Thanks in advance, this is a great forum.
I am new to CPAP and have lots of questions. My health care network is not cooperating. Specifically I am having probems with getting a humidifier, or actually one that is usable on my machine.
Background... I was given the choice of two machines. I chose the S8 with with nose mask and intregal humidifier. Now I know many of you like this machine but, my wife and I found it to be too noisy. The provider swapped me for a S7 and a regular mask. I like it, very quiet.
Problem is that they will not exchange the humidifier. I know... I got my "stink" on it so I have to keep it. That seem weak since I only used it for about an hour. It could be gas sterilized. It is no more contaminated than the CPAP itself. This single patient rule is a double standard. If there was any reason to it the machine would be single patient too. The humidifier looks absolutely new and has all packaging and literature. So short of it is I have a new humidifier that is not compatible with my current machine. My new machine has no humidifier.
How important is having a humidifier?
They quoted me 5 or 600 dollars for a humidifier, on-line sources have one for $230. That seems "fishy" to me.
I am getting no cooperation from the respiratory therapist, insurance or the Doctor. Consensus from them is "too bad for you". Should I just write it off and buy a humidifier on my own? EBAY the useless one?
Breaking news:
The site suggested shows the S7. It comes with a humidifier as part of the package. They must have removed it before they made the exchange. That is petty, and really lights a fire under me pester them until they make it right ! Now I'm mad.
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
Insurance problems with a humidifier
10 posts
• Page 1 of 1
Insurance problems with a humidifier
Last edited by Scota4570 on Fri May 26, 2006 4:18 pm, edited 6 times in total.
Hello Scota!
I'm new here and a brand new CPAP user myself! Welcome!
Well, there are a couple things here to look at and keep in mind.
The first you mentioned yourself - You did use the old humidifier. As these items are FDA labelled as 'Single Patient Use Only', there is the obvious requirement that they not be used again. Regardless of if they COULD be sterilized, it's a moot point. The FDA has seen fit to call them single patient use for whatever reason, so single patient use they are.
The second issue then becomes reimbursement. Who should pay for this? Here's where things can get a bit sticky. Please understand that what I am about to say is absolutely NOT a slam on you in any way, shape or form. You were provided with a machine and a humidifier. You did not LIKE this machine. It's not that it failed to perform it's designated task. Now granted, I will totally agree that a machine that is too loud basically is a pointless machine, but it doesn't change the underlying fact that it DID work.
So with that in mind, how do you convince the Insurance company to pay for it? Obviously, on the surface, an insurance company cannot go around buying new equipment for someone every time they decide they don't like something (To take this example to it's extreme).
What I would do then is contact the insurance company, and ask to speak with either a Case Manager or a Review Manager or whatever that particular insurance calls them. Someone who can look at unusual situations or extenuating circumstances. Basically, you want to get to a Review level. Explain to them 'Yes I know these are only covered every X months, however the unit I have will not work because the CPAP itself had to be switched out. This is an accessory that is Medically Neccessary and I would like to know if there is leeway based on the exchange of the primary covered item." Most importantly, BE POLITE. Understand that while it stinks to be in the situation you are in, you ARE trying to do something the system isn't setup to be able to do all the time, for very obvious reasons.
I hope this helps, and good luck!
Bingo
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
I'm new here and a brand new CPAP user myself! Welcome!
Well, there are a couple things here to look at and keep in mind.
The first you mentioned yourself - You did use the old humidifier. As these items are FDA labelled as 'Single Patient Use Only', there is the obvious requirement that they not be used again. Regardless of if they COULD be sterilized, it's a moot point. The FDA has seen fit to call them single patient use for whatever reason, so single patient use they are.
The second issue then becomes reimbursement. Who should pay for this? Here's where things can get a bit sticky. Please understand that what I am about to say is absolutely NOT a slam on you in any way, shape or form. You were provided with a machine and a humidifier. You did not LIKE this machine. It's not that it failed to perform it's designated task. Now granted, I will totally agree that a machine that is too loud basically is a pointless machine, but it doesn't change the underlying fact that it DID work.
So with that in mind, how do you convince the Insurance company to pay for it? Obviously, on the surface, an insurance company cannot go around buying new equipment for someone every time they decide they don't like something (To take this example to it's extreme).
