Insurance woes with my new machine!!

[joeattardi]

Hi everyone! Sorry it's been so long since I've posted. I've been away on a couple of trips and have been so busy.

My post here is two parts:

Part 1: I recently received my invoice from Praxair (my DME) containing the first month's rental of my new machine, the S9 AutoSet. Now, I was told by the DME and my insurance that they went by the procedure code for billing. Here's the difference between the two machines on my invoice:

Code: Select all

DATE         DESCRIPTION                         TOTAL BILLED   INSURANCE PORTION DUE
07/06/10     RENT CPAP                            135.00              95.05
08/06/10     RENT CPAP W/AUTO ADJUST              150.00              95.05

As you can see, they're billing the same amount to insurance, but a higher total for the AutoSet.

Now, on to Part 2. I received the Explanation of Benefits from my insurance company for this $150 charge, and got the following:
"Your Health Care Plan covers the use of durable medical equipment when your physician provides proof of medical necessity. Since proof of medical necessity has not been received, no payment can be made."



I've got to call tomorrow - am I screwed?? What do I do??

[needsomezees]

Often times your Health Ins will require your Dr to do a predetermination... or whatever it's called, prior to authorizing your sleep study, then a follow-up statement of medical necessity for the CPAP Rx. My guess is your Dr's office didn't do this - or if they did, they forgot to send it to your Insurance Co. Don't fret - I think it will just require a form or something from your Dr to clear it up. I will defer to the those folks in the know on this board, but that's my 2 cents.

Good Luck!

[LSAT]

Did you have an overnight sleep study that showed a need for a CPAP...or...did your doctor just send a prescription to the DME.

[joeattardi]

The problem isn't with a CPAP Rx in general, it's with the new machine in particular. I had a sleep study and all that, and started out with a piece of junk S8 Escape II. That was covered no problem. I was advised on here to try and get a fully data-capable machine, and had many phone calls with my insurance and DME. I was told that all CPAP machines fall under the same procedure code and so are billed to the insurance at the same amount. After a bit of fighting, the DME finally let me swap the S8 Escape II for an S9 AutoSet (technically an APAP machine, but running in CPAP only mode). So it's one CPAP for another.

The problem seems to be that the insurance had no problem covering the old machine, but doesn't want to cover the new one, even though they are both under the same HCPCS code E0601 - CPAP machine purchase. So I don't understand the problem here.

[Hospiceangel]

Hey Joe,
First take a deep breath then I would call your insurance to find out what exactly they need from Dr. office, the doctor's office to find out why they didn't send what insurance company needs, and last but not least the DME to find out why they are charging more for the S9. The Insurance companies will pay reasonable and customary charges so find out from ins company what that includes in the monthly rental. If your DME is one of "their providers" you usually are not responsible for the difference once you have paid your deductible or copay.
Good luck and keep us posted.
Shar:)

[elena88]

I know this is very upsetting, but I think your doctor can take care of this for you, and it shouldnt be a big deal..
so try not to worry to much..

Your insurance company doesnt think this is a "back up" machine do they?

is this billing monthly? quarterly or what?

if its not monthly they may think its for a second machine which would not be a medical necessity.

that happened to me..

[joeattardi]

I'm hesitant to call my doctor about it, because quite frankly he wasn't too interested in helping me with getting this new machine.

The billing is done monthly. I suppose that could be a possibility that they think it's a second machine... Hopefully I can work it out when I call tomorrow.

[elena88]

gosh, I know sometimes its hard to switch docs, but in the long run, if you could find a better more caring doctor
it might help a lot..

Everytime we got a letter from our insurance about them denying something, the doctor would write a letter, if that wasnt enough
they would quote some research, and then they always gave in to the doctors..

Your doctor should be your champion.

Hope you get it sorted out soon so it doesnt stress you out..

[jmcd]

You made it sound as if your DME gave you a more expensive machine (APAP instead of CPAP as doctor prescribed) than what your doctor prescribed as being medically necessary. I would expect the carrier to not want to pay for the equipment without a prescription for the more expensive equipment (APAP) even though it can be run in CPAP mode.

I have an S9 Elite and asked my DME if I could get the S9 APAP instead and run it in CPAP mode. They told me that my insurer would not pay for the machine because the doctor did not write the rx for an APAP. I figured that would be the case but thought I'd try just the same. I can't complain about my insurance, after my $400 annual deductible they cover 90% of the cost (rental and supplies). I pay $5 and change each month.

[Janknitz]

Call your insurance company and ask how much your out of pocket share is with the DME. The DME could charge $1000 per month, but they have a contractual arrangement with your DME and you may not be responsible for the full amount between what the DME pays and what they charge. You need to know the total allowable amount your DME covers and what portion you are responsible for.

If it's really going to cost you $55 per month out of pocket rather than $40 (my guess is that it won't), do the math and decide if you're better off buying a machine on your own online.

Edited to add: I explained it more clearly on another thread

In most cases, insurance companies set an allowable charge for something like a CPAP machine. This means that even if the DME company charges $150 per month for the rental of a machine, but the insurance company sets the allowable charge at $100 per month, the insurance company is only going to pay a percentage of the allowable charge, i.e. 80% of $100 or $80. And in most cases, you only have to pay the remainder of the allowable charge, or 20%= $20, NOT 20% of the $150 the DME wants to charge (or 20% plus the difference between $150 and $100). So you need to understand if that's how it works with your insurance company (and I bet a doughnut it does!).

[joeattardi]

You made it sound as if your DME gave you a more expensive machine (APAP instead of CPAP as doctor prescribed) than what your doctor prescribed as being medically necessary. I would expect the carrier to not want to pay for the equipment without a prescription for the more expensive equipment (APAP) even though it can be run in CPAP mode.

Insurance doesn't differentiate between a CPAP and an APAP machine. They both fall under the same procedure code for billing.

[Emilia]

Yes, they use the same code, but some insurance won't cover the APAP unless it is 'medically necessary,' and then they depend on your sleep study results to determine if you fit the criteria to meet that definition. This happened to me, and I was denied an APAP. Then they found a reason to deny me a CPAP with EPR as well...... ah, yes..... the joys of an HMO! All that left was a basic cpap box with a fan So, I said screw it.......

Anyway, for less than $500, I got a brand new IntelliPAP Auto Adjust w/Smartflex and heated humidifier, purchased out of pocket, and could not be happier! I have all the features I want, great software to monitor my therapy, and no one looking over my shoulder to see what I am doing! My doc is 110% supportive of this and I just see him periodically to show him my data.

[lovecpap]

Call the insuraqnce company and ask what they need. Sometimes it's as easy as a CMN from the dr submitted with the claim.

[needsomezees]

How did it go Joe?

Any luck with the 3 Stooges (Dr, DME, INS)???

[joeattardi]

How did it go Joe?

Any luck with the 3 Stooges (Dr, DME, INS)???

3 Stooges, love it!! Unfortunately I didn't get a chance to call today - work was crazy busy - but I'm planning on calling them tomorrow. I'll let you know how it goes, thanks for asking!