Newbie -- Need Help Getting Equipment (Evil DMEs)

[SomeJoe7777]

Hi Everyone,

I've been newly diagnosed with OSA. I've actually had a suspicion that I've had this condition for a number of years, but it recently got bad enough (with some cardiac arrythmias) that I went to have the sleep study. It confirmed what I always suspected -- OSA with an average AHI of 35. I supposed it's gotten worse just due to age -- I'm now in my 40s.

Anyway, I had the study which confirmed OSA (garden-variety OSA, no centrals, no complex), AHI 66 supine, AHI 45 REM, lowest O2 sat around 85%. Titration on standard CPAP came out to 11 cm/H2O, AHI <3, with REM rebound. I tolerated the CPAP and mask fairly well, no leak problems with a F&P Eson nasal mask on the night of titration, and the CPAP didn't seem to bother me. I needed to have the sleep tech turn the humidity off (made my nose stuffy), but that was the only bump in the road. I actually remembered a dream from the titration night, which is the first time I've remembered a dream in years. Needless to say, I'm anxious to actually get my own machine so that I can finally sleep ... seeing how I basically haven't since around 2002.

My problem is that I can't seem to find a DME that isn't trying to screw me. I've gone to two different ones, both tried to balance-bill me (charge extra because I wanted an S9 Auto), which is patently illegal in my state (and in most states). One of them had the nerve to tell me that I didn't know what I was talking about.

Anyway, I'm discouraged at having to deal with this billing/insurance/DME B.S. My question is, what should I do?

A. Try to find another DME in my area and see if I can get a decent one. Who is the best to ask about this? Should I ask my insurance company for a recommended DME? Should I ask my doctor? My doctor already recommended one, but I didn't even try with them because when they called me, the person on the phone had such a thick accent I couldn't understand what they were saying. Didn't give me a good feeling for their customer service. Does anyone here have a recommendation for a good DME in the Houston, TX area?

B. Do this myself by purchasing from CPAP.com, and then attempting to get reimbursement from my insurance company. If I do this, I eliminate the DME. Has anyone here done this? How easy is it to get reimbursement from your insurance company? What do I do if I need to return and try different masks? How quickly and how often can I get replacement supplies? Is there a guide that tells me how to operate the machine, clean it, perform maintenance, etc.? Do I file for reimbursement every time I buy a mask, nasal pillows, filters, etc.?

Thank you for any assistance you can provide. Good Lord, I just want to sleep. How is it in this day and age that that is almost too much to ask?

[Sir NoddinOff]

I would fill out your equipment profile, if I were you and include your geographic location in your description, allowing other members in your locale can help you find a good DME. If there are any Also IMO, it's worth driving a little bit to find a good one. Or else you can get your prescription in hand and shop at the online shops. CPAP. com, our host, is a very good one! Good luck finding what you need. I'm sure other members can address your insurance concerns.

[Drowsy Dancer]

Anyway, I'm discouraged at having to deal with this billing/insurance/DME B.S. My question is, what should I do?

<snip>

B. Do this myself by purchasing from CPAP.com, and then attempting to get reimbursement from my insurance company. If I do this, I eliminate the DME. Has anyone here done this? How easy is it to get reimbursement from your insurance company? What do I do if I need to return and try different masks? How quickly and how often can I get replacement supplies? Is there a guide that tells me how to operate the machine, clean it, perform maintenance, etc.? Do I file for reimbursement every time I buy a mask, nasal pillows, filters, etc.?

I think lots of experienced xPAPers do this. You might need brick-and-mortar folks for mask fitting though at first and the initial "patient education" on stuff like cleaning your tank (assuming you actually get any and not just a tattered handout). Some of DMEs will have a 30-day return policy if the mask doesn't work for you. They may not volunteer this information.

How easy it is to get reimbursement from your insurance company for a purchase from cpap.com depends entirely on your carrier. Call them and ask them. Expect the process of extracting this information to take some time. If you go this route you will have to have your physician give you a copy of your prescription. This can be surprisingly difficult.

