same as my portion for the machine, so it sounded like a $100 setup fee and the first month payment.

At this point, I wasn't happy about the machine, but just went with it for now, figuring I can argue my case further when the time comes. I called my insurance company again to verify the information with them, at which point I found out the pricing was all wrong. Due to the costs from my sleep study, I have met my yearly deductible for insurance, so I would only be responsible for 20% of the cost, not 50%. Also, my insurance plan is a "POS" plan, which I have both HMO and PPO coverage. Because my PCP is under the PPO, the pricing is different than what I was given by the DME, who gave me the HMO pricing. However, the insurance rep gave me the breakdown, so I know what it should be. Basically for the same machine, I should only have to pay $16/mo. for the 15 months.

I also asked the insurance rep about buying the equipment out of network, such as from cpap.com. She stated that I would be responsible for 80% of the cost if I take that route, but she even was willing to admit that the insurance company makes it extremely difficult to get reimbursed because they want you to use one of their DMEs, as they require pre-authorization. So for simplicity's sake, I am figuring that this route would be 100% out of pocket.

So now I have my appointment for my "fitting" for my mask this Friday, even though my prescription has on it the exact mask and size needed. I'm not sure what that's all about, so I am trying to call the DME to make sure I'm not paying a dime for this appointment Friday. I have already researched and found there is one other DME here in town that works with my insurance company, so I do have another option as far as that goes.

So at this point, I plan on asking the DME what the cost would be for the REMStar Pro through them, since they claim they only sell Philips products. Though there aren't a lot of reviews on it, it does have features I like, such as the C-Flex (this was the one thing that really bothered me during the sleep study was trying to exhale). The other thing that I'm not sure about, but can't see why I couldn't do it, is ordering a mask through the DME. Since my insurance will cover the mask and supplies 100% if bought through the DME, I'm leaning towards that and then buying my machine itself through cpap.com since I likely will save money, depending on the monthly cost of the REMStar Pro. Of course, if they are still going to charge me a setup fee to get my "free" mask, then I'd rather spend a little more money somewhere else just so they won't get anything from me since they aren't willing to work with me to get what I want.

Most importantly, I want to thank cpap.com and this community for all of the information that has been shared on here. It has been invaluable! Had I not come across all this valuable information, I know I would be overspending for inferior equipment.

[GumbyCT]

I think you are on the right track. Getting the mask fit (DME) can be a HUGE help so go with that if you can.

[KC5cychris]

WOW that is the run around
I can sympithize with the process taking a while, it was 4 months for me.

here is a philips machine that is auto pap and data capable, PR System One REMstar Auto CPAP Machine

I am sure some of the more experienced folks will chime in as well. if you search the forum a bit there is a list of data capable machines the DME gets the same amount regardless of the machine you chose notice I said you chose sometimes you have to push a bit but you can get what you want.
My DME special order my setup and even had the Rep come down from Atlanta

the Adventure begins,
Welcome to the Forum
Chris

[Julie]

Just getting the right size is not enough sometimes. It's important that (at least for the first time) you get help with wearing it, whether or not to tighten up in one place or loosen in others, whether to wear it higher on your face (talking about micromms) or otherwise. You will, of course play with it at home too, but it's better to at least get the 'party line' starting out and then tweak it.

[6PtStar]

when I tried to get my ducks in a row this is what generally happens!!!!!



Jerry

[Janknitz]

Good work so far, but I have a few suggestions.

Your insurance company said they pay 80% but 80% of what? In most cases, insurance companies set an allowable charge for something like a CPAP machine. This means that even if the DME company charges $150 per month for the rental of a machine, but the insurance company sets the allowable charge at $100 per month, the insurance company is only going to pay 80% of $100 or $80. And in most cases, you only have to pay the remaining 20% of the allowable charge, or $20, NOT 20% of the $150 the DME wants to charge (or 20% plus the difference between $150 and $100). So you need to understand if that's how it works with your insurance company (and I bet a doughnut it does!). Furthermore, I never heard of a DME charging a "set up fee". I would run, not walk to another DME company--this one is wanting to rip you off.

