3 month trial ???

mch441 · Post by **mch441** » Wed May 28, 2008 3:56 pm

my wife after some pushing by be was recently diagnosed with moderatly severe sleep apnea and her doctor sent here a letter stating that she has been aprroved for a 3 month cpap trial.i dont really get why they would give you a machine to use for 3 months then take it away,just doesnt make any sense to me.when i got my bipap i was to rent it for 10 months then i owned it and there was never any talk about a trial period .has anyone had any experience with this and can tell me exactly what this means to us ???

her insurance is thru my work and when they dropped the machine yesterday the tech told here that it was paid in full and that she owned the machine which also makes no sense to me since i have a 30 percent copay on durable equipment???
the name of the supplier is PRAXAIRE im thinking the guy just had no clue what he was talking about but well gladdly take the machine for free if that is the case !!

sleepycarol · Post by **sleepycarol** » Wed May 28, 2008 4:13 pm

Your PRAXAIRE is different from ours. Ours handles different types of gases -- oxygen, acytelene (for welding buy don't know how to spell it), etc. I thought they were a chain of suppliers. As far as I know they do not handle any DME here.

doxiedad · Post by **doxiedad** » Wed May 28, 2008 7:07 pm

I also use Praxair as my DME and love them! praxair.com shows it is a huge company

Slinky · Post by **Slinky** » Wed May 28, 2008 8:02 pm

Praxaire has an office in Rochester, MN just a block kitty corner from Mayo Clinic's Gonda building. They handle respiratory equipment. It is in the same building as the Day's Inn and I was surprised my local (Michigan) DME supplier didn't arrange for my 02 concentrator w/Praxaire instead of a company from Olmsted, MN. I was staying at the Day's Inn!! Turns out that Praxaire would NOT give my local DME a reasonable price for my equipment for that week. They got a better prcie having it provided by the company in Olmsted. Go figure!

new-to-BiPAP · Post by **new-to-BiPAP** » Fri May 30, 2008 6:43 pm

I've a similar experience. My hubby was told to get a CPAP machine last week. They had him buy it outright. He used a different sleep study place and DME (thru the sleep study place). Mine was dx as mild and I was told to go to an ENT and try some things at home first. Then they said I should rent the machine to see if it helps. My DME says that the insurance doesn't like to pay for it outright because people don't necessarily use them. My hubbies DME said the opposite! They said the insurance doesn't like people to rent the machine! Dunno if that makes sense...it certainly didn't to us. Maybe because the dr reluctantly diagnosed...wants to make sure it will help? I have been given a 1 month trial (had to buy everything but the machine which was to rent). Dunno why they do different things for different ppl with the same insurance...*shrug* Hope the machine helps her!

Slinky · Post by **Slinky** » Fri May 30, 2008 8:09 pm

Because some local DME suppliers are "less than truthful" AND because most local DME suppliers tend to not volunteer the "full" truth. They almost always have their profit margin close to the surface in their minds when dealing w/patients.

The closest you are going to get to the truth is thru your own phone call to your insurance company. What local DME CPAP suppliers are they contracted with and what are your DME CPAP benefits, copays and deductables. Do they rent w/option to buy (capped rental), rent one to 3 months, then purchase outright?, etc. etc. They reimburse by HCPCS code so don't waste your time and theirs asking about brands and models.

All CPAPs from bare bone compliance data only (and some don't even provide that) thru fully data capable CPAPs w/some form of expiration relief thru some autoPAPs are classified under one HCPCS code: E0601. Obviously there is a differnence in cost between each of the brands and models. But insurances contract by HCPCS code so they pay ONE set contracted price for HCPCS code E0601 regardless of whether or how many options the various brands and models have. And just as obviously the local DME supplier stands to enjoy a greater profit margin by providing a bare-bone CPAP than a fully data capable autoPAP w/some form of expiration relief and any xPAP in between.

Bi-levels (Bi-PAPs and VPAPs) plus the SVs, STs have entirely different HCPCS code than the CPAPs.

And when it comes to masks and mask exchange policies: Resmed, Respironics and Fisher & Paykel ALL replace FREE to the local DME supplilers most of their respective masks that patients have tried w/o success IF the local DME supplier fills out a form and returns the mask w/in 30 days.

Just another little "secret" most local DME suppliers would rather you didn't know and most likely wouldn't volunteer that info.

If you have the option of more than one local DME supplier "in network" and you aren't satisfied w/your xPAP or your supplier AND most important, you've had your xPAP less than 30 days. Shop your other "in network" local DME suppliers, see who will give you the xPAP you DO want and return your current xPAP and go w/the local you fee most comfortable with that will provide the equipment you want.

mch441 · Post by **mch441** » Mon Jun 02, 2008 11:07 am

my worry is that they are going to tell us in three months that they are coming to get their machine back and im going to be fighting with the insurance company over it.

