Reimbursement

[Sleepy all the time]

I have just been diagnosed and am praying this work because I am miserable and sleep disorders are literally ruining my life.

But I digress... Major medical insurance reimbursement is tied to Medicare. Are APAPs covered? Can one make arrangements with vendors to make up the difference? Has anyone had any experiences with this type of thing?

I know many of these question could/should be answered by my own insurance company, but I don't want to any unnecessary attention should I decide to try to be creative.

[jrfoster]

[quote="Sleepy all the time"]I have just been diagnosed and am praying this work because I am miserable and sleep disorders are literally ruining my life.

But I digress... Major medical insurance reimbursement is tied to Medicare. Are APAPs covered? Can one make arrangements with vendors to make up the difference? Has anyone had any experiences with this type of thing?

I know many of these question could/should be answered by my own insurance company, but I don't want to any unnecessary attention should I decide to try to be creative.

[Slinky]

AutoPAPS have the same billing code as straight CPAPS. Altho they cost more, the reimbursement is the same across the board for any CPAP or AutoPAP. The only other reimbursement code is for the Bi-PAP, Bi-Flex machines.

Thus DMEs will tell you that Medicare won't pay for an AutoPAP. Medicare does, but it can take some real jumping thru hoops and support from your doctor including medical documentation of the need. At least that's the way its been explained to me. There are those on the forum who have received Medicare payment for an AutoPAP.

[mattman]

Hiya Sleepy all the time -

I know this is a really difficult time. There's a lot going on right now. I definately feel for you.

Things can be different based on if you actually have Medicare vs private insurance. I suspect from your post that you actually have private insurance so I will focus on that.

Yes in many cases both for coverage criteria and for fee schedules most private insurances follow Medicare Guidelines. The biggest difference comes in items not normally covered which is what we are focusing on.

Most Insurance companies have deemed Auto-Titrating CPAP devices as 'luxury items' that do not provide a substantial benefit over standard cpap devices. This means that they do not have thier own billing code and are not seperately reinburseable.

There is 1 code for a CPAP device - E0161.

However, in many cases a DME provider can bill a CPAP using E0161 and actually provide an APAP and simply eat the difference in cost. This will depend on the specific insurance contract and if it will allow for such. Some insurances are very specific in that you must provide exactly what you bill. Then it will depend upon the specific DME company and if they are willing to do this. Some are, some aren't.

In some cases a provider can bill a CPAP using E0161 and actually provide an APAP and then bill the patient the difference in cost. This is again dependant upon the specific insurance company and thier contract. Then it would also depend upon the specific DME and if this is something they will do. Again - some will and some won't.

Finally, a situation essentially unique to private insurance companies is the ability to attempt to go through the Medical Review board of your insurance company and attempt to get the APAP specially approved. This is a lengthy process (In many cases taking 6-8 months) involving a great deal of work between your DME company, your Doctor and your insurance. Due to the amount of time involved not all DME providers are willing to go down this road. It's not uncommon for us to end up with files several hundred pages long of communications back and forth between doctors and insurance companies.
However - with this route if Medical Neccessity can be shown (Why a standard CPAP simply won't work for a patient) we have been someone successful in getting special approval for APAP devices.

I hope this helps -

mattman

[russpat]

Jeff, I too am on TriCare and I received my APAP machine last Wednesday. My DME told me that it was covered. I asked about a co-pay, but was told I didn't need to pay. However, I have a friend that also recently was diagnosed, got a machine (don't know if it's a CPAP or APAP) and he is paying a co-pay with TriCare. I expect that I will receive a bill down the line. When I went on line at my TriCare sight, it did have the approval listed as E0601, Continuous airway pressure device; E0562, Humidifier heated used with PAP; A7034-A7038, Nasal application device.

[mommaw]

SleepyAllTheTime,

To give you a simple answer to your question....YES Medicare WILL pay for an auto. They paid for mine and my husband is picking his up tomorrow!! I have the Remstar Auto (tank) and he is getting the new "M" series. The DME did no special billings, did not try to screw Medicare, just simply provided an auto for what medicare is willing to pay for a cpap machine. The DME people that tend to lurk here and come out when someone asks this question, IMHO, are trying to save ALL the DME providers money by telling you that medicare will not pay for an auto. That is just simply NOT TRUE.

[tomjax]

I do not know of any DME PEOPLE who lurk here and come out to save the DME providers money.

I do know of one who gives excellent amd accurate amswers based on his DME work.

