People with DME experience getting APAP vs. CPAP

schleima · Post by **schleima** » Tue May 13, 2008 11:34 am

Hi everyone--

I've been going through some DME/doctor hell lately... I won't recap here, but feel free to read my previous posting:

viewtopic/t30741/My-time-for-xPAP-has-c ... -Help.html

My question now is this:

For those of you with actual, real life experience securing APAP (not CPAP) from your DME, can you relate your story to me here?

I would like to avoid getting comments from people who do not have real life experience securing APAP (not CPAP) with insurance/DMEs

The reason is that I was told by my insurance company (Blue Cross) that because of insurance code restrictions (like the famous and oft repeated A0601), network providers are in fact allowed to charge the patient extra for "luxury" upgrade models. My DME, Aircare, wants to charge me an additional $400 for an APAP machine under this policy, even if the doctor prescribes it.

Everything I've read here at CPAPtalk.com says "The insurance pays the DME at one code, and they have to suck up the rest." However this seems totally contrary to what my own insurance company has told me.

SO... for those with practical, actual experience having their insurance pay for APAP through a DME, can you share your stories with me?

Thanks!

Linda3032 · Post by **Linda3032** » Tue May 13, 2008 11:42 am

Do a search on this site, there are many stories of how others obtained their Apaps.

Many of them simply changed DME's (if you are able to do that), and found one that was willing to upgrade at no additional charge.

schleima · Post by **schleima** » Tue May 13, 2008 12:04 pm

Linda3032 wrote:Do a search on this site, there are many stories of how others obtained their Apaps.

Many of them simply changed DME's (if you are able to do that), and found one that was willing to upgrade at no additional charge.

I have read through this site but it is difficult to tell which stories are second hand accounts and which posts are from people who have actual experience.

I'm hoping to make this a sharply focused thread with replies only from people who have actually gone through the experience of securing APAP from their DME/insurance.

I live in LA, and will be seeing a new sleep doctor tomorrow, and so I am hoping that he can direct me to several different DMEs.

Mr Taster

ww · Post by ww » Tue May 13, 2008 12:39 pm

The DME said they were bringing me a really nice CPAP that was data capable. It was the ResMed, but I told them not to bring it as I wanted the Respironics Auto w Humid and Aflex. They had to call my Dr and get the prescription changed, but I got it ok with no additional charges. I had also gone to another DME and explained the situation, and they said they could supply it for me, so I actually had at least two people willing to provide me an Auto Resp. You can usually find several DME's on the West Coast, so why don't you meet with them face to face and get what you want? You can also just purchase the DS510HS Respironics Auto PAP w smart card, heated humdifier and aflex for $596 on line. Based on 60 months of typical usage, that only comes to $10/month out of pocket for some well deserved sleep. If you check with your Insurance Company, they might work a deal with you since it actually costs them a lot less. The headaches will be yours and not theirs if something doesn't work, but that is not likely.

I also noticed that some of the companies that bill Medicare and Insurance companies solved the problem by NOT selling the high end machines like the DS510HS, or comparable ResMed machines. Good Luck.

bap40 · Post by **bap40** » Tue May 13, 2008 12:56 pm

I got mine from my 2nd DME, after the first one refused. I had my own GP write a script for exactly the machine I wanted and the 2nd DME happily got it for me. As far as my insurance goes, this is a rental for 12 months. After that time period if the machine is not totally paid for I am responsible for the rest. After doing the math, by the years end, it will be paid for with no out of pocket for me.

I was titrated on CPAP at 10cm. After getting my APAP and using it in auto for awhile. I have found my ideal pressure of 13cm so far. If I had not switched DME's and gotten my doc's prescription for the auto, I would have been doing a lot worse than I am since 13cm is higher than original 10cms.

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

schleima · Post by **schleima** » Tue May 13, 2008 1:00 pm

ww wrote:If you check with your Insurance Company, they might work a deal with you since it actually costs them a lot less. The headaches will be yours and not theirs if something doesn't work, but that is not likely.

