So, I went to National Jewish Sleep Center in Denver for my sleep study several weeks ago (for no special reason except they're suppose to be very good and are covered by my insurance co). I saw my MD (who I like very much) in a follow-up (40 episodes an hour) and today saw the tech at the Sleep Center about the xPAP machine the MD had ordered for me. I learned today that Nat'l. Jewish is a certified DME and to work with them I need to use them as my DME. The only problem I have with this is they will not set me up with an auto style. They insist on the Respironics Remstar Pro M Series C-Flex, which is great but they won't go with the auto. They say they don't think the auto variety is far enough along in their development to be effective -- create too many problems. It hasn't sounded to me like that's been the experience of many of you. Comments please.
Anyway, I'm bummed. After reading hours of posts on this forum and anything else I could find, I had made the decision I wanted to go with the Remstar M Series Auto w/C-Flex no matter what they said. Now, it seems I need to find another DME if I want to get an auto.
I've had no experiences with DME's before. My question is do DME's work with you on learning how to set the thing up and trying to find the right settings, mask, etc.? How helpful can one expect them to be . . . or are they not. Can one usually try several machines when working with a DME? Do I need to find a doctor who will allow me to work with any DME?
Also, I requested a copy of my sleep study and what I received was a 2-1/2 page physician's report summing up final impressions and recommendations. I think that's probably NOT what I had requested and must insist on the complete study. Should I expect more than the MD's report or is that what everyone has been telling me to get. Also, I still don't have the titration study. No comment . . . just intend to get it.
So, my husband and I spent 1-1/2 hours asking questions, pressing about the auto, discussing costs/insurance, etc. and I left with no equipment. I go back (assuming I go back) a week from tomorrow.
Should I be working with someone else? Do physicians have specific DME's they work with? Is my experience unusual? My insurance co. tells me Walgreen's is one of their in-network DME's that sell CPAPs -- has anyone had any experience with their DME operation?
I have a $1000 deductible which I've already paid this year. I really want to obtain the equipment through insurance before the end of the year -- am I dreaming here!?! (I know I'm not at night!)
Do I have unrealistic expectations here?
Colo ZZZ: My insurance doesn't have your DME as one of their in-network providers, so I didn't contact them. What's been your experience with them?
Advice anyone?
Newbie bummed after appointment w/DME
-
DenverCathy
- Posts: 38
- Joined: Mon Dec 04, 2006 11:37 am
- Location: DenverCO
It helps if your doctor is on your side for getting the auto, but if that doctor is also part of the sleep lab then you may have a uphill climb.
You should call your insurance again, ask how much DME equipment is covered, because if you have to pay a large deductible for the DME equipment you may be better off (money wise) just buying the machine outright.
Most likely they won't purchase the machine by the end of this month and your annual deductible won't apply anyway. They usually start off with a 3-month trial/rental then convert to some kind of rent to own. So you are into next years deductible any way you look at it.
If you bought the machine, you could bill insurance and maybe they would apply that towards your 2007 maximum out of pocket.
When I wanted to go to a certain sleep lab because they could get me in much sooner, the insurance didn't have a problem other than to warn me that the doctor, sleep lab and DME portion were all in cohoots with each other and they already had complaints of conflict of interest.
DME equipment provider doesn't have to be certified by anyone. IF you broke your leg and needed crutches you can go almost anywhere and get those. If your insurance has contracted with Apria or Lincare, you sometimes have to use them or you end up paying more in deductible. If you go to an out of network DME, coverage may be less but they still have to cover it.
Should be in your policy.
You should call your insurance again, ask how much DME equipment is covered, because if you have to pay a large deductible for the DME equipment you may be better off (money wise) just buying the machine outright.
Most likely they won't purchase the machine by the end of this month and your annual deductible won't apply anyway. They usually start off with a 3-month trial/rental then convert to some kind of rent to own. So you are into next years deductible any way you look at it.
If you bought the machine, you could bill insurance and maybe they would apply that towards your 2007 maximum out of pocket.
