DME and Machine Upgrade

[Sillyme]

I called my DME yesterday and insisted on an upgrade to a CPAP that has data feedback and C-Flex so that I don't have restricted breathing when I exhale thru the nasal cushion. I've had it for less than a week and have been 100% compliant from the first day but it forces me to mouth breathe and last night I woke up completely more than a dozen times with a severely dry mouth even though the humidifier was on high. They insisted that they chose the machine based on my neuro's Rx and that it is a standard model. I offered to pay extra out of pocket but they said that Aetna may not allow that. It seems most everyone else on this board is able to see their AHI and leak rate. Am I being unreasonable or did everyone purchase their own machine without insurance? The tech who fitted me said it was leased from the company and I would own it in time. I'm expecting a call back today and I have a hard time being obnoxious unless I know I'm in the right.

[LinkC]

Talk your Dr into writing a 'script that specifies the machine you want. Neither your insurance nor DME can argue with that.
Another option for the 'script is to state "machine and mask of patient's choice" on it. Then they must provide whatever equipment YOU want.

For me, all it took was a phone call and they faxed a new 'script to the DME while I waited. I even upgraded myself to an Auto once I got the new "patient's choice" script!

The "rent to own" thing is pretty standard with CPAPs because the compliance rate is so low. A lot of ppl quit after the ins co has paid the whole amount up front. Usually the cost is spread over 10 mos or a year.

[Sillyme]

For me, all it took was a phone call and they faxed a new 'script to the DME while I waited. I even upgraded myself to an Auto once I got the new "patient's choice" script!

Thanks so much. That's exactly what I needed to know!

[Emilia]

If your insurance is an HMO, believe me, they can totally ignore the wishes/Rx of your doctor. Been there, done that.

[LinkC]

I suppose they can if you ALLOW them to break the law...

[Emilia]

LOL..... well, if I had months to play their games of appeals and letters going back and forth, only to get to the end, and they have the right to refuse due to their medical review rules and regulations and fine print. But, when you are exhausted, suffering from brain fog, and want therapy NOW, it just isn't reasonable to do all that. And they know it.

For each Rx my doc wrote, with specific machine, pressure, DAW and all..... they had fine print reasons for rejecting it. Auto was denied based on medical review 'guidelines' that said Auto was only allowed for Central Apneas, of which I did not have. EPR was denied based on medical review 'guidelines' that said it was experimental treatment that was unproven. Believe, me they have their butts covered legally.......

HMO's are a different animal.... absolutely no out of network vendors were permitted. So, I bought my own machine. They do provide my supplies, though.... at least I get that much out of them.

[Amigo]

...

For each Rx my doc wrote, with specific machine, pressure, DAW and all..... they had fine print reasons for rejecting it. Auto was denied based on medical review 'guidelines' that said Auto was only allowed for Central Apneas, of which I did not have. EPR was denied based on medical review 'guidelines' that said it was experimental treatment that was unproven. Believe, me they have their butts covered legally.......

So sorry to hear you're stuck with the "HMO from Hell," and that they can totally ignore a physician's orders.

Have you complained to your employer about their unethical practices, or will that just cause other problems?

[Emilia]

Actually, my HMO isn't from hell....but the crazy DME middleman they use, called EMP, is! I have had nothing but good experiences with my health insurance...through illness, major surgery, and being able to see specialists without a PCP referral. When I got to this dx, and had to use a DME for the first time ever, it was a whole other world. I am insured by my former employer; I am retired, and will keep whatever insurance they offer current employees until I reach Medicare age so I don't have a lot to say about it. I have come to peace with this issue....and in some ways, I am happy to not have them breathing (no pun intended) down my neck about compliance, etc. I own my own machine with the features I want and will monitor my own data. My sleep doc is 110% supportive of my decision, and he will check my data reports every 3 months to monitor my therapy. That is good enough for me!!

[jmcd]

Prior to getting my script I researched machines and decided what I wanted. Aetna is my insurance carrier too. In reading user reviews, considering the amount of business travel I do, and being a bit of a tech nut I wanted the best machine out there. I had read somewhere that your DME (are you using Apria?) charges your carrier the same price for the machine regardless of what machine you get so they tend to try and give you a less expensive machine. Don't know if that's true but it sounded reasonable. When I met with my sleep doctor to review the results of my sleep study I asked him to specify the Resmed S9. He kind of looked at me like I was crazy and said he's never had a request for a particular machine but he was more than willing to add it to my script. I had no trouble getting the machine and mask I wanted. The doctor prescribed the same mask I used in the study which I really liked but did leave it open for substitution. The RT at Apria said that I can order any mask at replacement time and Aetna will cover the cost. Same thing with tubing. I can get the regular tube or the heated climate control tube.

