Insurance & DME strategy

[SleepyZ]

Hi guys,
I am waiting for the doctor to evaluate my sleep test and I am trying to develope a plan of action before this all gets going so I am not going in blind and just accepting what ever they want to give me. (doctor told me I am a "high prority" case" and it is still gonna take him 2 weeks to evaluate the test!! I would hate to see how long a "regular prority" case has to wait!!

Do you guys have any suggestions about Do's, Don'ts Ect. when dealing with Insurance Co. and DME's?

I have Medical Mutual and they said a CPAP is covered at 100%, but the doctor has to fax them a letter of medical nessessity and the supporting documentation to prove it. I have a feeling this is not going to be easy.

Can I request certain brands or models with features like ramp up? That was an issue for me during the sleep study. I was also thinking that I would probably like the C-flex feature as well.

Will they cover software and things like that? If they say no, what is the best procedure for combatting this? Seems to me that it would be beneficial and cost effective in the long run by cutting down on office visits and trial and error adjustments.

I really liked the Mirage Swift Nasal Pillow system. What if they give me something else?

Also, do you HAVE to go through a DME for the insurance to cover it? I don't have the money to buy it out right and then wait several months to get reimbersed.

Any help you can give me is GREATLY appreciated!
Thanks,
Neil

[Guest]

You will probably have to do the legwork yourself on this. Each person's coverage is different and it might be 100 % coverage of their choice of DME's and machines and 0 % otherwise.

You probably need to start by making a few calls to your insurance company and find out if they have in network and out of network DME's and what the real coverage is for an out of network DME. I assume they will want a copy of your sleep study report to approve the purchase.

There will people here who tell you to buy at cpap.com.

There will be some who tell you check billmysinsurance.com to see if they take it. If they do then you can have them do the legwork for you.

[snorzalot]

Most insurance companies pay partial or full on doctor prescribed PAP technologies for OSA. Check with your insurance provider to determine what percentage they will pay and what appropriate steps you need to take.

I have a $1,500 deductible, then my insurance company pays 75% on all medical equipment. Fortunately, my employer puts about 3/4 of the deductible amount in a medical reimbursement account that grows until used so it doesn't hurt quite as bad. My old insurance (first diagnosis back in 1999) paid everything sans a few $25 co pays on my part so it can be drastically different between providers.

In my particular case, there seems to be a close relationship between my doctor, my HME (home medical equipment provider) and my sleep lab. I was able to pickup a photocopy of my polysomnogram (sleep study results) from the sleep lab within two business days. Likewise, they had already sent the results to my doctor who had already signed a prescription with the HME I selected while at the sleep lab ( I had three choices in my area on which HME to use in compatibility with my doctor and sleep lab ). A member of the HME notified me within four days of my sleep study to come and install my equipment even though my doctor visit follow up wasn't for nearly nine days after my sleep study--this seems to be a common trend in my area.

I believe showing an interest in your therapy and a goal towards compliance will gain you that extra mileage with everyone involved. I couldn't begin to count the number of times when a respiratory therapist commented that I was the first patient they've had to be semi-knowledgeable regarding my therapy and how refreshing that was for them instead of hearing .. "Just show me how to turn this thing on and off."

Thanks!

[idahogal]

Having worked DME myself about 5 years ago as a medical biller I can tell you that an insurance company will do one of two things. They will rent your cpap until they have rented to the purchase price (usually 13 months) and then they will convert it to a purchase at which time them machine will become yours. The second possibility is that they will just purchase it out right. You can request any machine you would like to have but likely you will have to pay any "over and above" options out of pocket. The letter of medical necessity is actually much easier than you might think. This is usually a form letter tailored to you and your cpap. The DME provider fills this form out and sends it to the doctor for a quick signature and then sends it to the insurance for you. As far as a mask, the insurance will usually pay for a mask until you get one that works for you. It is kind of like giving someone a prosthetic leg .... it HAS to fit or it is useless. I hope this helps.

[Guest]

Lurking on this board for a while I've noticed the following trend. Mind you, there are exceptions to every rule, but not many.

People are happy when they:

Have insurance, call billmyinsurance.com, find out what is covered and what it costs vs buying direct from cpap.com.