There is a replacement schedule for the various supplies that most insurance companies adhere to which is based on the Medicare reimbursement schedule. Things like your dehumidifier tank probably don't need to be replaced as often as the schedule allows for. They seem to last almost indefinitely. Things like nasal pillows are a little more delicate, and should probably be replaced more often, although some people have figured out ways to nurse silicon parts along almost indefinitely as well.

I found that my filters are so cheap to buy in bulk on the web, and the DME prices are so overinflated, that I just buy them and don't bother to see reimbursement. I bought a pack of fifty and change them twice a month. The insurance company wants to send me two a month in a cardboard box (!).

When you get the machine, it will come with an owner's manual. The clinician's manuals can be had--if you order from cpap.com, I think they include them in any event. There is very little end-user maintenance that can be done on the machine itself. Change the filters, clean the tank (not everyone bothers), don't drop it . Most insurance companies allow you to replace your machine after five years (the technology/comfort measures do get refined).

Also very important--the software. I am a huge fan of SleepyHead, which is open-source and cross-platform, but if you insist on the manufacturer's software for your machine that can be made to happen as well (not by me, but there are resources).

[Drowsy Dancer]

PS: there is a treasure trove of information in the threads indexed here: viewtopic/t88637/CPAP-Basics--15--Table ... ml#p812768

Also take a look at the threads stickied at the top of this page.

And welcome!

[LSAT]

I would fill out your equipment profile, if I were you and include your geographic location in your description, allowing other members in your locale can help you find a good DME. If there are any Also IMO, it's worth driving a little bit to find a good one. Or else you can get your prescription in hand and shop at the online shops. CPAP. com, our host, is a very good one! Good luck finding what you need. I'm sure other members can address your insurance concerns.

She doesn't have equipment yet and she already said she is in Houston TX.

[RandyJ]

somejoe7777,

Do you know what your insurance was going to pay? Were they going to do it as a 10 month rental to own, paying the DME every month or do they pay a lump sum for the machine & humidifier? Do you know what, if anything, your out of pocket would be?

Those are the questions you need to ask your insurance in case you can't find a local DME to work with you. Based on that, we can make suggestions.

Note: The billing code for all cpap machines is E0601 (you may need to mention this code when talking to insurance).

As was said above, some insurances won't reimburse you for purchases you make a non-brick and mortar DME like cpap.com.

[hyperlexis]

I would definitely go through your insurance company -- because if you don't then you would likely be liable for non-participating provider fees for anything you get. Those fees could be vastly higher than if you bought through a participating provider DME.

Perhaps you could compile the list of participating provider DMEs in your area, and then ask your MD which ones of those are best to use.

[Denial Dave]

Your message is that you have standard garden variety OSA.

So just about any of the S-9's that provide data will meet your needs. Why do you feel the need to have an S9 auto?



"Hi Everyone,

I've been newly diagnosed with OSA. I've actually had a suspicion that I've had this condition for a number of years, but it recently got bad enough (with some cardiac arrythmias) that I went to have the sleep study. It confirmed what I always suspected -- OSA with an average AHI of 35. I supposed it's gotten worse just due to age -- I'm now in my 40s.

Anyway, I had the study which confirmed OSA (garden-variety OSA, no centrals, no complex), AHI 66 supine, AHI 45 REM, lowest O2 sat around 85%. Titration on standard CPAP came out to 11 cm/H2O, AHI <3, with REM rebound. I tolerated the CPAP and mask fairly well, no leak problems with a F&P Eson nasal mask on the night of titration, and the CPAP didn't seem to bother me. I needed to have the sleep tech turn the humidity off (made my nose stuffy), but that was the only bump in the road. I actually remembered a dream from the titration night, which is the first time I've remembered a dream in years. Needless to say, I'm anxious to actually get my own machine so that I can finally sleep ... seeing how I basically haven't since around 2002

My problem is that I can't seem to find a DME that isn't trying to screw me. I've gone to two different ones, both tried to balance-bill me (charge extra because I wanted an S9 Auto), which is patently illegal in my state (and in most states). One of them had the nerve to tell me that I didn't know what I was talking about."