He states OPINION clearly and makes the excellent point that different DMEs will have different policy toward apap reimbursement, but the fact remains that APAP can be provided.
Some may try to charge extra due to higher cost and $500.00 is clearly too much.
There is enough enough innacurate and gratuitous postings here that mislead others.
You can do better.

[mommaw]

tomjax,

Below, just ONE example to support MY OPINION of what is happening regarding autopaps and medicare. I did not imply that the dmes on this board, including mattman, were giving incorrect info on all subjects, merely to point out that YES medicare will pay for an auto. Or, at least, here in Kentucky they will pay my dme for one. And again, there was No secret billing codes, no cheating of the government. The invoice clearly stated that the machine was an autopap. Believe me when I say they will not bend over backwards to get you what you want nor will they resort to cheating or shady practices!

Gilda

QUOTE:

mattman



Joined: 04 Nov 2006
Posts: 166

Posted: Wed Jan 10, 2007 8:11 pm Post subject: Delete Spam

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Heya Slinky -

Sorry for the delay in getting back to you.

Here's the skinny:

As KRT said, Medicare flat out doesn't cover Autopaps. Period. At all.
There MAY be cases where you could get one covered under E1399 but I'm not personally aware of anyone who has pulled it off.
So the only way it could possibly happen is to provide the Auto under the E0601 CPAP code. There are some folks who feel it falls into the "technical" type of fraud catagory since with Medicare (As KRT said) you have to tell them exactly what's provided and it has to match with what they've approved. Since they haven't approved Autos you would have to list it as a CPAP and let's face it - that IS technically fraud. Is it the same kind of fraud as billing for something and never delivering it? No, but it is actually considered the same and people have been fined for similar situations. It's ugly and tricky and like anything with the government, NEVER simple.

[mattman]

This is a great example by the way of what I mean when I talk about just how difficult dealing with billing really is, why I mean it's a full time job and most importantly - why I keep advocating not going off on your provider that they are trying to screw you when you get different answers.

It's such a complex thing that it's no wonder there is so much misinformation and misunderstanding going on.

For reference, here is the direct quote of coverage straight from the most recent LCD with my added emphasis:

INITIAL COVERAGE:

A single level continuous positive airway pressure (CPAP) device (E0601) is covered if the patient has a diagnosis of obstructive sleep apnea (OSA) documented by an attended, facility-based polysomnogram and meets either of the following criteria (1 or 2):

1) The AHI is greater than or equal to 15 events per hour; or,

2) The AHI is from 5 to 14 events per hour with documented symptoms of:

a) Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

b) Hypertension, ischemic heart disease, or history of stroke.

Now, there is also a section where it's specifically stated that APAP units are not covered as they [I'm paraphrasing here] "do not provide a substantive medical benefit over single level cpap devices"

I'm trying to find it but as you can imagine, the manual is hundreds and hundreds of pages long and trying to find one sentance can be rough!

I'll get back to you when I do but that quote above certainly shows what I'm talking about.

mattman

[fidget]

From the Medicare manual-
Coverage and coding for autotitrating CPAP units is currently the same as conventional CPAP, using HCPCS code EO601.

I work for a major DME. Our price for an auto is $295 more than for a straight CPAP. Do you think our management is going to ok spending that much more for each unit with no better reimbursement? Not without a fight.
And if I as an employee, dispense a piece of equipment that costs that much more, I better have a darn good reason. When I have a patient that can't tolerate straight CPAP, I have to document, document to ok it with management.

If a DME is providing an auto without a major reason from a dr as to why it's necessary, they're doing it as a charitable thing. As a business, you can provide what you want, you can only bill for what Medicare allows, unless a patient agrees to private pay.

Anybody can look this stuff up at http://www.cms.hhs.gov.

[jrfoster]

Now, there is also a section where it's specifically stated that APAP units are not covered as they [I'm paraphrasing here] "do not provide a substantive medical benefit over single level cpap devices"

Why is it that APAP's are not considered as good as a CPAP? They both do the same thing by provided AP.??

Jeff in TN

[mattman]

Why is it that APAP's are not considered as good as a CPAP? They both do the same thing by provided AP.??

Jeff in TN

It's actually exactly the opposite - they consider them (APAPs) to be a "luxury" (thier term not mine). Again my paraphrase of the wording they used was that they "do not provide a substantive medical benefit over single level cpap devices".