They are happy because they pay the least amount and get to choose their own equipment.

They are sometimes unhappy because they choose equipment that doesn't work for them. That part the people of cpaptalk can help with, but this is still a weak spot for the internet companies.


People are unhappy when they:

Take what their DME gives them. Sometimes people scout out exactly what they want here on cpaptalk.com and then go to their DME for it. They are usually happy short term, until they realize that every single resupply will be another fight for the "good stuff". DMEs just aren't setup to give you the good stuff consistantly.


I hope this simplified it. I tend to ramble but I wish you good luck and restful sleep.

Limpy

[Guest]

Also important!!! Once you take the equipment from your local DME you are locked in. At that point, billmyinsurance.com can't help you. So, think REALLY hard and know what you are getting before you walk off with stuff!

Limpy (II)

[fcaen]

Once you take the equipment from your local DME you are locked in. At that point, billmyinsurance.com can't help you.

Why is that ? Isn't it possible to cancel the rental from the DME after a month or 2 and start a new one from billmyinsurance.com? I just got my cpap a couple weeks ago from Apria and this is something I'd like to do.

[Mcdreamer]

I'm wondering the same thing. ( If I can cancel my rental with the DME ) After researching for what equipment I wanted I was told they didn't have it and this is what my Dr ordered. The Dr had told me I'd have input.

Now it is time for a new mask and I'm told don't have it, can't get it, try this.
Do they have to get what will work for me?

[NightHawkeye]

Do you guys have any suggestions about Do's, Don'ts Ect. when dealing with Insurance Co. and DME's?

I have Medical Mutual and they said a CPAP is covered at 100%, but the doctor has to fax them a letter of medical nessessity and the supporting documentation to prove it. I have a feeling this is not going to be easy.

Can I request certain brands or models with features like ramp up?

SleepyZ it sounds like your insurance coverage may not be that much different from mine.

I was told there were two options; either I could rent for ten months, after which the equipment would be paid for, or if I purchased it over the internet they would reimburse me directly.

I chose the latter option and found out last week that they are paying 100%. It took a couple of months for them to decide to pay, but otherwise there was no hassle for me. Of course, I have no idea what, if any, communications they had with the sleep doc.

So, in summary, they are paying 100% for machine, mask and filters. All I did was submit the claim, sit back and wait.

Regards,
Bill

[clanrat]

Do you guys have any suggestions about Do's, Don'ts Ect. when dealing with Insurance Co. and DME's?

Here's the best piece of advice I can give you: Don't sign anything untill you've got what you want.

Once you're diagnosed, getting the letter/prescription is easy.

Insurance varies. Some plans are better than others.

It's the DME that's the hardest part about this whole thing. Let's say your insurance plan will pay up to $2000 for an XPAP machine. This means no matter what machine you get from the DME, they're going to bill your insurance for $2000. So of course they're going to try to give you a low-end, CHEAP unit. More profit for them.


Your best interests and the DMEs best interests are NOT the same. Remember this.


The second thing I'd suggest is to go to the meeting with the DME educated. Learn about the models, the features, and most importantly, the REAL COST of each unit. DMEs LIE. And they often don't even know what they're talking about.

It's frustrating, but doable. You have to take a real proactive role in the whole proccess, or the DME will run roughshod all over you.

Remember, you're the customer, and have the final say.

Good luck!

-Cam.

[sleepyred]

My insurance co was billed $485 for a breeze. The allowable amount is......
$375!!!!!!!!!!!!!!!!!!!

I am not complaining here - they will pay $100%, but I could buy 3 from cpap.com. When I told them this they said - well they are out of network and you would have to meet your out of network deductable ($1,000) and then we'd gladly pay 60%!

What is wrong with this picture? Again, I'm not complaining because 100% care is good coverage, but geez!

[NightHawkeye]

When I told them this they said - well they are out of network and you would have to meet your out of network deductable ($1,000) and then we'd gladly pay 60%!

I got the same response from my insurance when I called. Instead of 60% though, they remibursed me 100% of the cost of the machine and mask from cpap.com. They didn't pay for shipping though.

Maybe the folks at the insurance companies just toss the dice when they get a claim in, I don't know.

Regards,
Bill