When I wanted to go to a certain sleep lab because they could get me in much sooner, the insurance didn't have a problem other than to warn me that the doctor, sleep lab and DME portion were all in cohoots with each other and they already had complaints of conflict of interest.
DME equipment provider doesn't have to be certified by anyone. IF you broke your leg and needed crutches you can go almost anywhere and get those. If your insurance has contracted with Apria or Lincare, you sometimes have to use them or you end up paying more in deductible. If you go to an out of network DME, coverage may be less but they still have to cover it.
Should be in your policy.
What Snoredog said.
Doc and sleep center has nothing to say about where you get your machine, you insurance does (and then only if you are getting benefits).
Does the prescription say auto? If it doesn't I don't know of any local DME who will give AUTO. Online will.
In addition to that
Does your insurance require you to rent to buy? If so, you will not get it paid before 07. There will most likely be a new deductable to satisfy in Jan.
If it is a big deductable and you don't think you will meet it for other things, use that as part of out of pocket cost in deciding whether it is worth it to try to get insurance benefits. For example from a local DME the machine may cost $1500 - $1800 or more with humidifier (for ANY CPAP they are all billed the same). Online $400 - $700 (some select ones are higher as are bipap.
So if you have to meet another $1000 deductable (2007) because your insurance requires you to rent for 3 months, you might as well not stress and order up cash from CPAP.com. If you will meet your 2007 deductable anyway for other things, or your insurance will buy right now with no rental, then I would persue the insurance option as the deductable is paid and bound to cost less than cash purchase with no insurance.
Your question on is the DME useful. That all depends. If you can try multiple machines (different manufacturers APAP for example - and I would doubt that since you are having trouble getting them to give you any apap), then they would be what I would consider useful. If they allow you to swap masks, then again -- useful. You have to figure what you want to pay for useful. Out of pocket a mask is $100 - $150. If you buy 2 extras out of pocket then that is $300. Is the DME costing you more or less than $300 for the machine more than buying cash? Can you even get the DME to swap masks or once you try it on do you own it?
Set up is a piece of cake. If you can program your vcr or set up your phone answering machine you can set up a CPAP, in fact it is easier than either of those. If you buy cash you get the manuals, if you go to the DME they will set it up, and not give you your manual.
Some DME's are more supportive than others. Really hard to say how much support you will need. With a machine that does it all APAP (can be used as CPAP) exhale relief etc there is not much a DME can do for you. As long as you don't have really high pressures and might need BiPap, the differences in APAP machines are how they are programmed to respond to your events. If you end up being a person who is treated better by one manufacturers machine than by another, the DME and rental can be helpful. How many people run into that? I don't know. I doubt that many, but I have no statistics on that, only the commets I read here about people claiming they had trouble until they switched machines...
No it is not unusual for a DME to resist giving auto. In fact if your prescription doesn't say APAP the DME most likely will not.
Hang in there. Think about the financial implications of local DME vs. cash, and also how much out of pocket you expect to pay given your personal copay and the new insurance year, and whether you have to rent to buy and that may well give you an easy answer about what to do.
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): DME, Prescription, auto, APAP
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, humidifier, cpap.com, CPAP, DME, Prescription, auto, APAP
Doc and sleep center has nothing to say about where you get your machine, you insurance does (and then only if you are getting benefits).
Does the prescription say auto? If it doesn't I don't know of any local DME who will give AUTO. Online will.
In addition to that
Does your insurance require you to rent to buy? If so, you will not get it paid before 07. There will most likely be a new deductable to satisfy in Jan.
If it is a big deductable and you don't think you will meet it for other things, use that as part of out of pocket cost in deciding whether it is worth it to try to get insurance benefits. For example from a local DME the machine may cost $1500 - $1800 or more with humidifier (for ANY CPAP they are all billed the same). Online $400 - $700 (some select ones are higher as are bipap.
So if you have to meet another $1000 deductable (2007) because your insurance requires you to rent for 3 months, you might as well not stress and order up cash from CPAP.com. If you will meet your 2007 deductable anyway for other things, or your insurance will buy right now with no rental, then I would persue the insurance option as the deductable is paid and bound to cost less than cash purchase with no insurance.