Secondly, you should ask if the allowable charge the insurance company pays is for ANY cpap machine or if there are different rates for different cpap machines. This is important because a PR System One Pro (you are calling it a RemStar) is less expensive than a PR System One Auto, but your insurance company may cover both at the same rate, meaning your out of pocket costs would be the same whichever machine you choose. In that case, you should be asking for the auto instead of the Pro. You can always run the auto in CPAP mode, but you will have more flexibility with the auto machine if anything changes or you are having a problem and you want to run it in auto mode to see if you can figure out the problems].

Finally, while the PR System One machines are excellent machines, you should be able to get ANY brand or type of machine YOU want. You are paying for it (via insurance and through your co payment) and you are going to be stuck with it for 5 years or so, so get what YOU want. If they don't carry it, they can order it for you. That's what they are there for.

[cul8rv8]

As to the mask fitting, it just irks me that they want to do that, because I actually did the same thing at the sleep study. The mask I want is the same mask I used for my study, and the technician actually went through everything with me on it so I'm pretty confident and comfortable with it already. I explained this to the DME rep, but she didn't seem to care and said I still had to be fitted by them in order for them to place the order.

From what the insurance rep told me, because I'm already at my annual deductible, I pay 20% of the DME price. The big screwup here was by the DME, they should have contacted my insurance to get the approval, then provide the prices to me. Like I said above, she just quoted me the HMO prices, even though it will be through the PPO portion of my insurance. She actually said it was a good thing that I called them before doing anything because the pricing the DME gave me was for HMO. So when they submitted it to the insurance, it would have been denied, and I would then be responsible for 100% of the cost! You are correct, it is 20% of the allowable charge, hence why I have to clear that up with the DME because they gave me the wrong pricing. The insurance rep broke down what the cost should be based on the DS150, just so I am able to make sure the DME does give me the correct information. For the DS150, the DME charges $80.88 per month, so my payment should only be $16.18. Even at only paying that 20%, I can get a better machine from cpap.com. If they aren't willing to get what I want for a price I'm willing to pay, I will go elsewhere.

As to the setup fee, I don't quite buy that either, so that will be another big question. And just like you said, if they want to charge me that, I plan to walk away immediately. Like I said about the mask, if I have to pay a $100 setup fee even to just get the mask for nothing out of pocket, I'll pay the $175 price from cpap.com. I don't mind spending an extra $75 to make sure the DME doesn't get a dime.

As to asking the insurance company about what CPAP machines are acceptable, that is an excellent question. I will definitely be asking that, I had not thought of that before.

And I am TOTALLY ready to stand up for what I want, and if they aren't willing to get me what I want, then I will take my money elsewhere. Even if it means spending more out of pocket, I am willing to do that. One would hope that a company would take customer service serious enough that they would be willing to do whatever needed to get you to buy from them. If they aren't willing to get what I want, then I'm not willing to give them what they want ($).

[Janknitz]

Just a guess, but does this DME company's name starts with an "A" ends with an "A" and part of it rhymes with "crap"? They seem to be insisting on these "mask fittings" now.

[jdm2857]

Still, these mask fittings beat being told that if you open the mask package to try it on, you own it.

[cul8rv8]

actually, no. It's Preferred Homecare.

And that's a good point about the fitting. If I hadn't gone through the whole process once before, I'm certain I would be all about it. That being said, I'm also not totally against going through a fitting, as it certainly is a good idea. I'm more irked about the fact that the woman on the phone didn't want to listen or seem to care about the fact that I basically went through a fitting already. She just blew off the fact that I was explaining this fact. It's more about the customer service than the process of getting fitted. She couldn't give me any good reason, she just acted like she didn't even listen to a word I was saying.

Let's just say that so far I have been completely unimpressed with their customer service, and I'm not even a customer yet. They just seem to figure I'm going to be a lemming and do whatever they say, pay whatever they say, and they don't care at all. Having to do customer service all day at work as a phone network engineer, if I acted the way this woman has acted with me, I wouldn't have a job for very long. Not to mention the fact that if I call and leave her 3 or 4 voicemails over the course of a week, she never calls me back. When I actually call and speak with her, she just says, "oh yeah, I got your messages." So you got my messages, but you don't call me back?

I've already left a message with one of her co-workers (since nobody else can help me but her) that if I don't get a call back before my appointment, I will be cancelling and will take my business elsewhere. That was this morning, and I never got a call back today. I'm not holding my breath for tomorrow, either.

