Newbie-Senior & Insurance-Any Seniors Share Ins. Woes.

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 10:19 am

Hi....Newbie just about to get equipment from DME or cpap.com or whomever. Medicare doesn't okay auto cpap....they will only let you rent - basic cpap. I would like to buy/own my equipment....I'm willing to pay the differential, however, I don't know if Medicare will even allow me to submit asking for an auto machine.... In an ideal world I would purchase Respironics REMstar C-Flex Auto CPAP w/heated humidifier (doc's prescription indicates cpap w/heated humidifier 13 cm H20)... I'd like to monitor my progress with software (I heard ins. will not pay for that).... I'm wondering if my only choice is to buy outright and bite the bullet re. cost??? Any Seniors out there up against this when buying equipment for the first time? I have a call into cpap.com, too, and will ask them how to handle getting desired equipment....like others, I want compliance and comfort and want to see results through the software, etc... Help!!! Thank you.

johnnygoodman · Post by **johnnygoodman** » Tue Apr 18, 2006 10:28 am

Hello Gaspy and Welcome!

You need to call CPAPForSeniors.com at 1-877-258-7581. They accept Medicare as payment and will give you the Respironics REMstar C-Flex Auto CPAP w/heated humidifier if you are in network with them.

Local providers can't give you autos because they can not afford to, but CPAPForSeniors is a website and passes the lack of overhead on to you in the form of better quality equipment.

Good luck!

Johnny

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 10:54 am

Johnny, thanks for your input. I called cpapfor seniors and they informed me that the prescription must show the doc ordered an auto cpap....medicare will not accept it otherwise....my doc wrote the prescription that says it is absolutely necessary to add heated humidity for effective treatment of my sleep apnea, however he also wrote 'Start CPAP @ 13 cm H20 press. with heated humidity and supplies'.... they must be emphatic about auto cpap vs. straight cpap... I may have to get him to rewrite the prescription, but docs are funny about a patient advising them..... know what I mean???

Wulfman · Post by **Wulfman** » Tue Apr 18, 2006 12:36 pm

According to this document from Respironics website (if I'm reading it correctly), an APAP is qualified under Medicare as an E0601 CPAP device.

http://www.respironics.com/download/dow ... CMS2%2Epdf

Gaspy,

It seems to me that you should be able to order an APAP by having it set up as a CPAP with that pressure setting. What you do after you get it home is your business. Since an APAP has multiple modes, having it configured as a CPAP should be acceptable to Medicare.
Maybe you need to call "CPAP for Seniors" again and rephrase your request.

Ask them if you can order this item by part number: 1017476 (REMstar Auto C-Flex CPAP, REMstar Heated Humidifier with bag, hose and manuals) rather than by NAME and have it set up as per your prescription.....and whether it can be billed to Medicare that way.

Den

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 12:53 pm

Thanks, Den. I'll try it.....it's sure worth checking. Hopefully they will accept that. Seems as though they get very picky about what the doc has on the prescription.....and the docs seem reluctant to write prescriptions for the auto when it does so much more and seems more acceptable for compliance. I'll let you know what they say....thanks again..... Gaspy

johnnygoodman · Post by **johnnygoodman** » Tue Apr 18, 2006 1:26 pm

Greetings,

On the cash side of the CPAP world (CPAP.com) you can get an APAP with a CPAP Rx. This is because logic and dollars rule. The APAP can function just as a CPAP so it fills the Rx.

On the insurance side, you have logic and you have insurance company policy. If you don't meet both, the claim will not be paid, which is unacceptable to any company accepting insurance in exchange for CPAP equipment. Policy states that an APAP must be prescribed in order to be provided. There are two ways around this: #1 Buy from CPAP.com for cash (and their walk away or fight the insurance company yourself) #2 Work with CPAPForSeniors.com to ask your doctor to prescribe an APAP. Most doctors are smart, reasonable people. Prepare your case, explain that an APAP can function just like a CPAP but with even more helpful features. Most doctors will gladly work with you. If they won't, find another doctor.

You have a lot of save by going with Medicare. If I was you, I would go down that path first.

Johnny

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 2:46 pm

Johnny,

Thanks for the time you've taken to help me better understand all of this. I will try going through Medicare as they will be the least costly, I'm sure. I will let you know how this all plays out. The healthcare office said I may just have to pay an upcharge if I elect to go with a better system than what the prescription indicates.....ever hear of that? Maybe it's the cost over what Medicare allows??? I may go see them and get things ironed out in their office.....then make a decision which is the best avenue to pursue.....will let you know.....again, thanks for all the help. Regards, Gaspy

johnnygoodman · Post by **johnnygoodman** » Tue Apr 18, 2006 4:05 pm

Greetings,

Some local providers do impose upcharges for better equipment. The advantage CPAPForSeniors.com offers is that you choose the equipment you want with NO upcharges. So they'll get Medicare to cover it PLUS save you the upcharge fee. That's why I'm so pro-CPAPForSeniors.com. They deliver the goods and charge only the standard Medicare rates.

Johnny

Wulfman · Post by **Wulfman** » Tue Apr 18, 2006 4:30 pm

Johnny,

I was wondering if my "logic" is correct in what I posted to Gaspy (at 1:36).
If it's billed to Medicare as a CPAP machine with the E0601 code (and falls in the pricing range), how much more does Medicare scrutinize it?

