Trying to get new CPAP

[OaklandR]

Well after hearing people hear talk about the data features I tried to see what I could do to upgrade my CPAP. Apparently United Healthcare only cares about the basic features of the machine. They will not pay for a machine that provides data. The medical supply office said that it would be a $200 extra fee if I want data features. I asked them about not being sure if my machine is working and they did say all they could do is loan me a data capable machine for 1-2 weeks and then let the doctor look at the results. I'm trying to decide if paying the $200 is worth it. As of right now UHC pays 100% of my current CPAP and new mask/hose/filters every 6 months. What do you guys think? What does your insurance cover?

Thanks

[carbonman]

That's a crock of the familiar brown substance.
I had UHC when I started therapy.
The Big A tried the same thing.
Get a Rx from your doc for an Apap of patients choice
or a specific machine. They have no choice but to fill it.

They can't charge extra for a data capable machine.

.....geeeze, this story gets old.

It's your therapy.
Get what you want.

[LinkC]

My insurance treats a high-end APAP just like a no-frills CPAP. But I have a 'script that specifies "fully data-capable APAP".

That should be your next step. Get your doc to specify exactly what you want on your 'script. The DME then has no choice.

For the record, your ins pays the same for either. Your DME makes money either way...they just make less on the basic machine.

Good luck!

[Wulfman]

For the kind of money they want for an "upgrade", you could probably get a fully data-capable CPAP or APAP off of http://www.cpapauction.com

Make sure you have your prescription (the physical document).


Den

[Slinky]

Admittedly, cpap.com's prices are CONSIDERABLY lower than those of the local DME providers. However, take a good look at the difference in price between a Resmed S9 Escape and a Resmed S9 Elite, at the difference between the PR SystemOne Plus and the PR SystemOne Pro. The Escape and Plus are NOT fully data capable, the Elite and the Pro ARE fully data capable. Do you see anywhere near a $200 difference in price between the Escape and the Elite at cpap.com or anywhere near a $200 difference in price between the Plus and the Pro??

The Escape, the Elite, the Plus and the Pro AND the Resmed S9 AutoSet and the PR SystemOne Auto are ALL THE EXACT SAME HCPCS CODE: e0601. Most all insurances pay by HCPCS code, NOT by brand or model.

[oscar98]

Admittedly, cpap.com's prices are CONSIDERABLY lower than those of the local DME providers. However, take a good look at the difference in price between a Resmed S9 Escape and a Resmed S9 Elite, at the difference between the PR SystemOne Plus and the PR SystemOne Pro. The Escape and Plus are NOT fully data capable, the Elite and the Pro ARE fully data capable. Do you see anywhere near a $200 difference in price between the Escape and the Elite at cpap.com or anywhere near a $200 difference in price between the Plus and the Pro??

The Escape, the Elite, the Plus and the Pro AND the Resmed S9 AutoSet and the PR SystemOne Auto are ALL THE EXACT SAME HCPCS CODE: e0601. Most all insurances pay by HCPCS code, NOT by brand or model.

My DME wanted $600 to switch from a new S8 Escape to a used S8 Elite. I found a new DME and got a new S9 Elite without a single penny out of pocket.

If your DME won't cooperate take your business elsewhere if possible.

[OaklandR]

My insurance treats a high-end APAP just like a no-frills CPAP. But I have a 'script that specifies "fully data-capable APAP".

That should be your next step. Get your doc to specify exactly what you want on your 'script. The DME then has no choice.

For the record, your ins pays the same for either. Your DME makes money either way...they just make less on the basic machine.

Good luck!

I asked what if the doctor specifically asks for one and they said it doesn't matter what he asks for. The insurance company will only pay for the base machine. The DME did say the insurance pays the same either way and the data capable one was more. That is why they said it would be $200 extra.

If it's a one time fee I wouldn't mind paying it just to have the data as long as the DME doesn't lock out certain data features.

[Slinky]

Look, what we are trying to get across to you is that local DME providers have been known to be less than truthful.

CALL YOUR INSURANCE company and ask what your DME CPAP benefits are, ask what local DME providers they are contracted with. Hopefully you will have the option of more than just this one.

Ask your prescribing doctor to include "access to AHI, AHI and Leak" on your script and while you are at it you might just as well ask that he include "full face, nasal cushion, nasal pillows or oro-nasal mask of patient's choice". If you want an APAP ask that he write the script for two pressures, rather than one pressure.

[oscar98]

I asked what if the doctor specifically asks for one and they said it doesn't matter what he asks for. The insurance company will only pay for the base machine. The DME did say the insurance pays the same either way and the data capable one was more. That is why they said it would be $200 extra.

If it's a one time fee I wouldn't mind paying it just to have the data as long as the DME doesn't lock out certain data features.

Your DME is telling you that their bottom line is more important then your health. Again, I would take my business elsewhere.

If you can't find a new DME to take over your insurance payments and give you what you want then get a copy of your prescription and buy off of cpapauction.com I've seem some pretty nice data capable machines sell on there for $200 or less.

[Wulfman]

My insurance treats a high-end APAP just like a no-frills CPAP. But I have a 'script that specifies "fully data-capable APAP".

That should be your next step. Get your doc to specify exactly what you want on your 'script. The DME then has no choice.

For the record, your ins pays the same for either. Your DME makes money either way...they just make less on the basic machine.

Good luck!

I asked what if the doctor specifically asks for one and they said it doesn't matter what he asks for. The insurance company will only pay for the base machine. The DME did say the insurance pays the same either way and the data capable one was more. That is why they said it would be $200 extra.

If it's a one time fee I wouldn't mind paying it just to have the data as long as the DME doesn't lock out certain data features.