Slinky · Post by **Slinky** » Mon Jun 02, 2008 11:50 am

mch441 wrote:my wife after some pushing by be was recently diagnosed with moderatly severe sleep apnea and her doctor sent here a letter stating that she has been aprroved for a 3 month cpap trial.i dont really get why they would give you a machine to use for 3 months then take it away,just doesnt make any sense to me.when i got my bipap i was to rent it for 10 months then i owned it and there was never any talk about a trial period .has anyone had any experience with this and can tell me exactly what this means to us ???

her insurance is thru my work and when they dropped the machine yesterday the tech told here that it was paid in full and that she owned the machine which also makes no sense to me since i have a 30 percent copay on durable equipment???
the name of the supplier is PRAXAIRE im thinking the guy just had no clue what he was talking about but well gladdly take the machine for free if that is the case !!

Requesting a copy of both the doctor's dictated results (1-2 pages each) AND the full scored data summary reports w/condensed graphs (5+ pages each) from both your wife's sleep evaluation AND her titration studies PLUS a copy of her equipment order (script) from the sleep lab might well shed some light on the confusion about her xPAP machine.

These reports and the script are a part of her medical records and in the USA patients have a LEGAL RIGHT to copies of their medical records under HIPAA.

It may also be that your insurance company requires a full 3 months of compliance prior to their purchasing the xPAP outright to ensure that they don't pay for something that ends up gathering dust in the attic or sold at a garage sale.

pjd · Post by **pjd** » Tue Jun 03, 2008 6:26 am

My take on the rental thing is that with the rent to own in ten months the payments are not evenly divided. The first three months are considered compliance testing, but the DME is able to bill for about ninty percent of their total take for those first three months of rental. If you prove compliant then they continue billing at a much reduced rate for the remainder of the rental period, or until the max payable amount is reached.

This really works out great for the DME who can start you off with a used "rental" unit and bill you for most of their total payment as if you recieved a "new" unit. And then if you are not compliant they win again by getting their rental back for the next person in line. If you prove compliant they win with passing on a slightly used machine and now have you for all your consumables and future "maintaince".

Of course your situation is probably diffrent, and your Dr just wants to make sure you don't end up owning something you do not use. Sort of like leasing a car; paying for the depreciation and wear and tear of a new car and returning the unused part, but with the PAP its like returning the car after three months when you have a prepaid three year lease.

Just my take on things.

Rankbud · Post by **Rankbud** » Sat Jun 14, 2008 7:40 am

The new medicare guidelines recommend giving CPAP for 12 weeks to see if the patient is benefiting from the therapy. Of course the definitions of benefit can vary. CMS recommends not continuing therapy in event of absence of benefits or adherence to PAP therapy.

rested gal · Post by **rested gal** » Sat Jun 14, 2008 8:47 pm

I was thinking the same thing Rankbud wrote about...the doctor may have been referring to Medicare's recent change in how cpap treatment is handled if Medicare is doing the reimbursing.

Many insurance companies follow Medicare's guidelines. Not all insurance companies do, but many do.

mch441 wrote:my worry is that they are going to tell us in three months that they are coming to get their machine back and im going to be fighting with the insurance company over it.

My guess: If she uses the machine at least 4 hours a night five times a week (that's called "being compliant") during those three months; and when asked, "So, Mrs. ___, how are you feeling now?" replies, "Better! I think the machine is helping me." insurance will keep paying.

By the way, only 4 hours a night is not enough for effective treatment...the machine should be used for every sleeping moment, including naps. But 4 hours a night is enough to prove "compliance", meaning...insurance will say, "Yeah, the lady is using it, so we'll keep paying for it.

new-to-BiPAP · Post by **new-to-BiPAP** » Mon Jun 16, 2008 12:01 pm

oh...I'm glad to know what 'compliant' means in hours, thanks Rested gal! My hubby is having problems using his (but he had to pay outright for his) and I don't think he is 'technically' being compliant. I am renting mine...tho the dr doesn't care about compliance...my compliance meter is acting very strange indeed...so I am thankful that should not be an issue...hopefully!

feeling_better · Post by **feeling_better** » Mon Jun 16, 2008 2:21 pm

rested gal wrote:Many insurance companies follow Medicare's guidelines. Not all insurance companies do, but many do.

I think, even among the companies which follow Medicare guidelines, only their HMO types do this. The PPO types do not follow this.

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