Just wondering.....

Den

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 5:36 pm

Den and Johnny.....I'm going to call the doc in the a.m. and see if he'll write a prescription for the auto....if he doesn't want to do that I think I'll go to the healthcare equipment group and see what they can do w/the script that he wrote....if I don't like what they suggest, Ill pursue something else. How would these two measure up considering what I would like to have in a unit? The M Series REMstar Plus CPAP w/Integrated Heated Humidifier (this has c-Flex, right?) and secondly, the REMstar Pro 2 C-Flex CPAP w/Heated Humidifier? The Smart Card will be available for the M Series, correct? And the Pro 2 has the Smart Card on board, doesn't it? Isn't the C-Flex a plus along the comfort line? And mainly, aren't these both considered CPAP's, which is what the prescription is written for - staying in line with the doc's written order? I hope I'm not driving you guys crazy.....I just hate to blow it on my first purchase of equipment that is so very important to my health and especially compliance. Thanks guys! Gaspy

fujiinator · Post by **fujiinator** » Tue Apr 18, 2006 6:53 pm

Both units have the C-Flex feature.

Both have the ability to adjust due to altitude although the M series is thru manual settings versus the Pro 2 is automatic.

Both have the smart card available although you need to make sure it is ordered as an option with the M Plus or you will not get the smart card. I am not sure however what the smart card will record versus what a Pro 2 will record. I sent in a request for information on the REMstar M plus today and may hear back about what it will record.

I have the M series with the humidifier and i really like its small size (about a third of the Pro 2 w/humidifier). My original choice was the Pro 2 Remstar, and my DME gave me the M plus which in comparision had the WANTED features and most of the wish to have features. I have been using mine for around 4 nights and I like the machine.

johnnygoodman · Post by **johnnygoodman** » Tue Apr 18, 2006 6:55 pm

Greetings,

Wulfman: APAPs and CPAPs do share the E0601 code. However, you can only provide an APAP if you have an APAP Rx. There is no wiggle room on this.

Gaspy: You are a new user asking a lot of questions and trying to figure out what works best for you. Thats great and exactly what you should be doing. We're glad to answer questions.

In terms of the Respironics Line, remember that the new M Series line is being rolled out now. The Remstar line is the old one and is still a good line a CPAPs. From low end to high end it goes like this:

Lite (very basic model, blows one pressure and thats about it)

Plus (blows one pressure, the new M Series has C-Flex and a data card, but the card collects only basic data. I do not believe the older Plus supports data cards period, someone correct me if I am wrong on this point.)

Pro (blows one pressure, has C-Flex, collects advanced data. A very nice machine)

Auto (adjusts on a breath by breath basis, has C-Flex, collects advanced data. Many people end up using software in auto adjusting mode, determining their ideal pressure, and running their APAP as a strait CPAP).

Many people buy the pro and do very well. If that is "all" you can get, you've still gotten a great machine.

C-Flex is a feature that makes breathing out against CPAP pressure easier to do. Only Respironics machines have it. Resmed has EPR but is has some drawbacks, see the most recent CPAP.com newsletter, second article down:

https://www.cpap.com/DisplayNewsletter/22

Johnny

beneyw · Post by **beneyw** » Tue Apr 18, 2006 6:58 pm

All I know is when I went to the tech my doc suggested...I told him I wanted the best machine with all the bells and whistles..Well, you all know that the Medicare system dictated what would happen. I even said, I don't care about Medicare...I want to get this condition under control and will gladly pay myself..Bottom line I did not do my homework and just like Managed Care, what I wanted was never even acknowledged let alone complied with.

I am also having probs getting the right mask and already the tech asked.."what do you want me to do?"..I have the funds and I will get what I need and want and won't succumb to the "system."I blame myself for not challenging the doc...it is not over yet and as for the tech I have....very unprofessional.

Wulfman · Post by **Wulfman** » Tue Apr 18, 2006 7:10 pm

Johnny,

OK. Thanks for clarifying that for me.

Gaspy,

My personal preference of the two straight CPAPs you mentioned would be the one I've got.....the Pro 2.
Like Johnny said, the M Series Plus only collects compliance data.
The following is an excerpt from the description on CPAP.COM (emphasis added my me):

"The REMstar Plus M Series with C-Flex offers optional integrated humidification, optional Encore Pro SmartCard capability for basic compliance reporting, lighted controls, an easy-to-read display and the comfort of C-Flex."

Best wishes,

Den

Gaspy · Post by **Gaspy** » Tue Apr 18, 2006 7:37 pm

fujiinator, Johnny, Den and beneyw.... you've all been so helpful.... there is soooo much to know here and you are such a great group... I'm going to try and get the doc to write a script for an auto; however, my next move, if he won't go along w/it will be the Pro 2 we talked about.... hopefully Medicare won't balk at that one.... if they do, I'll just buy what I want outright - no more nonsense. Thanks again.... I will continue this saga tomorrow night and let you all know how my calls went..... Gaspy

Newbie-Senior & Insurance-Any Seniors Share Ins. Woes.

Newbie-Senior & Insurance-Any Seniors Share Ins. Woes.

Remstar plus M with integrated humidifier / REMstar Pro 2