The Good, The Bad and the Ugly

[Midnight Son]

I had posted an earlier thread about confirming equipment selection for a new user. It ended with a "final update" in which I followed the recommendations of rested gal in getting started with therapy using a prescribed Remstar Pro 2 w/ Cflex and Heated humidifier versus waiting to see the sleep doc April 14 and getting a prescription for a Remstar Auto w/ Cflex. I thought that was the end of the story but... (This may be helpful for other new users getting started on CPAP)

The Good: I had 7.5 hours of restful sleep last night, my first full night at home using the CPAP Equipment. This is better than good, it is GREAT and the first restful night of sleep I have had in a long time. javascript:emoticon('Very Happy')
Very Happy

The Bad: Yesterday I had my appointment with the DME, to receive the Remstar Pro 2 w/ CFLEX, heated humidifier, Mirage Swift Nasal Pillows, Chinstrat, etc (see earlier notes). Earlier in the day I called my HMO to confirm the coverage for the equipment.

Bad #1: Despite being previously told my HMO covers the equipment, yesterday I learned the "conversion HMO coverage" I have requires a 50% co-pay. Not the end of the world, 50% is better than nothing (or so I assumed), I just wanted to get clarity on what I would have to pay. javascript:emoticon('Rolling Eyes')
Rolling Eyes

Bad #2: When I arrived for my appointment lo and behold the unit being provided was not the Remstar Pro 2 w/ CFlex, Smart Card, etc, it was a bare bones Remstar Plus. No monitoring, no smartcard, no cflex (exhaust relief), etc. My prescription specifically called for the Pro model. I was told I had to have a different prescription to get the CFLEX unit, blah, blah, blah More later... javascript:emoticon('Twisted Evil')
Twisted Evil

UGLY: I had a very hard time pinning down the HMO and the DME on what I would be charged. Basic contract law requires agreement on terms, and I was not about to sign an open ended commitment for financial responsibility, without getting the details of what I was committing to.

That is where is got real ugly. javascript:emoticon('Evil or Very Mad')
Evil or Very Mad

For my 50% co=pay I was asked to commit to 15 months of rental payments at $65/month = $975.00 Supposedly the insurance company is also paying $975, for a total of $1,950.00. This was the cost for a machine (The Remstar Plus) that I can purchase on CPAP.com for $335 ($445 with humidifier). So, my 50% at $975 is twice as much as the unit costs.

I am a financial consultant, and understand the need for operating margins (overhead, staff, loaner equipment, respiratory therapist on staff, etc) but do not know of any other business with 440% markups.

So, I ended up getting the machine as a "loaner" while we sort through this mess. I spoke with the CPAP.com consultant last night and plan to order today the Remstar Auto Cflex unit (at my complete cost). The bottom line is I get a much better unit (from all the info here) at 25% savings from my supposed 50% covered costs for a much inferior unit. Go figure...

Even with the recent postings of last night by Derek on the potential benefit
of straight CPAP the unit will give me the option of running in this mode, and then occasionally using the auto mode to verify my setting (at 9cm) is still appropriate.

Lessons learned:

1) Don't assume the "expert" knows what they are talking about. Get educated yourself until you are conversant with your options, here or somewhere else. (specifically on Insurance coverage, Equipment choices, etc).

2) Question the costs. I have all the "billing codes", and the range of coverage rates quoted by my HMO. They made a big deal out of this.

3) Make informed choices. Don't assume the logical (ie having 50% coverage is "better" than no coverage at all). Not in my case.

Thanks again for the help and info sharing on this forum.

Midnight Son

ps. The good is really GREAT, the ugly is really ugly...

[Wulfman]

Midnight Son,

Sorry to hear you experienced what many these "hoseheads" have also experienced, but glad to hear you went in "well armed" with information from this forum.
It isn't hard to do the math (whether you're a financial consultant or not) on what's happening with this industry......cheapest for the most $$$.
As long as you've got your prescription, you'll be able to save a lot of money with CPAP.COM and get the equipment you want. And, it'll only take a couple of days to get it shipped to you.

Thanks for posting the lessons you've learned for others who are beginning on this journey, too.

Please keep us informed on how your progress is going.

Best wishes,

Den

[jthomas]

I have been conducting some of the same research and have realized that the cost of purchasing a cpap w/ins. versus with out is vastly different in cost.

I had started a new job and will begin on an ins. plan the 1st of April, I had been waiting to purchase the CPAP until my insurance kicked in, but after doing research with what will be my new ins. plan and some of the local CPAP providers, it is actually going to be cheaper for me to purchase the machine out right on CPAP.com.

I called several of the local providers to see how much it would cost for me to purchase the basic machine with a HH, I was quoted $2000, when I told them that I would be paying out of pocket they lowered it down to $875.
I am in finance as well and I understand the cost of ins. billing blah, blah, blah, but after some of the converstaions that I had with local providers, it made me understand why ins. costs are climbing and climbing.
When I would ask the local providers why they're equipment was so much higher than what I was finding on-line, they went on regarding service and how I would be consulted with trained nurses.
To me, working with some of the cpap.com reps, I would rather save the money and still feel like I was being consulted with people that know what they are talking about.

[sleepybarb]

Insurance for apnea and equipment varies widely. I have what is overall a good (and expensive) PPO insurance plan; but LIFETIME coverage for apnea is 2K, no matter what co-morbid conditions one has that may be exacerbated by apnea. As anyone whohas puchased cpap equipment this would not go far; and will go even less far when a DME is involved! So I've used most of this for initial sleep studies (of course I needed two studies because all of my symptoms showed up during the second half of the "split-study);" fortunately I was so annoyed by an unresponsive DME that I found CPAP.com and ordered my equipment directly from them. So now I put extra in the FSA to pay for masks, etc. I dont have the energy to argue the lifetime limit issue, although this one should be winnable given the number of studies showing benefits of apnea treatment.