Can they give me any CPAP machine they choose?

[y_chromosome]

Howdy!

I've been lurking in this forum for the past week or so, trying to soak up as much knowledge about breathing systems as I can. A couple of weeks ago I had my first sleep study, and they found 71 incidents where I stopped breathing over the course of the night. I'm ready for this to be over!

Today I go back to the sleep clinic to be given a machine. I have some significant concerns about this that I'm hoping y'all might be able to help with.

1) My insurance (Empire BCBS) says they will cover the cost of the machine for 100% of what is reasonable and necessary, but they won't tell me what that amount is. "We won't know until we're billed whether or not the cost will be covered." This makes me NERVOUS! If the sleep center charges $3,000 for a cheap DeVilbiss CPAP, and the reasonable amount is $500, Will I get a bill for $2,500??? How likely is this? Are insurance problems and vender fraud common?

2) During the titration, I almost had a panic attack when wearing the straight pressure CPAP. It felt like I was being smothered. Having some pressure relief when I exhaled was wonderful - almost like not wearing anything at all. I feel I need some form of pressure relief, like A-Flex. Can I mandate this when I talk to my doctor this afternoon?

3) I am concerned that the center might try to pawn off the cheapest machine possible on me, instead of the Respironics RemStar with humidifier + nasal pillow mask that I think would be a good choice. How much control do I have over which machine I'm given? I want to get the most flexible, best possible solution the first time, when insurance will pay for it.

I want to thank you all for the great resource you have built here. There is so much information out there on this subject that it's a bit dizzying, especially to someone who's coming into this physically exhausted and mentally confused. I feel very fortunate to have run across this site.

Scott Ferguson

[bap40]

This is the first hurdle for all of us starting therapy. Pretty much they give you what they want depending on the prescription. If the prescription says for example--CPAP only, they will give you the cheapest one they have. Ditto for a script that says AUTO... what I did was to get my family practice doctor to write me a script for EXACTLY the machine I wanted. The sleep doctor was connected to the DME as a whole unit and I fought with them for quite awhile until I got the new script. I then took my old machine back to that DME and had already started the process with the new one, and got the machine I wanted.

The best thing to do is to stick with your guns and if necessary get a new script from another doc. Any doctor can write prescriptions for CPAP, not just the sleep doc... Good Luck and keep us posted.

[rested gal]

1) My insurance (Empire BCBS) says they will cover the cost of the machine for 100% of what is reasonable and necessary, but they won't tell me what that amount is. "We won't know until we're billed whether or not the cost will be covered." This makes me NERVOUS! If the sleep center charges $3,000 for a cheap DeVilbiss CPAP, and the reasonable amount is $500, Will I get a bill for $2,500???

If the DME (the people who will be giving you the machine) have already told you they accept your insurance, then they already have a deal with your insurance company to "accept" as payment in full what your insurance has contracted to pay them for a machine, mask, supplies, regardless of what the DME bills them.

In other words, in your example they'd bill the insurance company $3,000 (knowing full well the insurance company isn't going to pay but $500) and they'll accept the $500 as payment in full. No further charge to you...you wouldn't be billed the difference. At least that's how I understand it to work according to many people who've posted on the board, including some DMEs who have posted.

You can check with the DME (the "center" you spoke of) to be sure this will be the case. But talking to any of them...insurance or DME... about billing stuff can be a runaround of no-real-answers. I don't know why it's done this way, but that's the way it seems to go.

2) During the titration, I almost had a panic attack when wearing the straight pressure CPAP. It felt like I was being smothered. Having some pressure relief when I exhaled was wonderful - almost like not wearing anything at all. I feel I need some form of pressure relief, like A-Flex. Can I mandate this when I talk to my doctor this afternoon?

Depends on how open your doctor is to what you want and how he feels about prescribing "autopap."

If the doctor is willing to prescribe "autopap" ask him to specify this one:
Respironics M series REMstar Auto with A-flex Be sure he understands to put "A-flex" (not C-flex, which is a term he's probably more familiar with...he may not have even heard of A-flex.)