It's funny, the more I type and talk about this, the more upset I'm getting about the whole situation. First thing in the morning I think I will call the other DME my insurance lists here in Vegas and see what they can do for me. That being said, I'm not holding my breath on that one, either, since when I do a Google search for that company, it comes up as a sub-page on my insurance company's website.

[GumbyCT]

Let's just say that so far I have been completely unimpressed with their customer service, and I'm not even a customer yet. They just seem to figure I'm going to be a lemming and do whatever they say, pay whatever they say, and they don't care at all. Having to do customer service all day at work as a phone network engineer, if I acted the way this woman has acted with me, I wouldn't have a job for very long. Not to mention the fact that if I call and leave her 3 or 4 voicemails over the course of a week, she never calls me back. When I actually call and speak with her, she just says, "oh yeah, I got your messages." So you got my messages, but you don't call me back?

Welcome to this sleep apnea world where it is ALL about the money and you are just an obstacle to getting the money.

You are getting your homework done - good deal. Keep in mind that (within 30 days) if your mask gives you trouble - you can get a replacement at no charge to you. Be sure to ask your DME about that.

Keep doing your homework - you won't be disappointed.

[cul8rv8]

Well I have officially given up on the DME. They claim they cannot waive the setup fee. They will not give me any other machine other than the DS150 without a prescription for a specific machine. And since I'm a PPO user and not an HMO user, they have to start from scratch just to give me a price. Based on what they have already given me and what my insurance tells me, it would be the $100 setup fee, $100 for the humidifier, then $16/mo for 15 months for the machine. Granted the mask is covered 100%, but that's still $440 for a bottom end machine, when I can spend less for a better machine on my own. I flat out told them I would not accept any machine without advanced data features, easy to transport (as I travel), auto altitude adjust (at least once a year I travel to Denver), and it needs to be a quiet machine. I told her I would like an adjustable machine rather than just straight CPAP, but that is not on my required list. She basically said she can't do anything of the sort unless I have a prescription that states I need these other features. I also asked about simply purchasing the mask through them and buying my machine elsewhere, to which she stated is also not possible. It comes as a package deal. I hung up and don't really care if they ever call me back or not, I'm done with them.

I haven't called the other DME in town yet, but after today's debacle with the first DME, I'm not hopeful at all. I will be calling my insurance company again to verify everything I need to do in order to buy the equipment on my own, and flat out let them know their DME was not helpful in any way. I would have loved to work with the DME because monthly payments would certainly be easier on me than paying the full amount up front then waiting for a reimbursement for part of it down the road. But when they aren't even willing to listen to the customer, it's not worth it.

[brazospearl]

cul8rv8, you're very wise! These people are NOT the ones you want to be dealing with. They told you outright lies because legally a prescription that says cpap and gives a pressure can be used to purchase ANY cpap at all. I hope you have better luck with the next DME, but if you don't please know that cpap.com knows how to do business.

[SleepyRae]

We are dealing with the exact same thing. I am also using Preferred Homecare, I imagine it's the same office. I was given pretty much the same story, except that the lady told me that NO machines EXIST that will give you any data. I have already paid and received my DS150, but I am desperately trying to get them to take it back. They have not returned my calls or emails either. Next is to go down there and practically leave the machines on their front porch. Good call not going with them; I've had nothing but run around and trouble!!

[Janknitz]

cul8rv8, you are doing great! Going by numbers if you are going to do a PR machine, the autoset is DS550.

You might want to give the other DME you are authorized to use through your insurance company a call, just to see if they treat you any better, but if not, and you can afford to take the risk of the full online price, go for it! You can still get your masks and other supplies which are covered 100% from the other DME--there is no such rule that you have to buy the machine to get the mask from a particular DME, Preferred Homecare just wants to sell you a cheap machine at maximum reimbursement and make more money off of you. And as you can see from SleepyRae's post, they are totally willing to lie.

I was given pretty much the same story, except that the lady told me that NO machines EXIST that will give you any data.

SleepyRae, call your insurance company and tell them you want to return the machine to Preferred Homecare and use another DME because they are treating you poorly. Find out from the insurance company how you can do this--don't let Preferred Homecare tell you if you can or not.