Your question on is the DME useful. That all depends. If you can try multiple machines (different manufacturers APAP for example - and I would doubt that since you are having trouble getting them to give you any apap), then they would be what I would consider useful. If they allow you to swap masks, then again -- useful. You have to figure what you want to pay for useful. Out of pocket a mask is $100 - $150. If you buy 2 extras out of pocket then that is $300. Is the DME costing you more or less than $300 for the machine more than buying cash? Can you even get the DME to swap masks or once you try it on do you own it?
Set up is a piece of cake. If you can program your vcr or set up your phone answering machine you can set up a CPAP, in fact it is easier than either of those. If you buy cash you get the manuals, if you go to the DME they will set it up, and not give you your manual.
Some DME's are more supportive than others. Really hard to say how much support you will need. With a machine that does it all APAP (can be used as CPAP) exhale relief etc there is not much a DME can do for you. As long as you don't have really high pressures and might need BiPap, the differences in APAP machines are how they are programmed to respond to your events. If you end up being a person who is treated better by one manufacturers machine than by another, the DME and rental can be helpful. How many people run into that? I don't know. I doubt that many, but I have no statistics on that, only the commets I read here about people claiming they had trouble until they switched machines...
No it is not unusual for a DME to resist giving auto. In fact if your prescription doesn't say APAP the DME most likely will not.
Hang in there. Think about the financial implications of local DME vs. cash, and also how much out of pocket you expect to pay given your personal copay and the new insurance year, and whether you have to rent to buy and that may well give you an easy answer about what to do.
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): DME, Prescription, auto, APAP
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, humidifier, cpap.com, CPAP, DME, Prescription, auto, APAP
Cathy,
On the other hand....... (and if all else fails)
Having an M Series Pro would not be "the end of the world".
You would have a machine with recording capabilities to analyze your sleep statistics. The fact is, MOST people do extremely well (if not better) on straight pressure. With the software, you can find out if your pressure is right and still tweak it if necessary.
Best wishes,
Den
On the other hand....... (and if all else fails)
Having an M Series Pro would not be "the end of the world".
You would have a machine with recording capabilities to analyze your sleep statistics. The fact is, MOST people do extremely well (if not better) on straight pressure. With the software, you can find out if your pressure is right and still tweak it if necessary.
Best wishes,
Den
(5) REMstar Autos w/C-Flex & (6) REMstar Pro 2 CPAPs w/C-Flex - Pressure Setting = 14 cm.
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
-
SelfSeeker
- Posts: 779
- Joined: Tue Sep 19, 2006 6:25 pm
Cathy, Sorry to hear about your woes with the DME.
Will the doctor give you an Rx for an auto? If yes, then no problem.
Your question about the DME, each DME is different. Ask them what their policy is for trying on masks at the office. (Some DMEs will not even let you try them on without buying them at the office.)
Can you take a mask home for a trial period, ask if you do not know. For me getting my masks fitted with the DME, was great, because I got to try on different masks at home, then swap them if they were not right. Some masks you can not try on etc.
Not only are DMEs different but so are the insurance policies.
Ask your insurance if you can get the machine for much less, will they pay part of it as online.
I was able to buy the machine on line and then go to a DME for the interfaces/masks.
Have you checked with billmyinsurance, which is a part of CPAP.Com to see if your insurance will work with them.
http://www.billmyinsurance.com/
If you get a machine from the DME, no they do not work with you on setting things up, not only that from what I have read online, they take the manual on how to set things up.
WIll the DME give you the auto if you pay more for it?
The auto can be used as a straight CPAP machine as well.
Good Luck.
Will the doctor give you an Rx for an auto? If yes, then no problem.
Your question about the DME, each DME is different. Ask them what their policy is for trying on masks at the office. (Some DMEs will not even let you try them on without buying them at the office.)
Can you take a mask home for a trial period, ask if you do not know. For me getting my masks fitted with the DME, was great, because I got to try on different masks at home, then swap them if they were not right. Some masks you can not try on etc.
Not only are DMEs different but so are the insurance policies.
Ask your insurance if you can get the machine for much less, will they pay part of it as online.