What I would do then is contact the insurance company, and ask to speak with either a Case Manager or a Review Manager or whatever that particular insurance calls them. Someone who can look at unusual situations or extenuating circumstances. Basically, you want to get to a Review level. Explain to them 'Yes I know these are only covered every X months, however the unit I have will not work because the CPAP itself had to be switched out. This is an accessory that is Medically Neccessary and I would like to know if there is leeway based on the exchange of the primary covered item." Most importantly, BE POLITE. Understand that while it stinks to be in the situation you are in, you ARE trying to do something the system isn't setup to be able to do all the time, for very obvious reasons.
I hope this helps, and good luck!
Bingo
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP
Last edited by Bingo on Fri May 26, 2006 3:33 pm, edited 1 time in total.
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Guest
Here's one for $175.
https://www.cpap.com/productpage/resmed ... ifier.html
Maybe you can sell the other one.
If the other one was noisy, there was probably something wrong with it and they should have given you a different one (new). The S8's are the newer technology.
They took advantage of you. (that's as nice as I dare put it)
https://www.cpap.com/productpage/resmed ... ifier.html
Maybe you can sell the other one.
If the other one was noisy, there was probably something wrong with it and they should have given you a different one (new). The S8's are the newer technology.
They took advantage of you. (that's as nice as I dare put it)
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Offerocker
- Posts: 1109
- Joined: Tue Jan 24, 2006 5:08 pm
- Location: ...I forget...
Insurance problems with a humidifier
Bingo Thanks for the insight and information.
I must add two things: My local DME has changed my machine due to a change in Rx. Now, where does the health issue come in on that? The water container is the only part that would need to be 'de-contaminated' imho. I've been in the office and seen her just spray a piece of mask and considered it 'cleaned'.
This "sounds like" he has PURCHASED the machine w/humidifier. If so, nothing to add.
If still RENTING, then it is the JOB of the DME to supply you with a complete unit that is satisfactory. Yes, YOU MUST BE POLITE, KIND, AND ANYTHING ELSE IN YOUR REPERTOIRE.
Have you considered taking back the original machine and attempting to make some adjustments that would affect the noise? That way you would have the humidifier without any hassles.
Frankly, I don't know what the insurance company has to do with it - they've already paid, or are still paying, for a humidifier. And shame on your doc or Respiratory Therapist...because you're NOT GETTING "THERAPY".
My DME is supposedly fighting my new Rx for an Auto CFLEX with the insurance company. Don't know why, because there's only one code according to the ins co, to which a cpap machine of any kind is billed. The DME doesn't want to absorb the extra cost (I'm still renting) of the more expensive machine. I told the DME that I have (pay for) three insurances, and certainly by submitting through all of them it would be covered. Yes, I will double-check ----again.
Good luck. Again, are you renting, or did you purchase, and how long did you have the first machine?
I must add two things: My local DME has changed my machine due to a change in Rx. Now, where does the health issue come in on that? The water container is the only part that would need to be 'de-contaminated' imho. I've been in the office and seen her just spray a piece of mask and considered it 'cleaned'.
This "sounds like" he has PURCHASED the machine w/humidifier. If so, nothing to add.
If still RENTING, then it is the JOB of the DME to supply you with a complete unit that is satisfactory. Yes, YOU MUST BE POLITE, KIND, AND ANYTHING ELSE IN YOUR REPERTOIRE.
Have you considered taking back the original machine and attempting to make some adjustments that would affect the noise? That way you would have the humidifier without any hassles.
Frankly, I don't know what the insurance company has to do with it - they've already paid, or are still paying, for a humidifier. And shame on your doc or Respiratory Therapist...because you're NOT GETTING "THERAPY".
My DME is supposedly fighting my new Rx for an Auto CFLEX with the insurance company. Don't know why, because there's only one code according to the ins co, to which a cpap machine of any kind is billed. The DME doesn't want to absorb the extra cost (I'm still renting) of the more expensive machine. I told the DME that I have (pay for) three insurances, and certainly by submitting through all of them it would be covered. Yes, I will double-check ----again.
Good luck. Again, are you renting, or did you purchase, and how long did you have the first machine?
