DME Lies?

[IZATIRED2]

You can do what I did. It took me a week to convince my insurance to reimburse me for the purchase of a apap from cpap.com . I showed them how much money they would save. My situation is probably different then yours. There is only one dme in the town I live in and they were not on my ppo list. So the insurance treated them as if they were in network.

After proving how bad the service was from this dme they let me buy from cpap.com and give me the in network benefit . The only bad thing is I'll have to pay for the 2 month rental fee. It is worth it to not have to deal with
the local Dme.

I hope you can win your battle.

Dealing with(lin don't care) is worse than OSA.

[Sleepy-in-AL]

All of this depends on your particular insurance company as to how they process and pay. As inacpapfog said, some will base it on a documented medical need, others pay strictly by billing code. So if they pay strictly by billing code, the DME gets the same $ if they give you a $255 PB or an $900 top of the line APAP (these are cpap.com prices DME charges would be much higher).

One option is request a written estimate of the difference in cost between the straight cpap and the apap and offer to pay that difference if your insurance doesn't cover it. However, before doing this I would carefully study the prices on cpap.com because it is not at all unlikely that you can buy the apap out of pocket from cpap.com cheaper than the DME will charge you for the difference.

I would contact your patient representative at your insurance company and explain what is happening and ask them to document in writing exactly what they cover in this situation and how it is handled. However, this will probably be easier to say than to do because many carriers will determine claim eligibility only once the claim has been filed.

[Wulfman]

JayPSU,

Your insurance provider sounds like they might go along with what I'm going to suggest (which was also touched on in some previous posts).
This also assumes that you can purchase out-of-pocket (up front).

Contact your insurance provider and ask them if YOU would be considered "in-network" for out-of-pocket purchases.

Apparently you've explained to your insurance provider the problem you've been having with your local DME, so then tell them that you would like to save them a LOT of money by purchasing your equipment from CPAP.COM......and then if they would reimburse YOU (at whatever the in-network rate is).

Then, if they say they will go along with that idea (lots of them will).....purchase your equipment from CPAP.COM.

Then, make out an invoice from YOU to your insurance provider as if you were the DME. The invoice from CPAP.COM will have all of the correct insurance billing codes on it, so you can probably use the text of that invoice in your own invoice.

Send your insurance provider your invoice and then they sould send you a check for your reimbursement.

It's that simple.

Best wishes,

Den

[Guest]

What about going back to the dr. or calling them and asking the DR or NURSE to call the DME and say, uh, the prescription says needs apap, so medically needed - so give them the da$% APAP machine - couldn't you try that? I think the DME will cave if they get a call from the dr - along with frequent calls from you - believe me I know, they will cave just to shut you up - worked for me!!

[Guest]

Yeah, I think that is what I'm going to try. My doctor prescribed a machine, and the DME is effectively going against her order. The DME is supposed to simply provide what the doctor requests, and right now they are not.

[quote="Anonymous"]What about going back to the dr. or calling them and asking the DR or NURSE to call the DME and say, uh, the prescription says needs apap, so medically needed - so give them the da$% APAP machine - couldn't you try that? I think the DME will cave if they get a call from the dr - along with frequent calls from you - believe me I know, they will cave just to shut you up - worked for me!!

[Guest]

I have to add a thing or two and sum up what I know from both my own experience and from others who have posted

One way is to take the CPAP and complain as one person said (air swallowing...). Risk is that they still say no and you might be locked into a particular DME after billing starts.

Another is to call insurance as you have done and then pressure the DME to do what the insurance says they will cover. Be a royal pain in the you know what. It would also be good to know from your insurance if you have more than one DME to choose from. If so try another DME and/or tell the first DME that you are going elsewhere.

You can see if your insurance will reimburse you for buying from Cpap.com some will (mine won't). Tell them how much money they would save (mine didn't care).

