Problems getting APAP machine

[dunkonu23]

I've been prescribed an APAP machine with Aflex and data card (as well as a new mask) to replace my bare bones machine that I've had for approximately two months. The prescription was faxed to Apria The DME Wednesday morning. Thursday, I called to get status and was told I would be called later that day. No call. Today, I called Apria and asked for status. I was told my prescription had been denied by my insurance company, UHC. I called UHC and they stated they had no record of me ever having a CPAP machine. It was explained to me that if a machine costs under $1000 they don't keep track of it. UHC also told me they had no record of my prescription ever being denied.

I called Apria again, played some phone tag and finally got a man who stated my doctor didn't want me to have the new machine that he just wanted a two week tritation study and that they would send me an APAP machine that I would have to return two weeks later. When I stated that wasn't my doctors intent--and I know it wasn't because I specifically requested the machine and my doctor agreed it would be best, the Apria representative told me that the pressures ordered would not help me--the machine was ordered with settings of 7 to 15 (my original tritation study was from 5 to 12 with a prescribed setting of 7). Apria then said they'd call me Monday to set up an appointment for delivery of the temporary machine, and that was it.

I'm at a loss. Why would they deliberately ignore my prescription? Since UHC has no record of my machine and it's on rental, it's immediately a swappable item--according to my coverage. Is this normal? I'm thinking I should call my doctor Monday to get a specific request spelled out to Apria, or should I take another strategy with Apria?

Scott

[Wulfman]

I've been prescribed an APAP machine with Aflex and data card (as well as a new mask) to replace my bare bones machine that I've had for approximately two months. The prescription was faxed to Apria The DME Wednesday morning. Thursday, I called to get status and was told I would be called later that day. No call. Today, I called Apria and asked for status. I was told my prescription had been denied by my insurance company, UHC. I called UHC and they stated they had no record of me ever having a CPAP machine. It was explained to me that if a machine costs under $1000 they don't keep track of it. UHC also told me they had no record of my prescription ever being denied.

I called Apria again, played some phone tag and finally got a man who stated my doctor didn't want me to have the new machine that he just wanted a two week tritation study and that they would send me an APAP machine that I would have to return two weeks later. When I stated that wasn't my doctors intent--and I know it wasn't because I specifically requested the machine and my doctor agreed it would be best, the Apria representative told me that the pressures ordered would not help me--the machine was ordered with settings of 7 to 15 (my original tritation study was from 5 to 12 with a prescribed setting of 7). Apria then said they'd call me Monday to set up an appointment for delivery of the temporary machine, and that was it.

I'm at a loss. Why would they deliberately ignore my prescription? Since UHC has no record of my machine and it's on rental, it's immediately a swappable item--according to my coverage. Is this normal? I'm thinking I should call my doctor Monday to get a specific request spelled out to Apria, or should I take another strategy with Apria?

Scott

In a word......"Profit".
They'll make more money by slipping you a bare bones machine rather than the one you want (and apparently have been prescribed).

Always....always.....ALWAYS....get the physical document (your prescription).

That way, you know what it says. Don't let doctors fax them.....take them in person. Or, if they DO fax them, make sure you still get the original.

It also sounds like Apria hasn't sent in the paperwork to your insurance yet, either.

Den

[tdm5032c]

I have to deal with Apria for my insurance too, and all I can see is that they are TOTALLY incompetent. Just keep insisting on the machine and mask you want. They are not educated AT ALL about the new machines or the software. Both my local office and the main branch at the 1-800 number told me that Respironics doesn't sell the Encore software for these machines anymore, which isn't true. They DO sell the Encore Viewer software and it does work with ALL of their Autpap machines.

Anyway, just insist on WHAT you want. It's your treatment after all and your health.

[Colin Southern]

I'll bet you wish you could get all these people in a room at the same time!

[dunkonu23]

In a word......"Profit".
They'll make more money by slipping you a bare bones machine rather than the one you want (and apparently have been prescribed).

Always....always.....ALWAYS....get the physical document (your prescription).

That way, you know what it says. Don't let doctors fax them.....take them in person. Or, if they DO fax them, make sure you still get the original.

It also sounds like Apria hasn't sent in the paperwork to your insurance yet, either.