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| Humidifier: HC150 Heated Humidifier With Hose, 2 Chambers and Stand |
| Additional Comments: Comfort Sleeve |
Hello Offerocker!
You also raise some interesting insights. I'll share thoughts on some of them:
Firstly, a lot of this is a moot point when discussing rental equipment. Most CPAP machines (excluding autopaps) will be purchased equipment, which since the S8 is a CPAP I was sticking to.
However, that being said. If a machine is changed out due to a change in Rx, there is a lot more wiggle room there. The reason being that in many cases if a patient requires a significant enough change in equipment to require a new prescription, there will also often be a large enough change in the underlying diagnosis to placate the insurance companies.
Insurance company states they will pay $X dollars to purchase a CPAP for a patient. They will do this once every 3 years.
So it becomes increasingly difficult to switch purchased machines around because of that rule. Add in that NO ONE wants a used machine, and bringing back in old equipment becomes that much more difficult.
Looking at Scota's issue, it's much the same. The insurance company has paid for 'A humidifier'. They will pay for 'A Humdifier' maybe once every 6 months. Sending them a claim for another one will automatically get it shot down. That's why I suggested going to a review level.
Primary Insurance - Expected to be the first and primary payor. Assume normal insurance that pays at 80% U&C
Secondary Insurance - Expected to be the supplemental insurance that will pickup the 20% U&C that the Primary does not cover
Tertiary Insurance - Medi-Gap payor that expects to pickup on certain items that the Secondary Payor will not pay for but the primary payor generally will.
Realize that both the Secondary AND the Tertiary will generally base their coverage on what the PRIMARY payor covers. If the Primary covers the claim, Secondary and Tertiary will cover it. However, it the Primary DENIES coverage, the Secondary and Teriary will generally also deny coverage. This means for example, using the case I outlined above, if the Primary payor denies a claim due to overutilization (Another humidifier before the 3 months is up) than the Secondary and Tertiary payors will also deny that claim.
Note that this is an example. Individual insurances obviously will be different. This is just a very customary arrangement in a 3 payor situation.
Much like before, I have to finish with 'It can be a real pain, but there are ways to deal with it. It just usually requires patience!'.
Bingo
You also raise some interesting insights. I'll share thoughts on some of them:
Offerocker wrote: Thanks for the insight and information.
I must add two things: My local DME has changed my machine due to a change in Rx. Now, where does the health issue come in on that? The water container is the only part that would need to be 'de-contaminated' imho.
Firstly, a lot of this is a moot point when discussing rental equipment. Most CPAP machines (excluding autopaps) will be purchased equipment, which since the S8 is a CPAP I was sticking to.
However, that being said. If a machine is changed out due to a change in Rx, there is a lot more wiggle room there. The reason being that in many cases if a patient requires a significant enough change in equipment to require a new prescription, there will also often be a large enough change in the underlying diagnosis to placate the insurance companies.
Well, consider this - I very much doubt that the provider was going to be re-selling that mask. I would bet that more likely it is a "demo" or store-use item. In which case it doesn't fall under the SALE problems of 'Single Patient Use Only'. Additionally, most of the cleaners any providers office will use are extremely expensive and S-T-R-O-N-G cleaners. These are products that can kill anything from 50 paces in about 0.2 seconds.Offerocker wrote:I've been in the office and seen her just spray a piece of mask and considered it 'cleaned'.
In most cases, it will work out like this. I will use a slightly different scenario:Offerocker wrote:Frankly, I don't know what the insurance company has to do with it - they've already paid, or are still paying, for a humidifier. And shame on your doc or Respiratory Therapist...because you're NOT GETTING "THERAPY".
Insurance company states they will pay $X dollars to purchase a CPAP for a patient. They will do this once every 3 years.
So it becomes increasingly difficult to switch purchased machines around because of that rule. Add in that NO ONE wants a used machine, and bringing back in old equipment becomes that much more difficult.
Looking at Scota's issue, it's much the same. The insurance company has paid for 'A humidifier'. They will pay for 'A Humdifier' maybe once every 6 months. Sending them a claim for another one will automatically get it shot down. That's why I suggested going to a review level.