You can see if your insurance will work with Bill My Insurance (mine won't)

You can keep pestering your DME. Call, call, call and ask when your APAP that your doc ordered will be there. (Essentially that is what I did but they kept calling me to tell me my CPAP was in (and I went from there, "you mean my APAP that my doc ordered..."

You could offer to pay the difference. But be careful that the total amount you pay (copay for Cpap and differential doesn't exceed the total price for outright purchase at Cpap.com).

As for no one using APAP as a regular machine. Horsehockey. I do as do many others. I have a pressure of 13 and don't want that if I don't need it (which is a lot of the night). It bothers my ears enough as it is. I also am in the same boat as you. Want to be able to adjust as pressure needs change over time. Don't want another sleep study -- my copay (to meet my deductable of $618) for a sleep study is almost as much as an APAP with no insurance coverage. And I did NOT enjoy the sleep study nor do I have the utmost confidence in the results. Oops, I forgot the $220 sleep doctor charge for reading the sleep study (at 20% that I have to pay).

Before you cave, try all the above. Be a pain in the you know what. What have you got to lose.

Most of all, get a hard copy of your prescription from your doc and hold it. It doesn't expire. Then you have options in the future. Get a copy of the sleep study too. It is yours you can file it for the future.

Good luck.

[DME_Guy]

Do you have to use that DME?

In general, it's not a cut and dry issue. Look at it as if you're buying a new car. The dealer won't give you the top of the line model for the price of the entry level car. If they did, they wouldn't be in business very long.

Your insurance company will pay for an APAP. The problem is they pay the same price as they do for a basic CPAP so your DME doesn't want to make less profit or no profit at all depending on what your insurance pays.

If I were your DME, If your insurance reimbursment is sufficient to cover the cost, I'd give you an APAP. If the reimbursment wasn't sufficient, I'd ask you to pay the difference in cost between the CPAP and APAP, or a portion of it. $150 to $250 should cover it. I think that's fair for everyone. If I get an RX for medication, I have the option to either get the generic brand or the brand name version of the drug. If I prefer the brand name, I know I'll have to pay more out of pocket and I am okay with that.

The bottom line is the RX rules. It is unethical for the DME to put out something other than what the RX says. DMEs are not Medical Doctors and they are not to over-ride what the Dr prescribes. They can refuse to do the order, but not change what the DR prescribed.

If you must use this DME, ask to talk to whomever is in charge. Ask them why they are giving you something other than what the Dr prescribed and document it. Let them know you are documenting it. Also, ask them to put it in writing why they are dispensing a "medication" that a Dr did not RX. If something goes wrong with your health, they are putting themself at risk for a lawsuit.

Do you know how much your insurance company pays for the machine?

[rested gal]

Excellent info and advice, DME_Guy. Would that there were more DMEs like you.

[Rastaman]

I'm still reading this very long thread but I wanted to share my experience and I hope that it helps.

I was diagnosed about 6 weeks ago. My DME and Sleep doc are in the same office. I didn't even get my sleep study results until my 1 month checkup. But that aside they started me out on a Remstar Plus M Series (Straight CPAP) and it was a fine machine. I had no complaints. But the more I learned here and the more I tried this machine out the more I realized that an APAP would be better for me because I need different pressures in different positions AND when I have a few occasional adult beverages I might need a higher pressure.

I was told up front when I got the machine that I would come back in 1 month and decide whether or not to rent or buy. This never happened btw. Right off the bat I contacted someone at the Sleep Doc's office about my results and was told I was having 124 events per hour. They put the xPAP on me during the sleep study after only 1 hour and 15 minutes. They prescribed a 13 pressure setting. I asked this "representative" all the questions I could and explained a few issues I was having and he said Oh we can change out that mask with another and he even suggest I NOT use the chin strap and just 'try that out.'