[chunkyfrog]

If your doctor is cooperative (or your dentist, nurse practitioner or ANYONE you know authorized to write a RX);
get someone to rewrite your prescription for EXACTLY the machine you want--with DISPENSE as WRITTEN.
DME's in network will HAVE to fill this RX EXACTLY as written or they are in violation of most insurance contracts.
Get insurance on the line when you are at the DME's. Sometimes you gotta get tough. (but stay polite.
"I don't really want you to get in trouble" (grin)
BTW there are two different S9 Auto's--the AutoSET is the good one--the Escape auto, not so much.

[zoocrewphoto]

Your message is that you have standard garden variety OSA.

So just about any of the S-9's that provide data will meet your needs. Why do you feel the need to have an S9 auto?

That means the S9 Elite or the S9 autoset.

Why get the Elite if you can get the autoset and both options?

[purple]

You did not say which insurance company. Medicare is a 13 month rent to own, and Medicare does not pay for the humidifier, which you have to pay for as part of the first payment. And the first two payments for the machine itself are larger than the later ones.

My sleep doc's office keeps a list of DME's and in the order of which are more customer friendly. So all I had to do was pick from the top.

You should ask your insurer as to the exact DME's in their network that they will pay for.

I have always found that those at the DME who help me with machines, and masks have no knowledge of money issues. That group does not care about the money, they are just trying to help you. So sometimes it seems it is hard to get a straight answer from them.

Despite all the negative things that are said here about DME's, I have never met a bad one. Medicare requires that their patients use a brick and mortar DME, not an internet one.

I think about half of those who get to the point of having a machine, mask, quit treatment because of the frustrations. A good DME can help you. For one thing, sitting in a room with a lot of masks can be more helpful that reading about advice on which mask is better on a forum. If you have a problem at some odd hour of the night, being in a relationship with a DME, would allow you to call an expert in the middle of the dark.

Make sure your DME allows you thirty days of free mask trials at the beginning, which you also can not do with buying off the internet.

[Pugsy]

Medicare does not pay for the humidifier

Medicare does pay for the humidifier. It's just a one time single fee instead of the monthly smaller payments.
Once Medicare pays and you pay your copay...you own it. Not returnable. Most insurance will do it this way.

Heated humidifier HCPCS billing code is E0562 and Medicare's allowable one time charge for it will vary (depending on region)
between around $278 and $237 so Medicare pays their 80% (assuming Part B deductible has been met) and the other 20% patient or their supplement is responsible for.
These were 2012 allowable amounts..I can't find 2013 yet.


http://www.resmed.com/us/documents/1018 ... rd2011.pdf

[SomeJoe7777]

Thank you to everyone for your pointers and advice.

I asked my doctor for a specific DME that they've worked with before that they know are reputable. They sent me to them, they called me yesterday, and promptly told me that there's an extra charge for the S9 Autoset. (Balanced billing again).

I'm just not having any luck here guys. That's 3 different DMEs now that just blatantly won't obey the law. It's not even the money, really. I could cover it. But I can't stand being willfully raked over the coals by dishonest criminals.

I'm going to go back to my doctor and see if she will rewrite the prescription for the S9 AutoSet and have it noted to "dispense as written". Maybe this will change some minds.

By the way, someone asked what me insurance company was willing to pay. I got them on the phone and asked them that very question and they couldn't answer it. They claim they have to know how much the DME is going to charge them before they can determine what they're going to pay.

- SJ

[idamtnboy]

They claim they have to know how much the DME is going to charge them before they can determine what they're going to pay.

More likely they need to know who the DME is, not what they charge. The insurance co may have different contract amounts with different DMEs depending on the negotiating skills of both parties.

[StuUnderPressure]

Does anyone here have a recommendation for a good DME in the Houston, TX area?

Do this myself by purchasing from CPAP.com, and then attempting to get reimbursement from my insurance company.

CPAP.com has a brick & mortar DME operating in Houston, TX.
It is called Health Management Services, Inc. Go to https://www.hmssleep.com/contact.php for directions to their location there.

There is also a tab at the top of that page to click on where they tell you what insurances they accept.
Yours might be one of the numerous insurances they do accept in Texas.

I can't tell you whether or not they are any good.
Users of some of their locations in other areas do complain of their quality of service (just like at most other DMEs).