I was able to buy the machine on line and then go to a DME for the interfaces/masks.
Have you checked with billmyinsurance, which is a part of CPAP.Com to see if your insurance will work with them.
http://www.billmyinsurance.com/
If you get a machine from the DME, no they do not work with you on setting things up, not only that from what I have read online, they take the manual on how to set things up.
WIll the DME give you the auto if you pay more for it?
The auto can be used as a straight CPAP machine as well.
Good Luck.
I've had no experiences with DME's before. My question is do DME's work with you on learning how to set the thing up and trying to find the right settings, mask, etc.? How helpful can one expect them to be . . . or are they not. Can one usually try several machines when working with a DME? Do I need to find a doctor who will allow me to work with any DME?
I can do this, I will do this.
My disclaimer: I'm not a doctor, nor have I ever worked in the health care field Just my personal opinions.
My disclaimer: I'm not a doctor, nor have I ever worked in the health care field Just my personal opinions.
Cathy-if your doctor writes for an auto that's what they have to give you. A lot of times the insurance companies will balk when an auto is ordered because of cost of an auto compared to a straight CPAP. Always the almighty dollar!
_________________
| Mask | ||||
 | ||||
| Additional Comments: Machine:Resmed S7 Elite; Oracle Mask(YES! My DREAM mask!!) | ||||
-
DenverCathy
- Posts: 38
- Joined: Mon Dec 04, 2006 11:37 am
- Location: DenverCO
A shout out to all of you who responded. Thanks so much! I'm not as bummed. Since the physician and the DME are in cahoots, chances are good I can't get a prescrip for the auto -- forgot about that part.
The info about working with a DME is so helpful -- strange, new world out there for me.
They're inquiring now if my insurance will require me to rent or if I can purchase outright. I'll call insur. tomorrow also.
I had a large number of central apneas (great -- my brain doesn't talk to my body!) Does that affect anything that I'm doing equipment-wise?
Think I'll stick with the doc and DME so I can get the support and follow up I'm looking for as well. It'll all work out, no doubt. Timing is the issue -- if I wait until nest year to purchase, I'll still get my insurance deductible out of the way for '07 although I doubt I will incur the $1000 worth of costs to use up the deductible if not through the purchase of the CPAP.
I CAN do this -- just a need to be patient.
Thanks again to all of you for all your do -- this is a wonderful group of peps!
Happy holidays everyone!
The info about working with a DME is so helpful -- strange, new world out there for me.
They're inquiring now if my insurance will require me to rent or if I can purchase outright. I'll call insur. tomorrow also.
I had a large number of central apneas (great -- my brain doesn't talk to my body!) Does that affect anything that I'm doing equipment-wise?
Think I'll stick with the doc and DME so I can get the support and follow up I'm looking for as well. It'll all work out, no doubt. Timing is the issue -- if I wait until nest year to purchase, I'll still get my insurance deductible out of the way for '07 although I doubt I will incur the $1000 worth of costs to use up the deductible if not through the purchase of the CPAP.
I CAN do this -- just a need to be patient.
Thanks again to all of you for all your do -- this is a wonderful group of peps!
Happy holidays everyone!
I know from firsthand experience that isn't true! My DME has outright refused to give me the auto machine. She told me her manager said I CAN'T HAVE IT! I have found another DME in my area that has no problem filling my prescription as written as long as the ins co agrees to it. I have spoken to the ins company and they also said it should not be an issue. Beware of DME's that give you a hard time over YOUR treatment. I am more tired playing these silly games, than I was having sleep apnea!Cathy-if your doctor writes for an auto that's what they have to give you.
-
SelfSeeker
- Posts: 779
- Joined: Tue Sep 19, 2006 6:25 pm
Yes Cathy,
You can do this.
Cathy, you asked about Central apneas.
I am not sure of the specifics but there are some warnings about using Auto with Central apneas for various reasons. A high pressure may cause more centrals as well.
I do not know at what severatiy of Central apnea would a Bi-level machine be used, maybe not. Not sure.
Sorry, I can't be more useful about Central apnea. Maybe doing a search on it, you may get more answers and ask more questions.