The way my insurance works is that for network providers, they pay 100% after $250 deductible is met (which I have done). For non-network providers (like CPAP.com, for example) they pay 80% after a $500 deductible. If I were to buy a machine out of pocket, it would cost me the additional $250, plus 20%... say $150. Certainly a little cheaper than paying cash, and a lot less hassle, but when I consider the alternative is a 100% free CPAP, I don't think I can pass that up.

NightHawkeye · Post by **NightHawkeye** » Tue May 13, 2008 1:12 pm

schleima wrote:The way my insurance works is that for network providers, they pay 100% after $250 deductible is met (which I have done). For non-network providers (like CPAP.com, for example) they pay 80% after a $500 deductible. If I were to buy a machine out of pocket, it would cost me the additional $250, plus 20%... say $150. Certainly a little cheaper than paying cash, and a lot less hassle, but when I consider the alternative is a 100% free CPAP, I don't think I can pass that up.

Now, the thing your insurance didn't tell ya is that if you purchase outright through CPAP.com and submit a claim, then they reimburse you the same as in-network, at least my BC/BS insurance did. They paid 100% on about $1600 for auto-BiPAP, mask, HH, etc. And, yeah, they told me the same thing about online providers being out-of-network.

It may be academic though if you can find a local provider willing to provide you with an APAP. Otherwise, it might be worth another call or two to find out if they will reimburse you same as in-network if you file the claim.

Regards,
Bill

yardbird · Post by **yardbird** » Tue May 13, 2008 1:18 pm

It's not a "luxury" if your doctor prescribes it and checks the "Dispense as Written" box on the script.

When I saw what a local DME charged my insurance company for a mask I almost gagged. Therre's a code for a cpap mask, complete with headgear, etc. Then there are codes for replacement parts.... headgear, hose (short), hose (long), cushions, and so on. They charged my insurance company the PER PIECE codes instead of the mask-complete code and my insurance paid it.

What's the big deal if they gave me everything it said, right?

I have 50% copay on durable medical equipment. My COPAY was more than the cost of the mask-complete!

When I wanted my APAP I got my REGULAR doctor to write the script.

I understand what you're saying about deductibles and all that junk. Consider what your time is worth. Consider what getting what you want is worth. You're going to have it a while

DreamStalker · Post by **DreamStalker** » Tue May 13, 2008 1:33 pm

I was given a CPAP on day one. I now have 2 APAPs.

My experience? I wrestled my doc/dme conflict of interest combo into trading my CPAP for an APAP with less hassel than many on this forum have had.

Nevertheless, if I had to do it all over again ... I would have just purchased from CPAP.com and paid out-of-pocket in the first place (which is what I ended up doing in the end). The unit they gave me was recalled after the first 6 months and when I got a new replacement, I sold it and purchased the APAP I really wanted from our host. I then purchased a second one as back-up. Of course by then I understood well optimal treatment vs. poor or non-treatment.

The problem is that most people place to little value in their own health. So you fight your DME over an APAP ... what difference will it make if in the process you get all stressed out and have a heart attack or stroke due to having to wait and fight a DME/doc?

People have no problem plopping down a couple of grand on a trip to Disney or Las Vegas or to buy a wide-screen TV or a new PC to surf the web ... but they get all fired up about not wanting to pay half that out-of-pocket for an APAP. Its all about priorities but as is often the case -- different strokes for different folks.

Just buy the damn thing and get PAPing!

Best of luck to your health!

pratzert · Post by **pratzert** » Tue May 13, 2008 1:53 pm

APRIA would NOT give me an APAP machine even though my sleep Doc had very specifically written my prescription for an APAP machine.

I ended up buying it from CPAP.COM and submitting the charges to my insurance company as an out of network provider.

Ya... it ended up costing me out of pocket to get the machine my Doc said I needed, but it was worth it just to be able to stop dealing with those fools at APRIA.

Maybe it's an option for you if you want a specific machine.

Tim

CentralScrutinizer · Post by **CentralScrutinizer** » Tue May 13, 2008 2:05 pm

I don't understand... If Blue Cross told you that they pay a single fee to a DME and that the DME can charge you more if you want a "luxury" model if they want... Why don't you believe them?