I think you answered your own query there. If there is only 1 code to bill under, than you can darn well bet it is going to be for the lowest possible modality that will address the diagnosis. IE - plain old CPAP. Toss in the dramtically higher cost of a Flex-capable autopap, and you can see why someone would have some difficulties with that. Don't forget to toss in the same situation above where the provider is also stuck with the old used equipment that they can not re-use!Offerocker wrote:My DME is supposedly fighting my new Rx for an Auto CFLEX with the insurance company. Don't know why, because there's only one code according to the ins co, to which a cpap machine of any kind is billed. The DME doesn't want to absorb the extra cost (I'm still renting) of the more expensive machine. I told the DME that I have (pay for) three insurances, and certainly by submitting through all of them it would be covered.
One thing worth mentioning here. This is not NEARLY as simple as it seems. Many insurances work like this:Offerocker wrote:I told the DME that I have (pay for) three insurances, and certainly by submitting through all of them it would be covered.
Primary Insurance - Expected to be the first and primary payor. Assume normal insurance that pays at 80% U&C
Secondary Insurance - Expected to be the supplemental insurance that will pickup the 20% U&C that the Primary does not cover
Tertiary Insurance - Medi-Gap payor that expects to pickup on certain items that the Secondary Payor will not pay for but the primary payor generally will.
Realize that both the Secondary AND the Tertiary will generally base their coverage on what the PRIMARY payor covers. If the Primary covers the claim, Secondary and Tertiary will cover it. However, it the Primary DENIES coverage, the Secondary and Teriary will generally also deny coverage. This means for example, using the case I outlined above, if the Primary payor denies a claim due to overutilization (Another humidifier before the 3 months is up) than the Secondary and Tertiary payors will also deny that claim.
Note that this is an example. Individual insurances obviously will be different. This is just a very customary arrangement in a 3 payor situation.
Much like before, I have to finish with 'It can be a real pain, but there are ways to deal with it. It just usually requires patience!'.
Bingo
Bingo is dead on with how my insurance works. Primary and Secondary are
exactly as he described it. Cost doesn't matter. If the item was $1.00 and
the primary said no, the secondary will too. If the cost is $3500 and the primary says yes and pays most of it, the secondary will pay the balance...
for me.
As for talking to the insurance people. Make sure the second thing you ask
of the insurance company employee is: "After reviewing my file and my problem, do YOU have the authority to buy me the humidifier?" If the answer is no, ask for their supervisor. If that supervisor cannot authorize it, why waste your time and theirs? Escalate it until you reach a person who can authorize whatever you want. Of course, just because they can, doesn't mean they will.
AND if that unit or that humidifier is that noisy, why not tell them that? Why go for an S7? If this unit was medically needed for your sleep...and the unit was too loud for you to sleep with it going...you needed a new unit. I have
no idea how loud the S8, etc. is, but what made you think an S7 would be
quieter? IF both units were working correctly??? Put another way, it I had
an S7 and an S8 running, side by side, and we knew both units were running
ok, why would YOU want an S-7?? That may be what the insurance company
is asking.
I am playing devil's advocate here. I am NOT against you getting the
new humidifier. To me, common sense indicates most people want the
newest unit, but here is someone wanting an S7. WHY? And if you told them it was too noisy to sleep with, it seems the DME would have been required to replace it with a quiet one. Maybe I misunderstood something
you said? Regardless, Good luck with it....
exactly as he described it. Cost doesn't matter. If the item was $1.00 and
the primary said no, the secondary will too. If the cost is $3500 and the primary says yes and pays most of it, the secondary will pay the balance...
for me.
As for talking to the insurance people. Make sure the second thing you ask
of the insurance company employee is: "After reviewing my file and my problem, do YOU have the authority to buy me the humidifier?" If the answer is no, ask for their supervisor. If that supervisor cannot authorize it, why waste your time and theirs? Escalate it until you reach a person who can authorize whatever you want. Of course, just because they can, doesn't mean they will.