Do you know how high your pressure is going to be?
You can do this.
Cathy, you asked about Central apneas.
I am not sure of the specifics but there are some warnings about using Auto with Central apneas for various reasons. A high pressure may cause more centrals as well.
I do not know at what severatiy of Central apnea would a Bi-level machine be used, maybe not. Not sure.
Sorry, I can't be more useful about Central apnea. Maybe doing a search on it, you may get more answers and ask more questions.
Do you know how high your pressure is going to be?
DenverCathy wrote:...
The info about working with a DME is so helpful -- strange, new world out there for me.
They're inquiring now if my insurance will require me to rent or if I can purchase outright. I'll call insur. tomorrow also.
I had a large number of central apneas (great -- my brain doesn't talk to my body!) Does that affect anything that I'm doing equipment-wise?
Think I'll stick with the doc and DME so I can get the support and follow up I'm looking for as well. It'll all work out, no doubt. Timing is the issue -- if I wait until nest year to purchase, I'll still get my insurance deductible out of the way for '07 although I doubt I will incur the $1000 worth of costs to use up the deductible if not through the purchase of the CPAP.
I CAN do this -- just a need to be patient.
Thanks again to all of you for all your do -- this is a wonderful group of peps!
Happy holidays everyone!
I can do this, I will do this.
My disclaimer: I'm not a doctor, nor have I ever worked in the health care field Just my personal opinions.
My disclaimer: I'm not a doctor, nor have I ever worked in the health care field Just my personal opinions.
Yes last poster I concur.
Even with a script for AUTO the DME doesn't have to give it (other than to charge you for the whole thing out of your pocket then the won't care if they give you one) if your insurance won't pay. All policies are different. Some cover Auto some don't.
AND my personal experience is that the Insurance company employs its own doctor who reviews your records (doesn't meet you), and decides what you need and can overrule your doc. Of course you can appeal, but who do you think wins? I know this for a fact who won in my case on appeal.
On the Pro2 discussion. Wulfman is correct. Pro2 is a nice machine and works well for most people. As he said some even do better on fixed pressures. A number of us here prefer the auto for flexibility if we are spending our own money or can manage to get the insurance to pay but basically any well built machine with data capability will do the job just fine.
You now mention central apneas. I am not a doctor, but with CA you may very well be much better off with the straight CPAP. Had you mentioned that up front I think you woudn't have gotten as much encouragement to get the auto.
If you have already met this year's deductable (I think you said you had) there is really no reason for you to wait to get the machine. You won't save any money by waiting and will just delay your treatment.
You sound like you like the confort of having a DME on call. If that is the case and given your central apneas you probably should go get the pro2 (as long as you are good with the price and your portion of it). If not visit another local dme to compare. Definately check quickly with your insurance to see if you have to rent or if you can purchase (squeeze it in this year and save yourself a bundle).
Only other good option I can think (if you have to rent for a while) of is if you are a healthy person and won't use much or any of that $1000 deductable for 2007 you can get the pro2 online for $540 cash out of pocket with humidifier or $484 without (could get humidifier and mask from dme and since these are purchased (2006) immediately you could get insurance coverage without paying 2007 insurance deductable).
But as I said, you sound like you want DME support and I want you to do what makes you comfortable and you where you feel you have the support to succeed. Sometimes $$ don't rule everything.
Even with a script for AUTO the DME doesn't have to give it (other than to charge you for the whole thing out of your pocket then the won't care if they give you one) if your insurance won't pay. All policies are different. Some cover Auto some don't.
AND my personal experience is that the Insurance company employs its own doctor who reviews your records (doesn't meet you), and decides what you need and can overrule your doc. Of course you can appeal, but who do you think wins? I know this for a fact who won in my case on appeal.
On the Pro2 discussion. Wulfman is correct. Pro2 is a nice machine and works well for most people. As he said some even do better on fixed pressures. A number of us here prefer the auto for flexibility if we are spending our own money or can manage to get the insurance to pay but basically any well built machine with data capability will do the job just fine.