To boil it right down - Medicare is concerneed with (Somewhat understandably) trying to find the lowest cost treatment that works. Remember we are dealing with serious numbers here. While it is true that an Autopap in some cases may even only be $100.00 more.. think about the millions of OSA patients Medicare potentially covers. Even if it's a small number - say - 1 million... that $100.00 more is now $100,000,000.00. That's a lotta zeroes! And let's face it - both those numbers are a good deal higher.

Most studies show that the AVERAGE patient will see OSA resolved to acceptable (Average AHI<5) with a standard CPAP. Therefore, as a standard issue piece of equipment - the APAP is considered a luxury. Medical Neccessity of why the patient needs the item and why the lower-cost alternative will not work is required.
Unfortunately, with Medicare this is a horrendously difficult process and therefore most providers simply won't pursue it. It literally costs much more to fight the case than it is worth.

mattman

[Wulfman]

....the APAP is considered a luxury.

We're worth it!

When one takes into consideration the fact that "the system" (insurance or Medicare) gets billed the same amount for an E0601 (RR or NU), the only factor is how much more or less profit the DME makes.
And, considering the low compliance statistics, a better machine (along with a few other factors) should translate into better compliance.
That may look like a lot of zeros, but when you consider that low compliance contributes to loss of life in automobile accidents and health costs from the medical effects of OSA.......it's a drop in the bucket, compared to the REAL costs of this affliction.

YEP......we're worth it!

Den

[fidget]

We're not the ones you need to convince. Convince Medicare, and your insurance, that APAP should be standard care, convince the manufacturers to stop producing standard CPAP.

Until then, those of us down here in the trenches don't own the DME, we don't make the decision on how company dollar is spent, and we can't give a more expensive piece of equipment than is standard care.

Y'know, I like the way Nexxium works way better than Prilosec OTC. My Dr says that Nexxium is better for my GERD. It really does make me feel better. My insurance won't pay for it since Prilosec is available over the counter. Now I could hold my breath and stamp my feet and say they OWE it to me to give me the product my Dr wants me to have. The pharmacy is glad to dispense it, if I want to pay out of pocket price for Nexxium. I have the prescription, I can sure get it, but my insurance isn't paying for it, amen. And Walgreens sure as thunder isn't going to sell it to me for the price of Prilosec as a kindness.

Maybe you all need to look at the APAP the same way, you can sure get it, if you have the script, you just have to pay for it out of your pocket.

And blasting DMEs for making a profit is just silly. They aren't non-profit organizations. They're a for profit business every bit as much as a pharmacy. They don't give things away, or they'd go out of business. And don't fool yourself, they're a BUSINESS, not a charity.

[mattman]

When one takes into consideration the fact that "the system" (insurance or Medicare) gets billed the same amount for an E0601 (RR or NU), the only factor is how much more or less profit the DME makes.
And, considering the low compliance statistics, a better machine (along with a few other factors) should translate into better compliance.
That may look like a lot of zeros, but when you consider that low compliance contributes to loss of life in automobile accidents and health costs from the medical effects of OSA.......it's a drop in the bucket, compared to the REAL costs of this affliction.

YEP......we're worth it!

Den

It is an interesting problem, isn't it?

By the way, to correct one thing:
" the only factor is how much more or less profit the DME makes."

I know lots of folks around here love to toss that out but it's simply NOT the case. There are many very specific cases where you CAN NOT provide a unit beyond what you bill for. I've said this time and time again and everyone seems to want to just ignore it but it's a fact of life.
To try to once again portray all DME providers as greedy pigs who don't care about the patient is simply UNTRUE.

However, as to the real point at hand:

There is something to be said for APAP being a better machine. There is something to be said for the fact that some people absolutely do better on an APAP than on a CPAP.
However, where does the MAJORITY lie?

Is it at all fair to say that putting everyone on APAP would increase compliance? Is there even any way to know??
Is there any way to know if putting everyone on APAP would reduce the indirect problems assosciated with OSA (The car accidents and such you allude to)?

Without knowing of any way to actually prove these things I personally think it's hard to justify the increase in costs. I admit that I am a believer (and I've stated it repeatedly) in trying the lowest cost option first and then moving up if treatment fails.

I'm just not sure that (with the way the current system works) I'm willing to fork out the extra hundreds of millions of extra dollars to provide everyone with an APAP just in case it helps more.

Of course, what I would rather see is a different system where so many of these types of things don't have to be considered but that's a whole seperate ball of wax!

mattman