After that call I called the DME back about 2 weeks after getting the machine. I told her about my concerns and told her that I would like to get an APAP. I told her sometimes the pressure seemed too high like when I'm laying on my side, and sometimes the pressure didn't seem like it was enough (adult beverages). She told me the same thing she told you. The doctor has to write a special prescription and your insurance won't cover this. My wife calls insurance companies all day long on her job and she made the call for me before I called the DME. They said they would cover DME equipment with no limit on that. In or out of network. I contacted Billmysinsurance.com but they told me that I had already started the process with another DME and they couldn't intervene at this point.

She tells me that I'd have to pay the difference for the APAP over CPAP. She also said the APAP was heavier than the CPAP as if that was a deterent too. LOL! I asked her how much the difference in price would be and she said $200 to $300. I think she thought she defused me on that call. I called my wife and discussed paying the difference to get what I really wanted and needed. Then I called back during lunch time and left a detailed message that I didn't mind if it was heavier and I would pay the difference to get the APAP and that was what I wanted. I was very firm in my message. I basically re-countered everything she had told me. She calls me back, gets my voice mail because I'm on the other line. I call her back and she's on the phone with another patient. I ask to hold. Receptionist comes back on saying she'll be on the phone awhile, did I still want to wait. I did. She finally came on the line after a couple of minutes.

She said okay, just bring the machine in and she'll switch it out for a Resmed S8 Autoset Vantage. Originally I was asking for a Remstar Auto w/C-flex but she stated they only had the CPAP's in that brand right now. She said I would need to pay $25 for a water chamber. And then I asked how much will I have to pay for the difference and she said "Don't worry about it." So I come right in the next day and bring in my Remstar Plus M Series and she switches it out. I end up paying $35 for a water chamber. But that's all I paid.

I was prepared to ask for my prescription and buy online if needbe. My insurance had told me they would cover in or out of network. On my initial visit the DME seemed impressed with my insurance. They pay 100%. And unlimited on DME. We specifically asked about out of network and they said they would cover that too. We even asked specifically about APAP and they said they would cover that too if the doctor wrote a script for that.

All this time I'd been using a Mirage Swift and having trouble with it. Sore nares. And on my 1 month check-up they told me to bring in my machine. I assumed for compliance or something. I go in and I'm not scheduled to see the DME at all. Nope, I get to see the Sleep Doc instead and he goes over my Sleep Study Results with me and gives me a print out. He had gone over my file before I arrived and didn't realize until I pointed it out that he had prescribed the APAP. He kept talking about my CPAP and pressure of 13. It was now 8 to 17 on the APAP. I reminded him and he looked further down in my file and there it all was. Obviously, the poor doc has too many patients. And I understand the volume they go through if it's anything like the volume of customers I deal with at work.

Anyway, I tell him about my sore nares and mask trouble (really I liked the Swift, it was easy to take apart and clean for one) so I asked about another mask. He went to check to see if the DME had an opening. She did. She gave me a Mirage Activa instead. And took my Swift back. I believe they only charged me for nasal pillows on my insurance. They never looked at my machine though. Or if they did, it was so fast I didn't notice. Maybe they did get my #'s off the machine. I'm sure they did already with the prior machine I had exchanged. The Sleep Doc said if all goes well he won't need to see me for another year.

Here I am 6 weeks total into this and I feel great. My APAP is working well. I got the machine type that I wanted and I ended up being very pleased with this particular APAP. The M series for the Remstar Auto wasn't out just yet. It was within 2 weeks though. And I felt like I had already won a battle regarding getting APAP in the first place. But get this! I mentioned to the sleep doc that I was supposed to talk to the DME about whether to rent or own and he looked confused and said we always rent to buy. And the DME never mentioned renting or buying. Good Grief!

While I felt like I had to overcome an obsticle the DME ended up getting me the machine and mask that I use today. And while she might've had her pat responses to my questions she eventually realized I meant business. Now, I might've had more lee-way than most insurance-wise but this is what happened to me and how it ended up being handled. Now, I'm able to see online how much they're billing my insurance company and my insurance has already paid them $1650 between the sleep study, mask, machine rental for 1 month, humidifier, etc. But what was billed was much much higher. For example the sleep study was billed at $1950 and my insurance only paid $672. And so on and so forth. They're not losing any money on me, that's for sure. But eventually I'm going to buy a back-up unit and probably from cpap.com and I'm going to call the Sleep Doc and request a copy of my script before I do this, although I guess I really don't need to unless I buy Resmed products, which are about to go up in price 40% in August. Fat chance on that brand ofcourse. But I don't think a Respironics machine would require that according to the website. Or other brands they sell. Correct me if I'm wrong.