You now mention central apneas. I am not a doctor, but with CA you may very well be much better off with the straight CPAP. Had you mentioned that up front I think you woudn't have gotten as much encouragement to get the auto.
If you have already met this year's deductable (I think you said you had) there is really no reason for you to wait to get the machine. You won't save any money by waiting and will just delay your treatment.
You sound like you like the confort of having a DME on call. If that is the case and given your central apneas you probably should go get the pro2 (as long as you are good with the price and your portion of it). If not visit another local dme to compare. Definately check quickly with your insurance to see if you have to rent or if you can purchase (squeeze it in this year and save yourself a bundle).
Only other good option I can think (if you have to rent for a while) of is if you are a healthy person and won't use much or any of that $1000 deductable for 2007 you can get the pro2 online for $540 cash out of pocket with humidifier or $484 without (could get humidifier and mask from dme and since these are purchased (2006) immediately you could get insurance coverage without paying 2007 insurance deductable).
But as I said, you sound like you want DME support and I want you to do what makes you comfortable and you where you feel you have the support to succeed. Sometimes $$ don't rule everything.
From what I've read since my earlier post, the Central apneas could be a problem.....and I would strongly urge you to get the software to monitor your therapy. It's possible (as has been mentioned) that you may need a (special) Bi-PAP, so documentation would be extremely important.
I also see a problem with your doctor and DME being in cahoots.....be sure to get your prescription (preferrably the original).
A problem I see with getting a humidifier (separately) from your local DME would be that they would most likely charge your insurance about $400 just for that one item.....almost the price of the CPAP itself (from CPAP.COM).
And, as snoregirl mentioned, if your insurance is on a calendar year with deductibles, you would get "dinged" again in January. You can check with your insurance provider and see if they'll reimburse you for our-of-pocket purchases if you purchase from someone like CPAP.COM. (Many will) If they will, maybe they could reimburse you before the end of the year.
Good luck.
Den
I also see a problem with your doctor and DME being in cahoots.....be sure to get your prescription (preferrably the original).
A problem I see with getting a humidifier (separately) from your local DME would be that they would most likely charge your insurance about $400 just for that one item.....almost the price of the CPAP itself (from CPAP.COM).
And, as snoregirl mentioned, if your insurance is on a calendar year with deductibles, you would get "dinged" again in January. You can check with your insurance provider and see if they'll reimburse you for our-of-pocket purchases if you purchase from someone like CPAP.COM. (Many will) If they will, maybe they could reimburse you before the end of the year.
Good luck.
Den
(5) REMstar Autos w/C-Flex & (6) REMstar Pro 2 CPAPs w/C-Flex - Pressure Setting = 14 cm.
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
"Passover" Humidification - ResMed Ultra Mirage FF - Encore Pro w/Card Reader & MyEncore software - Chiroflow pillow
User since 05/14/05
The only way to get an Auto WITHOUT a prescription that states "Auto Cpap", is to buy online.
You need your doctor to give you a prescription for an Auto before you can take on the DME. If your doctor gives you the prescription for the Auto then you should be able to insist that you be given one. Your insurance company should not even be involved in which machine is given to you. They pay the DME the same money whether it is a basic cpap or an auto cpap (same billing code). Keep them out of it. Just be sure the DME is on your list of covered providers.
Here is a link to the thread I started describing my quest for an Auto.
viewtopic.php?t=15015&highlight=
Remember this is a machine you will have to live with for 5 years or more. Get what you want now. The great thing about the Auto is it can be set as a straight cpap as well. So if straight cpap proves to be better for you then you have the machine that can provide it.
Stick to your guns and don't be afraid to go toe to toe.
I hope this helps and good luck.
DB
You need your doctor to give you a prescription for an Auto before you can take on the DME. If your doctor gives you the prescription for the Auto then you should be able to insist that you be given one. Your insurance company should not even be involved in which machine is given to you. They pay the DME the same money whether it is a basic cpap or an auto cpap (same billing code). Keep them out of it. Just be sure the DME is on your list of covered providers.
Here is a link to the thread I started describing my quest for an Auto.
viewtopic.php?t=15015&highlight=
Remember this is a machine you will have to live with for 5 years or more. Get what you want now. The great thing about the Auto is it can be set as a straight cpap as well. So if straight cpap proves to be better for you then you have the machine that can provide it.