Den

Here's the really odd thing: I do have a copy of the prescription as faxed. Nowhere on it does it say tritation study, but my mistake seems to be as you say and that the prescription doesn't specifically say "swap" anywhere on it.

Scott

[dunkonu23]

I have to deal with Apria for my insurance too, and all I can see is that they are TOTALLY incompetent. Just keep insisting on the machine and mask you want. They are not educated AT ALL about the new machines or the software. Both my local office and the main branch at the 1-800 number told me that Respironics doesn't sell the Encore software for these machines anymore, which isn't true. They DO sell the Encore Viewer software and it does work with ALL of their Autpap machines.

Anyway, just insist on WHAT you want. It's your treatment after all and your health.

Thanks for sharing your experience. I'll be insistent and try to get to them before they call me Monday. I do wonder about the legality of an intermediary changing a prescription and interpretting intent.

Scott

[carbonman]

Thanks for sharing your experience.
Scott

23, this is such a common, repeating story.
I have to use Apria also. Same story.
If your doc will work w/you, have him write a refillable 'script,
that says something like Apap of patients choice,
mask of patients choice.

That is what I did. Apria has NO choice then.

[Slinky]

And here is another possible option - or maybe even two. Call your insurance and ask what local DME CPAP suppliers they are contracted with other than Apria. Hopefully you have the option of more than one. If you do you have a great bargaining/negotiating chip!!!

The other possibility is to ask your insurance if you would be considered "in network" if you were to purchase your equipment out of pocket (quote the better price) and submitted the paid invoice w/proper HCPCS and CPT codes would they reimburse you the cost at 100% or at what percentage of cost?

That might provide some great satisfaction to purchase your APAP online and then get your masks, etc. from Apria via your insurance thereby letting Apria know what it cost them to be such PITAs about your APAP!!!

[dunkonu23]

And here is another possible option - or maybe even two. Call your insurance and ask what local DME CPAP suppliers they are contracted with other than Apria. Hopefully you have the option of more than one. If you do you have a great bargaining/negotiating chip!!!

The other possibility is to ask your insurance if you would be considered "in network" if you were to purchase your equipment out of pocket (quote the better price) and submitted the paid invoice w/proper HCPCS and CPT codes would they reimburse you the cost at 100% or at what percentage of cost?

That might provide some great satisfaction to purchase your APAP online and then get your masks, etc. from Apria via your insurance thereby letting Apria know what it cost them to be such PITAs about your APAP!!!

The first option is a definite possibility. There are two other DME's I can use and it's my choice. I chose Apria based on a recommendation of a co-worker. I knew something was up when Apria was quoting me different re-supply intervals. The co-worker and I have exactly the same health insurance from our employer, so I approached Apria Friday with that in mind.

I will attempt the second option if necessary.

I truly appreciate the suggestions!

Scott

[Slinky]

Well, good luck! Stick to your guns! Be DIPLOMATIC, but FIRM. Don't be bashful about letting Apria know that you are aware you have other options and will be shopping your other local DME options to get the equipment that you want.

[rested gal]

I do wonder about the legality of an intermediary changing a prescription and interpretting intent.

Scott

That struck me, too, when you wrote earlier in this thread what the DME told you:

finally got a man who stated my doctor didn't want me to have the new machine that he just wanted a two week tritation study and that they would send me an APAP machine that I would have to return two weeks later. When I stated that wasn't my doctors intent--and I know it wasn't because I specifically requested the machine and my doctor agreed it would be best, the Apria representative told me that the pressures ordered would not help me--the machine was ordered with settings of 7 to 15 (my original tritation study was from 5 to 12 with a prescribed setting of 7).

When I read, "the Apria representative told me that the pressures ordered would not help me--", I thought, "WHOA!! So the Apria guy likes to play doctor??? Only we message board cpap users are allowed to do THAT!"

[Slinky]

... When I read, "the Apria representative told me that the pressures ordered would not help me--", I thought, "WHOA!! So the Apria guy likes to play doctor??? Only we message board cpap users are allowed to do THAT!"

Good 'un, RG!!!! #-o

[dunkonu23]

... When I read, "the Apria representative told me that the pressures ordered would not help me--", I thought, "WHOA!! So the Apria guy likes to play doctor??? Only we message board cpap users are allowed to do THAT!"