But first find out whether he plans to prescribe "bipap" for you, Scott...because....

....when you described your experience with how "pressure relief" felt when that got turned on during the sleep study titration, they may have switched the lab's machine from cpap mode to bilevel mode.

If they switched you to bilevel during the sleep study, then the doctor might prescribe a bilevel machine for you. That kind of machine will have a lower pressure set for exhaling and a higher pressure for inhaling.

So, if your doctor tells you he's prescribing "bipap" or a "bilevel" machine for you, that's good! A very comfortable type of machine to use. If that's the case, I'd ask that this bilevel machine be specified on the Rx:
Respironics BiPAP Auto with Bi-flex M series. It does not have the word "REMstar" in the name.

If the doctor balks about the word "Auto" in the name of that machine call his attention to the fact that that machine can be set to work purely as a simple bilevel machine if "autotitrating" is not turned on.

3) I am concerned that the center might try to pawn off the cheapest machine possible on me --

You're right to be concerned about that, because that's almost surely what they will try to do.

-- instead of the Respironics RemStar with humidifier + nasal pillow mask that I think would be a good choice.

Well, be careful what you ask for. Asking for just "the Respironics REMstar" could mean a lot of different models with those words starting the name. Be sure to spell out the ENTIRE model name that you want.

If you have to accept simple cpap:
Respironics REMstar Pro M series (it will have C-flex in it for exhalation relief.)

Don't accept a "REMstar" with "Plus" in its name. That one cannot give full data..it records only hours of use onto its Smart Card...no useful AHI or leak data for you to see later if you want to monitor your own treatment.

If you can get an autopap:
Respironics REMstar Auto with A-Flex M series (it will have C-flex AND A-flex in it..you can use either one, can't use both at same time.)

If you are to be prescribed a bilevel (bipap) machine:
Respironics BiPAP Auto with Bi-Flex (can be set to work either way -- as a regular bilevel machine or as an autotitrating bilevel machine.)

How much control do I have over which machine I'm given?

It depends. Depends on what the doctor is willing to write on the Rx. Depends on whether the DME is willing to fill that prescription. Depends on whether the insurance is willing to pay for the "type" of machine (bilevel as opposed to straight cpap) for a new user, or whether the insurance requires all new users to use "cpap" at the beginning and have to "prove" that cpap is not working for them before the insurance will reimburse for a bilevel machine.

Note that I left "autopap" out of that "have to start with cpap before a bilevel machine will be paid for" scenario. That's because, in the eyes of insurance, an autopap is a "cpap." There are only two billing codes -- one for "cpap" (and that includes autopaps) and one for "bilevel" (bipaps, including the bipap auto.) Whether you are given a cpap or an autopap, insurance pays the agreed upon "cpap" price to the DME.

Which leads us to this....

If either the doctor or the DME try to tell you that you can't have an "autopap" because your insurance won't pay for an autopap...that it will pay "only for a cpap", that might be the DME's way of trying to wriggle out of giving you a more expensive "cpap"...the autopap. Because in the eyes of insurance, the autopap IS a "cpap"...an autotitrating cpap. It can be set to operate as just a simple cpap by not turning on "auto-titration." Of course there's more profit for the DME in giving you a simple cpap instead of a more expensive "cpap" that happens to have an auto-titrating mode too. Insurance is going to pay the DME the one set amount regardless of whether the cpap machine can have autotitration turned on or not.

I want to get the most flexible, best possible solution the first time, when insurance will pay for it.

Then either the autopap with A-flex or the bipap with Bi-flex that I mentioned would be what I'd go for.

One last thing... the humidifier. If it were me, and I were getting an M series machine, whether it be cpap, autopap, or bipap, I'd NOT want the integrated heated humidifier for an M machine. I'd have a different brand of heated humidifier specified on the Rx. I'd want the standalone Fisher & Paykel HC150 heated humidifier instead of the M series integrated humidifier. The F&P humidifier can work with ANY brand/model xpap.

Good luck, Scott!!