I think it's pretty clear, you have several options.. You take a straight CPAP.. you shop around for a DME that will NOT charge you extra for a luxury model... You pay the extra fee for a luxury model... or you buy one on line for about $500 and work through the paperwork to get Blue Cross to reimburse you as a out of network provider.

xyz · Post by **xyz** » Tue May 13, 2008 3:30 pm

> Why don't you believe them?

Because history shows that they're often wrong. That goes for DMEs and also your insurance company's customer service with regard to DME issues. It's a simple fact of life.

Here's a "qualifier" when you call your insurance company. Ask the C.S. rep what "DME" stands for. If they can't answer that right, you can't believe anything they say.

the O.P.:
> will be seeing a new sleep doctor tomorrow, and so I am hoping that he can direct me to several different DMEs

Have your doctor write the model number on the prescription and "do not substitute".

snoregirl · Post by **snoregirl** » Tue May 13, 2008 3:40 pm

You can search on my id for posts. All first hand experience. For a very gross recap I got my APAP from Apria by holding out and hounding them. Of course I got my doc (GP) to write for one, then I just kept answering their calls "We have your machine ready" they would say,, "my apap???" I would say, after about 3 or 4 calls like this they caved. Total copay about $250(apap, humidifier and mask). Backup machine (same machine) from CPAP.com and all future supplies from them too. I never meet my annual deductable (other than in the sleep study year) and it is much cheaper to buy online.

As for $400 luxory fee??? My invoice says E0601. Have you looked at what the machine would cost you out of pocket? Not all the much more. And some have been successful at out of network reimbursement..I will leave those stories up to them since I was not able to make that happen.

sleepycarol · Post by **sleepycarol** » Tue May 13, 2008 6:51 pm

Here is my story and how I dealt with it.

With my script in hand I went to the local DME to pick up my machine. I wanted to deal locally so I chose a DME that is locally owned. I expected great service and knowledgeable and caring sales reps. They appeared to be very caring and waited on me promptly. Gave me all the necessary paperwork, forms to sign, etc. and then had the RT talk with me. She went to the back and brought out my machine. I was uninformed and didn't know a cpap from a car battery, truth be told. My script was for a "smart cpap -- range 8 to 12 -- with heated humidifier and a Fisher and Paykel 431 full face mask." When the RT set the cpap on the table she made a big deal that the doctor knew what he was doing as the had "prescribed for me the Cadillac of masks." The RT went on and on about how that mask was the most expensive mask there was and how it was the best mask available, etc. etc. She then preceeds to show me the cpap machine. I didn't know any better and she shows me the M series Plus machine with the heated humidifier. She states that it is a great machine and even shows me the data card and tells me how she can read "my data" from it. She sets the pressure at 10. When I asked about the range of pressures she tells me that the doctor "always" prescribes a pressure range and that they pick the middle pressure as the "set" pressure. She, also, told me some outlandish tales about bipaps.

I read and read the postings on this site and asked a bunch of questions. After 2 weeks I felt worse and knew that the sleep tech and said that I needed a pressure of 12 to keep events from happening. I took my machine out there and asked them to reset the pressure to 12 as written on my script. They refused and said I would need to have the doctor call and request it -- even though it was on the script. This was on a Friday.

By then I am mad!! On Monday, I am now aware that I was prescribed an apap with a range of pressures. I call my insurance company and ask them what other options are available to me and if I can switch DME's. I, also, call the doctor and tell them I will be switching DME's. I took the Plus machine back to DME #1 and fire them. Went to another DME and got an apap machine as prescribed with a pressure range of 8 -12.

RachelM · Post by **RachelM** » Tue May 13, 2008 7:55 pm

I was given an APAP with data card for first month on treatment for determing what pressure was needed. Titration was not possible during sleep study. From this forum I realized what a gem I was using.

I have BCBS and checked with them before returning to dr. They said they paid for whatever doctor prescribed as necessary. Dr did try to give me a straight CPAP. He seemed surprised I knew what I wanted and had checked things out with insurance company already. They did say their policy was to charge the patient extra for APAP but they never did.

Machine

Machine	Humidifier