I've only been at this for two nights but so far I like the machine. Good luck.

[Amigo]

...
For each Rx my doc wrote, with specific machine, pressure, DAW and all..... they had fine print reasons for rejecting it. Auto was denied based on medical review 'guidelines' that said Auto was only allowed for Central Apneas, of which I did not have. EPR was denied based on medical review 'guidelines' that said it was experimental treatment that was unproven. Believe, me they have their butts covered legally.......

Actually, my HMO isn't from hell....but the crazy DME middleman they use, called EMP, is! I have had nothing but good experiences with my health insurance...

I'm confused. You said, "they had fine print reasons for rejecting it."
I assumed you were speaking about your HMO, since the DME has no authority whatsoever to "reject" what is written on the prescription.

It appears the HMO is pulling the strings here, and your holding them in such high regard is very puzzling regardless of your other "good experiences."

[Hospiceangel]

Sillyme,

They insisted that they chose the machine based on my neuro's Rx and that it is a standard model. I offered to pay extra out of pocket but they said that Aetna may not allow that.

I have Aetna insurance too and I ended up with a PR auto with aflex, no questions asked. Check with Aetna~they told me they didn't care what machine I got. They would pay the same rental regardless.
Hope that helps.
Shar:)

[Emilia]

OK.... let me try to clearer. EMP, the DME middleman, refused to fill the doc's RX and said they were not authorized to give me that 'type' of machine (auto/ flex) and that it needed to go back to BCBS for 'medical review' at which point they denied it. So, yes, it was the insurance company that denied it. However, I also realize these faceless 'reviewers' are probably in a dept. whose sole purpose in life is to save the company money. They sent me all the documents and the fine print with their rationale. They have their butts covered every which way.

So, when I said I had no problems with my insurance company, I thought I was clear in saying as far as the usual things folks use it for.... doc appts, illness, major surgery, and being able to see specialists w/o an referral (not very common w/HMO's). I've never had a problem with any of these uses. However, once dx'd with OSA, it was like stepping into another dimension of their company. This was the first time I had encountered any type of dismissal or argument over anything, and I've had this insurance for several years. I find it perplexing that when it comes to medical equipment, they put on the brakes, and say, whoa...you can only have the cheapest, most basic equipment available. It seems to me that if the codes and allowable rates are set, then what is preventing the approval is the contract between BCBS and EMP that is really the culprit.

Anyway...for me it is water under the bridge. I couldn't be happier owning my own machine!

[Janknitz]

HMO's are different, but MOST (not all) insurers in the US pay by HCPC's codes. HCPC is a billing code and there is ONE billing code E0601 for ALL CPAP/APAP machines (NOTE: BiPAPs, SV's etc are NOT covered under that code).

In most (not all) cases, insurers decide on a single allowable fee for ANY machine under the E0601 code--from the most basic straight CPAP non-data brick to the fanciest bells and whistles auto with everything. And generally, the contract with the DME says that the DME is allowed to charge you only what the allowable fee is for any machine under that code, and the insurer will pay the percentage they have contracted with you to pay.

It's important to understand this--the bill from the DME may say $2,700 for your machine, but in most cases your insurer's allowable fee will be a fraction of that--and in most case you are NOT responsible for the difference.

Capped rentals (renting the machine for a period of time, then it belongs to you) are common and required by Medicare (13 month capped rental period).

So what does this mean to you? The DME is going to try to give you the least expensive machine they have in inventory, because they get paid the same amount for that as they do for the fanciest machine--hence a much larger profit margin. But if your insurer works like most, it doesn't CARE what machine you get because basic or fancy, it doesn't cost them a penny more. It costs the DME more, so they are the ones who care.

And, of course, you should care. At the very least, you need a data capable machine to make sure that you have optimal therapy and to allow you to identify and solve problems that may occur.

So I'd suggest you take that Plus machine back and request a data capable machine and C-Flex for comfort. You may need your doctor's help to get a prescription that specifies those features and states that they must "dispense as written". If that DME won't cooperate, find a DME that will (check with Aetna to see if you are limited to particular providers) and end the relationship with your current DME.

You are going to be stuck with this machine for 5 or more years, and you have a right to have the best machine for YOUR needs, not the DME's pocket.