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CPAPopedia Keywords Contained In This Post (Click For Definition): resmed, mirage, activa, swift, CPAP, DME, Nasal Pillows, Prescription, auto, APAP, clean

[JayPSU]

At this point I want to get a copy of the prescription my doctor sent to the DME. If it says nothing about a 1 month stint on the apap, followed by a cpap, and just simply says an apap, I'm going to raise hell with the DME. The DME has no right to go against what a doctor prescribes, I would think that it'd be illegal! This whole situation has me so mad!

[Rastaman]

[quote="JayPSU"]So essentially there is nothing I can do? Is that what all of you are saying? I can only get a cpap even though my doctor prescribed an apap? Is there a way that I can get an apap and pay the difference in price between the cpap and apap? Please be patient with me as I have ZERO experience with insurance companies. All I have ever needed before this in the past is checkups, blood tests, and twice x-rays. I don't really have experience working with insurance companies.

[Rastaman]

[quote="inacpapfog"]JayPSU, your case kinda sounds like the same ordeal I went through to get my apap through insurance. I wanted an apap from the very beginning for the same reasons as you. When DME told me the same story you got, I argued the same points you stated! After I left the DME office, I called insurance (BCBS) and got it from the horse's mouth, IF THE DOCTOR WRITES APAP AS A MEDICAL NEED (via the prescription) DME will fill the prescription! I called my doctor after 1 week and reported excessive aerophagia and inability to breath with the mask on at random times through the night. He documented this in my records and wrote the specific prescription for the apap w/ humidifier ! I had my apap within 24 hours after that! Moral of story, if the front door sticks, try the back door! (Heck, I'll climb through the window if needed!)

[snork1]

i agree that the first line of defense is to find another DME if at all possible.

If thats not possible, the squeaky wheel does indeed get the grease, it seems. Escalate from irritated to obnoxious with no end in sight as to where you might go and keep reminding them you have a written prescription, and are only trying to get what you have a LEGAL right to get.

I did have to jump through some hoops to change from a trial CPAP to APAP, now that I think of it. (it was a few years ago). My doc only believes in CPAP, unless you have a problem and show the need for APAP.
So I became a squeaky wheel about problems with a CPAP (not hard to do!) until they switched me to an APAP. I was telling him how I had to keep hitting the ramp button all night and effectively had a manual APAP. (yes I know thats a contradiction of terms). I also complained of terrible Aerophagia due to being at the higher pressure. Even docs and DME's get tired of hearing about your farts to the point they will eventually do most anything to shut you up.

So.....first see if there is ANY competition that is covered by your insurance and let the competition know why you are shopping for a new DME.

Secondly....squeak squeak SQUEAK!!!!

Good luck!

[Severeena]

JayPSU, I would first, I would go back to that DME, call the insurance company in front of them and hopefully you have a cell phone with a speaker phone built in. Again, ask the insurance company yourself if they will pay for an APAP machine. If the company says yes they will pay for the APAP as long as you have a script for a particular APAP machine with heated humidifier, you have the DME at a great disadvantage and you have also burned their @$$with the insurance company, because once called in front of them the DME has to go by what was said and don't leave home without it. This way the DME cannot mess things up for you.

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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, DME, APAP

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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, DME, APAP

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CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, DME, APAP

[Guest]

Jay,

You mention getting the doc's office to send a copy of the prescription. Get the prescription yourself, then if it needs to go to the DME, you can opt to send it or if the office is backed up you can hand them a copy in person (not the original). You need to have your prescription in your hands.