Is my DME fibbing?

[beadedbiker]

So I get a call from my DME.

They say, they have the S9 Autoset on order, but that the insurance company won't pay for an APAP versus a CPAP, being as there is nothing in my sleep study notes to indicate an APAP over a CPAP. Even though my sleep doctor specifically requested the Auto based on my request because I wanted to be able to auto-titrate if my numbers change, and because I have positional apnea (my sleep study does show that I get a lot less events on my side).

Anyway, I questioned the DME that it was the same insurance code, and he said, it was, but it wasn't ???? that because the APAP is so much more expensive the insurance company won't cover it. (and by sooo much more expensive, I guess he means less than $50, which is the price difference between the S9 CPAP and APAP online via CPAP.com ). He also tried to talk me into an S8 - but I told him I wanted the heated hose, so then he tried to talk me into an F&P with one, and I told him (without knowing anything about that model that it was too big, that I needed to travel a lot for work, and heck it doesn't even have data, so my sleep doc wouldn't let that fly anyway).

I told him to call my sleep doctor if he needed something in writing that said the APAP was medically necessary. As my original notes prescribed a CPAP at 12 cm with EPR of 3, but when they faxed the order they did it by exact machine - S9 Autoset (I have a good sleep doc). He said he would but that he likes to keep patients 'in the loop'...

Am I just being fed a line by the DME? Should I call my sleep doc, insurance company or someone?

[Uncle_Bob]

Yes I think you are. I'd walk away and buy online. He just wants to make the most money out of you. I'd try on a few masks first to find out what mask and size you would like to start off with, then say no thanks and buy machine and mask on line.

I don't about legal stuff but if the Rx states an AUTOSET then that's what he has to give you.

Good on you for challenging him.

[oscar98]

I'm not sure the price difference to the DME between the Elite and the Autoset but it will definitely be more then the $50 you see online. I read a discussion about this on here somewhere.

The DME is being sort of honest with you. They agree the billing code is the same but what they are saying to you is that their profit margin shrinks more then they are willing to accept with the autoset.

Are they wanting you to pay extra to get the autoset?
Can you call different DME's in the area to see if another one would be willing to fill it as written?
Does your prescription say dispense as written? Someone on here said that if it says that then they have to fill it that way. Kinda like when you go to the pharmacy with a prescription for a name brand drug that says do not substitute.

[Wulfman]

I would use the word "lying" to describe what your DME told you.


Den

[jmelby]

If you doctor prescribed an AutoPAP machine, the DME cannot legally fulfill the prescription with a non-auto machine.... your prescription should contain a pressure range... and therefore a CPAP machine would not be able to meet your prescription since it can only deliver a single pressure. This is why cpap.com will NOT consider an APAP prescription acceptable to buy a CPAP. The other way around is fine since an APAP machine can fulfill a CPAP prescription.

EDIT: I see in your original post that you were prescribed a single pressure... so my comment does not make sense in your situation. Your doctor did really prescribe CPAP, not APAP--they just specified the machine you wanted. You should call your insurance company to find out if it is them denying the APAP or not. Your doctor may need to change your prescription to a range as opposed to a single pressure in order to make an APAP machine required.

[akcpapguy]

Many people here will say YES don’t believe them and don’t pay anything extra!!! Run as fast as you can and find another DME, they are lying to you!!! Up until a few months ago I too repeated this mantra, today however I am a bit more cautious about jumping to conclusions.

Until a couple of months ago ALL of our insurance companies simply paid on the CPAP/Bi-LEVEL claims that were sent to them without question as long as the person met their diagnosis criteria. Recently however two of the companies we deal with have started asking for the make/model/serial# of the PAP machine supplied to the patient. Both of those companies are requiring preauthorization for APAP’s, both have informed us that this process takes 60-90 days to complete. Furthermore if the prescription is written for just APAP with a range of pressures and they deny the claim nothing will be authorized, but if just a single pressure is noted on the prescription they can authorize a straight CPAP if APAP is denied. I’m sure you can all read between the lines there.

Anyhow, getting an APAP is no longer as simple as getting a Doctor to write a script for it unfortunately. Also remember some insurance companies allow their contractors to charge an upgrade fee for anything other than a basic CPAP. We do have a contract like that with one of the insurance companies we deal with; however we do not exercise that option.