Stick to your guns and don't be afraid to go toe to toe.
I hope this helps and good luck.
DB
-
Guest
DerekB
You say
_____________________________________________________________________
"Your insurance company should not even be involved in which machine is given to you. They pay the DME the same money whether it is a basic cpap or an auto cpap (same billing code). Keep them out of it"
-------------------------------------------------------------------------------------
Great suggestion to keep the Insurance company out if it (of course after you inquire and understand your benefits) if at all possible.
BUT and it is a very big but, if the DME won't give the APAP as e0601 and wants to use that other misc billing code -- mattman mentioned the numcer in a previous thread (to try to recoop more $$ and they do this because the contract between the DME and the Insurance excludes APAP (whichgives them leverage not to spend the money) and this is a very real possibility, then, while the Insurance company does not have a say in what treatment provides, they do very definately have a say in what they pay for. They all have doctors who review cases and can rule that the treatment is unnecessary or some other treatment will suffice and deny coverage for the treatement (in this case APAP).
So a DME or Insurance company cannot tell a person they can't have treatment that a doctor prescribes, they can tell the person that they won't pay since it is not covered in their policy or is not medically necessary. This of course could be resolved as a last resort thorugh the court system. But I would bet many of these would be very hard to prove the medical necessity of APAP.
Wulfman.
Just a comment on the price of a heated humidifier. I was charged what you mention for the humidifier when I got it WITH my machine through the local DME. Of course I did this since insurance was paying and my deductable was satisfied. The reason I suggested this to Cathy, was not that the price isn't outrageous, but assuming 20% copay and 2006 deductable satisfied and the humidifier is not a rental but a purchase in 2006 then she would pay $60 to $80 instead of just over $80 cash. Of course since I don't know Cathy's copay she would have to look and see if it is cheaper to buy out of pocket as a bundle online, or with insurance from DME. It does seem like 20% copay is about the break even point. So you are most likely right about buying it all together if going cash online. I was thinking of the stand alone humidifier price of close to $150 online. All depends on deducatble in the insurance policy.
You say
_____________________________________________________________________
"Your insurance company should not even be involved in which machine is given to you. They pay the DME the same money whether it is a basic cpap or an auto cpap (same billing code). Keep them out of it"
-------------------------------------------------------------------------------------
Great suggestion to keep the Insurance company out if it (of course after you inquire and understand your benefits) if at all possible.
BUT and it is a very big but, if the DME won't give the APAP as e0601 and wants to use that other misc billing code -- mattman mentioned the numcer in a previous thread (to try to recoop more $$ and they do this because the contract between the DME and the Insurance excludes APAP (whichgives them leverage not to spend the money) and this is a very real possibility, then, while the Insurance company does not have a say in what treatment provides, they do very definately have a say in what they pay for. They all have doctors who review cases and can rule that the treatment is unnecessary or some other treatment will suffice and deny coverage for the treatement (in this case APAP).
So a DME or Insurance company cannot tell a person they can't have treatment that a doctor prescribes, they can tell the person that they won't pay since it is not covered in their policy or is not medically necessary. This of course could be resolved as a last resort thorugh the court system. But I would bet many of these would be very hard to prove the medical necessity of APAP.
Wulfman.
Just a comment on the price of a heated humidifier. I was charged what you mention for the humidifier when I got it WITH my machine through the local DME. Of course I did this since insurance was paying and my deductable was satisfied. The reason I suggested this to Cathy, was not that the price isn't outrageous, but assuming 20% copay and 2006 deductable satisfied and the humidifier is not a rental but a purchase in 2006 then she would pay $60 to $80 instead of just over $80 cash. Of course since I don't know Cathy's copay she would have to look and see if it is cheaper to buy out of pocket as a bundle online, or with insurance from DME. It does seem like 20% copay is about the break even point. So you are most likely right about buying it all together if going cash online. I was thinking of the stand alone humidifier price of close to $150 online. All depends on deducatble in the insurance policy.