P.S. That was good advice from Brooke (bap40) -- that ANY doctor, even a family doctor can write the prescription for any machine you want. So, if push comes to shove and the center's doctor balks for no good reason (there can be treatment reasons for some people needing a specific type of machine) and if you have a cooperative family doc, you can get the Rx you want from your family doctor.

[CentralScrutinizer]

I have a follow up question to this... If I choose to pay for a machine on my own and my Dr has prescribed "CPAP", can I buy a Auto CPAP from a internet site with that prescription, or do I have to specifically have a prescription for APAP?

Similarly.. if I have prescription for CPAP only, can I buy a BiPAP machine using that prescription? or do I have to have a prescription specifically stating BiPAP?

[Wulfman]

I have a follow up question to this... If I choose to pay for a machine on my own and my Dr has prescribed "CPAP", can I buy a Auto CPAP from a internet site with that prescription, or do I have to specifically have a prescription for APAP?

Similarly.. if I have prescription for CPAP only, can I buy a BiPAP machine using that prescription? or do I have to have a prescription specifically stating BiPAP?

The answers are here:

https://www.cpap.com/cpap-faq/Prescript ... l#FGID-130

But, yes, you can buy an APAP on a CPAP prescription.....the insurance codes are the same.....Bi-PAP/Bi-Level are different and the prescription has to have IPAP and EPAP pressures.

If your prescription says "APAP", that's all you can get (like if you wanted to get an inexpensive CPAP for a backup machine.....you couldn't do that).


Den

[Wulfman]

y_chromosome,

REFUSE TO BE A "VICTIM"!

It's YOUR money, it's YOUR therapy......those people are working for YOU.

Don't accept anything less than a data-capable machine. There's nothing wrong with an M Series Pro.....it's a fully data-capable CPAP. Autos are nice, but not everybody needs them and for many, the therapy may not be as good as straight pressure.


Den

[canyongirl]

your doc should write a script to make sure you get a data capable machine. he should write "no substitutions or DAW"You may need to do the research for him to pick your a machine. otherwsie, the dme can give you whatever will meet your basic needs. They pay for the machine and your insurance company doesn't delineate between auto, cpap, etc. it's one billing code. so the money comes from the dme to buy the machine eventually. you will have a hard time changing it once it happens.

you will want to know your data eventually or atleast have a machine that will adjust to you.....

i learned way too late till i started to need an automachine.. data capable... and i was stuck with my straight cpap.. but im fighting the insurance company

good luck.. get data capable.. and choose a machine if you can... resmed and respeironics see, to be favorites

[bjdfw]

As someone wrote "Pretty much they give you what they want depending on the prescription." And they do what they want.

My insurance is also very good, but after the sleep study, those that did the sleep study never met with me (face to face) with their recommendations, the prescription eventually went to the insurance company and to the DME that they selected. ???? This DME called and set an appointment to delivery at my home the equipment and mask they have selected or prescribed in their wisdon.

No complaints with the CPAP machine they provided, very happy, but never was offered a chance to select among manufacturers or features. And as far as the mask, is a high quality, expensive, but too big for me, too much leaks. They show up with one mask, one size, that's it. (No sizing, no measurement, no templates, just what they provided.) Eventually bought one on my own $ that suit more my needs. In summary is sort of a strange mysterious business.

Question for the group, if after six months the insurance company pays for a replacement. How do I get one? Do I have to request through the same DME that provided the first one? How do getting replacements works?

Again, no much explanation in how they do their business.

[Pineapple]

Not knowing who your DME is, I can't tell you the exact procedure you need to follow, I would call them and ask. They should have given you this information in the first place.

I will tell you that I was given an 800 number. The young man on the phone was very good about making sure I got everything I was intitled to and needed for the month. He also told me that I would need to call in for the monthly supplies, but they would call me about the 3 month and 6 month items. There was a message on my answering machine yesterday which was my 3 month anniversary.

Don't let them dump another ill fitting mask on you, refuse it if it doesn't fit. Even if your insurance pays the money, you are paying the insurance, so you are still paying for it in the long run.