AND if that unit or that humidifier is that noisy, why not tell them that? Why go for an S7? If this unit was medically needed for your sleep...and the unit was too loud for you to sleep with it going...you needed a new unit. I have
no idea how loud the S8, etc. is, but what made you think an S7 would be
quieter? IF both units were working correctly??? Put another way, it I had
an S7 and an S8 running, side by side, and we knew both units were running
ok, why would YOU want an S-7?? That may be what the insurance company
is asking.
I am playing devil's advocate here. I am NOT against you getting the
new humidifier. To me, common sense indicates most people want the
newest unit, but here is someone wanting an S7. WHY? And if you told them it was too noisy to sleep with, it seems the DME would have been required to replace it with a quiet one. Maybe I misunderstood something
you said? Regardless, Good luck with it....
Installing Software is like pushing a rope uphill.
I have Encore Pro 1.8.65 but could not find it listed
under software.
I LOVE the SV.
I have Encore Pro 1.8.65 but could not find it listed
under software.
I LOVE the SV.
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Offerocker
- Posts: 1109
- Joined: Tue Jan 24, 2006 5:08 pm
- Location: ...I forget...
Bingo, dllfo:
Sigh, .....thanks..... ...sigh
There IS NO gravity...the world sucks!
Seriously, WOW, some great info, and sideways thinking. Thanks.
You know, through this ordeal I've had since 10/27, I've spent far too much time battling. Disappointed they gave me a PRO instead of PRO2, now that they won't GIVE me (sarcasm) an AUTO. I rest my case, and wait for the verdict. I rest my self - I purchased what I really wanted (w/Rx)
Like I said early on: "It irritates me to be wrong when I know I'm right"
OH BOY, I just thought of the word "LIFE" as an acronym. sometimes I just can't help myself - my mind is a dual-processor(when working at all), and I cannot control the other half. Hey, if a split personality each needed cpaps, what would happen then? Ouch. Sorry about that.
Sigh, .....thanks..... ...sigh
There IS NO gravity...the world sucks!
Seriously, WOW, some great info, and sideways thinking. Thanks.
You know, through this ordeal I've had since 10/27, I've spent far too much time battling. Disappointed they gave me a PRO instead of PRO2, now that they won't GIVE me (sarcasm) an AUTO. I rest my case, and wait for the verdict. I rest my self - I purchased what I really wanted (w/Rx)
Like I said early on: "It irritates me to be wrong when I know I'm right"
OH BOY, I just thought of the word "LIFE" as an acronym. sometimes I just can't help myself - my mind is a dual-processor(when working at all), and I cannot control the other half. Hey, if a split personality each needed cpaps, what would happen then? Ouch. Sorry about that.
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| Humidifier: HC150 Heated Humidifier With Hose, 2 Chambers and Stand |
| Additional Comments: Comfort Sleeve |
Oh well that's easy. You would just need 2 prescriptions. Of course, you will also need 2 Letters of Medical Neccessity and you will need to submit those to two seperate Medical Review Boards at your insurance.Offerocker wrote: sometimes I just can't help myself - my mind is a dual-processor(when working at all), and I cannot control the other half. Hey, if a split personality each needed cpaps, what would happen then? Ouch. Sorry about that.
Oh, and you also will need 1 notorized duck. Preferably a Mallard.
Bingo
While my INS. covered my cpap 100% they only covered 50% of my humidfier. DME called me adn ask for the other half adn tried to get me to pay 150 for a passover humidfier, remind you this is only 1/2 the cost.
Needless to say I bought one onli for 95.00 and saved myself 55.00 adn my INS some cash as well. I also didn't need a script for me humidifer
Needless to say I bought one onli for 95.00 and saved myself 55.00 adn my INS some cash as well. I also didn't need a script for me humidifer
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Offerocker
- Posts: 1109
- Joined: Tue Jan 24, 2006 5:08 pm
- Location: ...I forget...
BINGO:
Methinks you're as nuts as I yam! Hey, welcome to the club
Thanks for the laffs - I/we sure need them!
Some days, it's not even worth chewing through the restraints.
Methinks you're as nuts as I yam! Hey, welcome to the club
Thanks for the laffs - I/we sure need them!
Some days, it's not even worth chewing through the restraints.
_________________
| Humidifier: HC150 Heated Humidifier With Hose, 2 Chambers and Stand |
| Additional Comments: Comfort Sleeve |
10 posts
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