Good 'un, RG!!!! #-o

LOL! Yeah, that's what I've seen. But y'all aren't at all stupid about it! You have the best intentions, the Apria guy, well lets just say he's in for an experience Monday.

[sleepycarol]

I had this problem as well. Only mine was a locally owned DME of which there are two stores -- one in our community and another located about 30 miles away.

My original script was for a "smart cpap with heated humidifier range of 8 -12 and a F & P 431 mask" (I didn't dig out the script to be super specific but this is the jest of it.)

I was given a M series Plus machine set at a pressure of 10. Being new and without any knowledge of machines of course I took it. That evening I discovered this forum and started learning. Boy was I in for a rude awakening. The machine given to me was not what was ordered. When I contacted the DME they stated they had given me the correct machine -- yada yada yada.

I switched DMEs. Took them their Plus machine set it on the counter and told them they could keep it. Went to another DME. My insurance and doctor were behind me 100%. I would recommend you include them in your fight to get what was prescribed. At least mine were invaluable in my quest to get the right machine.

[rocketdork]

I had a very similar experience to yours. I don't want to hijack the thread, but I'll do a quick description of my DME experiences...

When I had my sleep study they recommended a pressure of 10 and set up an appointment with a local DME. Once I had the diagnosis, I started some research and found this forum, and CPAP.com. I wanted to get a feel for how much money I would be spending. My insurance company pays 80% after a $500 deductible. Local DME said bring a check for $587...I arrived armed with price lists from CPAP.com, and wondered what I would be getting for my money. Turns out each item in the CPAP box was itemized..$50 for the hose, $30 for the white filter, etc. The mask and headgear were itemized too. Rental for three months required by DME, total cost ~$2200. I was going to get a Respironics DS-100 with a Comfort gel mask. No data logging, cheapest Respironics offered. CPAP.com had the identical setup for $408.

I walked out of the DME without a machine.

I talked to my company about getting the machine from CPAP.com and waiving the deductible. They refused stating "if we waive the deductible for you, we have to do it for everyone." They would require me to go "out of network" to purchase from CPAP.com with a $1000 deductible and 60% payment. Still, it was lower cost to me.

I decided I didn't want the cheap machine. I wanted to be able to monitor my stats and have at least CFlex. I borrowed a machine from a friend, bought a mask at my expense from CPAP.com and started my own therapy. In the mean time, I talked to several DME's that were "in network" and really found out what a scam this business is.

Prices for xPAP machines are set by several things, the primary is by Medicare. The price is fixed by them and the DME isn't allowed to modify more than +-20% without starting an investigation of fraud. I heard this from several DME's, so I suspect its true...although, I am not sure. Additionally, the have a contract with the insurance company that won't allow them to reduce the $500 deductible or modify the price they charge for any specific machine. They *must* sign this contract to be an "in network provider".

None of the DME's that I talked with were willing to provide me with the machine I wanted...so, I made an appointment with my Dr.

He admitted two things.
1. He wasn't as interested in my therapy as I was...
2. He wasn't that familiar with CPAP machine specifics.

He sent me to the respiratory therapist in his office. I explained my situation to the therapist and he agreed that I would be better served with a APAP machine with data logging. I requested that he write the prescription for the exact machine I wanted (Respironics DS-510S) and he did it.

Further conversations with the DME revealed that if you have a CPAP machine already and are buying another as a backup would allow them to adjust the price more than Medicare allowed, because Medicare didn't care about backup machines...neither do the insurance companies. A primary machine can be ANY machine, from ANY source...Garage sale, loaner from a friend, etc.

Finally, I was armed with a prescription that detailed EXACTLY what the DME was required to provide and that's exactly what I received.

Like the others have said, be firm, don't be afraid to walk out, don't allow them to pressure you into something you don't want. Remember that you've lived with Apnea for a long time prior to the diagnosis, and that another couple of days or weeks isn't that long to suffer with something you've pby had for YEARS. Be informed about what they can and can't do for you, and don't allow them to "pull the wool over your eyes".

Sorry for the long post, hope your experience improves. Its nice to actually get some good rest when I sleep.