For the record, WHO told you that?
Why should your insurance care which model you get? They pay by the billing code.....E0601.....doesn't matter if it's the bottom of the barrel or the top of the line......they will pay ONE amount.
It's the DME whose profit margin will vary according to which model you're given.


Den

[allen476]

For the record, WHO told you that?
Why should your insurance care which model you get? They pay by the billing code.....E0601.....doesn't matter if it's the bottom of the barrel or the top of the line......they will pay ONE amount.
It's the DME whose profit margin will vary according to which model you're given.


Den

But I wonder if this is a "Preferred" or "Allowable" DME to the Insurance company. If that is the case, they might have a contract with them for a lower amount for the HCPCS code. That would explain the $200 upgrade and only a basic cpap.

So to the OP, Is this a DME the insurance company said that you had to use?

I know under our new insurance, we have to mail our drug prescriptions in to some place. If we have it filled at the local pharmacy, we have to pay a co-pay of $10 plus 10% of the billed amount. For most of my medicines, that is nothing. But for one, it would be $45 a month. If I mail it in, $0. Go figure.

Allen

[OaklandR]

For the record, WHO told you that?
Why should your insurance care which model you get? They pay by the billing code.....E0601.....doesn't matter if it's the bottom of the barrel or the top of the line......they will pay ONE amount.
It's the DME whose profit margin will vary according to which model you're given.


Den

But I wonder if this is a "Preferred" or "Allowable" DME to the Insurance company. If that is the case, they might have a contract with them for a lower amount for the HCPCS code. That would explain the $200 upgrade and only a basic cpap.

So to the OP, Is this a DME the insurance company said that you had to use?

I know under our new insurance, we have to mail our drug prescriptions in to some place. If we have it filled at the local pharmacy, we have to pay a co-pay of $10 plus 10% of the billed amount. For most of my medicines, that is nothing. But for one, it would be $45 a month. If I mail it in, $0. Go figure.

Allen

This is the DME my ENT doctor set me up with. He sent the orders directly to them and they contacted me.

I will call UHC to day to see what my CPAP benefits really are to make sure the DME is not yanking me around.

[oscar98]

This is the DME my ENT doctor set me up with. He sent the orders directly to them and they contacted me.

I will call UHC to day to see what my CPAP benefits really are to make sure the DME is not yanking me around.

That is exactly how my doctor did things too. The DME he set me up with is affiliated with the hospital he works for. I didn't even know I had choices in DME or machines until I found this site and all I can say is I'm so thankful that I found these helpful people BEFORE my rental time was up and it was too late to find a new DME/machine.

[stumamma]

Hello OaklandR,
I have been on my CPAP machine for a little over a month and just today received a notification from United Healthcare stating that the machine itself is not covered under my insurance. Does your insurance policy have a specific section for CPAP machines? The claim shows they paid for all of the equipment, but not the machine itself. They even went so far as to say "We will not cover any excluded service, treatment, item or supply even if it is recommended or prescribed by a physician or other health care professional or is the only available treatment for your condition". I was diagnosed with "severely severe" sleep apnea with over 350 in a 6 hour period. I'd really be interested in knowing how I can make this company pay for a machine that I desperately need. Any assistance you could provide would be extremely appreciated.

[Janknitz]

I think the DME is yanking you around.

See https://www.unitedhealthcareonline.com/ ... Coding.pdf

These are

Coding for Durable Medical Equipment Coverage Determination Guideline October 6, 2010

--CPAP is listed under E0601--that means ANY CPAP or APAP is covered.

NEVER, NEVER, NEVER, I mean NEVER take a DME's word for what is covered by your insurance and whether or not they can charge you for an "upgrade".

Are you on Medicare? Then ANY CPAP should be covered unless you are on a Medicare Part C/HMO plan, then you may have a limited forumlary--you will only find out by asking UHC.

Call UHC and ask the following questions (from my blog):

A. Does the insurer pay by HCPC code, or are only certain machines covered? If only certain machines, does it pay more for some than others? If the insurer covers only part of the DME’s cost, are you required to pay the difference between the insurer’s allowable cost and what the insurer pays, or between what the insurer pays and the DME’s retail price?

B. Does the insurer purchase the machine outright, or require a rental period?

C. What are your co-pays and deductibles? This is important! If a rental period spans more than one calendar year, your out of pocket expenses for co-pays and annual deductibles could easily cost more than buying the machine yourself online. Or, if you will be changing insurers, you could lose the “credit” for co-pays and deductibles already made or have to change machines. Make sure you understand all of this before you sign on the dotted line with a DME.

D. Does the Insurer cover only certain masks or all masks from the DME? Again, does the insurer cover supplies (hose, filters, masks, cushions and nasal pillows) by HCPC’s codes or have a limited “formulary” for supplies?

E. Does the insurer require you to use only certain DME providers, or will it pay for any DME company? Do you get better coverage if you go to a “preferred provider”?

F. What is the insurer’s schedule for replacement of supplies? Many, but not all, follow Medicare guidelines (2 nasal pillows or one mask cushion every 30 days, 2 paper filters every month. 2 foam filters every 6 months, 1 hose every 6 months, one new mask and headgear every 3 months).

You may need a specific RX, just to shut the DME up. Or, if you have a choice, you may need to go to a different DME. But don't expect anything but lies from the DME, because an auto machine cuts into their profit margin (by about $20 or $30, NOT $200!!!) and they won't be straight with you.

Stumama, my guess is that they either coded the CPAP wrong or failed to provide the medical justification for it. Appeal the denial and ask the DME to look over the billing to make sure they did it correctly. Also, call UHC to verify your DME coverage.

BTW, NEVER take a DME's word for what is covered!