I would advise you to call your insurance company and ask them if the DME is allowed to charge you an upgrade fee. I would also call around and ask other DME’s in the area that are contracted with your insurance if they would fill your prescription.

[Uncle_Bob]

cpap.com will sell you a APAP even if the Rx says CPAP

[DreamDiver]

In lieu of a lie detector, it may help to visually ascertain whether garments covering the posterior and/or lower extremities of your DME are in a state of combustion at or just after the moment of suspected prevarication.

[dwsupt]

You know what they say...."If their lips are moving then they are lying......."

[beadedbiker]

Just to clarify. My script is for an S9 Autoset set 4-20cm dispensed as written. The cpap recommendation is written on the sleep study interpretation. The doc is very particular about making sure his patients get data capable machines, so writes them like that.

[jmelby]

Just to clarify. My script is for an S9 Autoset set 4-20cm dispensed as written. The cpap recommendation is written on the sleep study interpretation. The doc is very particular about making sure his patients get data capable machines, so writes them like that.

Ok... then it sounds like a CPAP machine could NOT fulfill the prescription unless the DME can figure out how to set a straight CPAP machine to a pressure range

[Nord]

Just to clarify. My script is for an S9 Autoset set 4-20cm dispensed as written. The cpap recommendation is written on the sleep study interpretation. The doc is very particular about making sure his patients get data capable machines, so writes them like that.

Hi Eva...

As everyone here realizes... the DME is going to extra lengths to convince you.
Your Dr prescribed as you listed... the DME cannot issue another machine, it would be outside Federal Legislation.
The costing is between your insurance, DME and you.
If you are concerned... this forum cannot help... you need to contact your insurance about another DME or straighten this one.

IMHO... if I could, I would prefer a different DME. This is like a bad boyfriend... if it starts like this... its not going to get better.

Nord

[DreamStalker]

Just to clarify. My script is for an S9 Autoset set 4-20cm dispensed as written. The cpap recommendation is written on the sleep study interpretation. The doc is very particular about making sure his patients get data capable machines, so writes them like that.

Quit wasting your time and effort and find another DME. They lied to you once they will lie again. Your Rx is quite clear on what you should get.

[beadedbiker]

I think first thing Monday morning, I'm gonna call the doctor and get them to fax me a copy of my equipment order, that way I'll know for sure if the DME has been lying. If it turns out he has, then I'm going to mention it to the doctors office and see if I can switch to a different DME.

I mean, heck, I don't know what the actual cost of the machines are, but there's a difference of $50 online, so you know they are not that vastly different to the DME itself, and if that $50 so much more important to them than all the money they'll make from the masks and supplies down the line, I'm not so sure they are the ones to be doing business with.

Let this be a lesson folks. I did my research, I made the extra effort to read and re-read threads on forums, did my research on machines, models, etc. Got an extra appointment with my sleep doctor to make sure I'd be prescribed the exact machine I wanted, I even called around every DME in my county on my preferred providers list to try and 'judge' who would be best to go with, mostly based on what brands they carried, how knowledgeable they seemed and how helpful they were to my inquiries.

And I STILL run into the old DME 'bait and switch' attempt.

It makes me so mad, I mean, I'm lucky, I've done my research, and I'm fortunate to have a medical background, and I know I'm not going to stand for this s**t, but for all the other less knowledgeable sufferers out there, they are being preyed on by these people.

[DreamDiver]

...there's a difference of $50 online, so you know they are not that vastly different to the DME itself, and if that $50 so much more important to them than all the money they'll make from the masks and supplies down the line, I'm not so sure they are the ones to be doing business with. ...

The DME is a local business in a brick and mortar. That it's only $50 more than on line suggests to me they are not gouging the price. They have to make a living too. Nobody can compete with online prices. That's why so many book stores are going out of business. Amazon is killing them. Even used book stores are dying.

Unfortunately, RT's are not paid the same way regular PT's are by insurance - by the session. Their costs are instead bundled in with the machine when you first buy it. That's one of the reasons why it's always just a little bit more. If your DME's RT goes the extra effort to be friendly and actually let's you try different masks, maybe you actually have a good DME.

At that point it comes down to this: Do you go for cheap on line, or do you support your local business? It can be a difficult decision, but when I have the ability, I try to support my local businesses. It's better for the local economy, and it fosters good relations with others in your community.

Just some early morning thoughts...