The call to the DME regarding an APAP vs CPAP (today)

[Rastaman]

I called my DME manger today (who is in the same office as my sleep doctor) and told her about some of my findings regarding pressure settings. Sometime the pressure seemed a bit much and wakes me up if I'm on my side. Other times, like after visiting friends and enjoying a few adult beverages, it seems like it's maybe not enough pressure.

So, I called the DME to address my concerns and "Prep" her for the possibility that I might require an APAP instead of this fine M series CPAP that I have now. Well, long story short she said that my insurance wouldn't pay for an APAP and I would have to pay $200 to $300 out of pocket. Before she talked about my upcoming appointment and I would have to decide then if I was going to rent or buy. This time she seemed to want to discourage me by focusing in on only one part of what I was saying. Instead of acknowledging that my setting might not be right for sleeping on my side, she said drinking alcohol worsens sleep apnea and to try and avoid drinking 4 hours before bed. I do wish I lived in that fairytale world. If I had THAT much will power I wouldn't be overweight at all either.

I asked about the new M series Auto that's supposed to come out at the end of the month. She said there is no set date and that it could be another 6 months before that unit comes out. So I asked about the current Remstar Auto with C-flex (non M series). She said that one is much heavier than the one you have now. (2.9 lbs instead of 2.2 lbs! Wow big difference!) And we kind've left it at that.

This whole thing has caught the wife and I offguard. We don't have alot in savings right now and have just put our baby girl into daycare which is costing us an additional $580 a month. And in the fall when my son starts back to 1st grade it'll be another $175 a month for afterschool day care. My wife balked a bit at paying the additional cost since we're low on funds and I understand that. We have to be careful with expenses.

I'm not a very confrontational person unless you catch me at just the right moment. I calm down quickly and tend not to hold grudges. And afterall, I am getting alot more rest now on this CPAP machine than I did without it. I am waking up on a nightly basis now, where before CPAP I didn't wake at all. My nose gets very sore at night even after switching from the medium pillow to a small. Last night the back of the mask slipped off my head and the nasal piece was about 2 inches from my face. It's just ONE situation I have to wake my wife up at night to help me with. Because when I'm that out of it, I can't figure out what's wrong. I just know I can't sleep. I told her I'm just going to get up and go into the living room when this happens so I don't keep interrupting her sleep. And I'll try to use the CPAP machine as much as I can. Hopefully, some day I'll get used to it. But not yet.

Looks like the DME might've won this round. Oh well.

[Wulfman]

Rastaman,

Is your present contract with your DME costing you anything out-of-pocket (co-pays)?
If it is, you may want to "do the math" on that and see how much it's going to cost you over the life of the contract.
Have you spoken with your insurance provider? Since the CPAP and APAP billing codes are the same, she may have been "stretching the truth" about your insurance company not paying for an APAP.
When I talked to one of the DMEs in this area last year, they said I could have any machine I wanted (except a Bi-PAP) for a flat dollar amount......which was still more than twice as much as I would have to pay CPAP.COM......but at least they SAID I could have ANY machine I wanted.

Good luck,

Den

[Rastaman]

No dollars out of pocket. My insurance pays 100% and has an unlimited DME. We called and asked. I'm going to ask my wife again to call them and ask specifically about an APAP machine vs. CPAP. Their website says CPAP and supplies.

[sleepylady]

Rastaman,

Don't think of this as confrontational, it's merely you working toward getting the equipment you need. Instead of having your wife call, you may want to do so since you're the one who is using this treatment you'd be better able to deflect any negatives and explain what's going on with you. Also, don't talk to the DME. A DME is simply a "store" you go to for the purchase of your equipment. The person you have to get past is YOUR doctor. Talk to him and let him know this isn't working out and why. From there, see if he'll write a new script and put the paperwork through to get the ok from your insurance. Then go from there. As Den said, the insurance has only two codes, one for CPAP and one for BiPAP. My insurance didn't even know what I was talking about when I asked about an APAP. You may want to say it's an auto-adjusting CPAP machine.

Good luck and let us know how it goes. Like I said, doctor first, then insurance, and then DME (or insurance and then doctor). If the doctor won't write the script, then you'd be stuck if you need to go through a DME.

Melinda

[Wulfman]

Also, if you get a Respironics REMstar Auto w/C-Flex and it is set up at a fixed pressure (not a range), it is STILL, technically a CPAP machine.

Good luck,

Den

[Rastaman]

I'm trying to find how much the insurance pays for cpap and how much they pay for apap. IF it's the same amount, then I understand why the DME is balking.

[Bonnie]

Den is right about the billing codes. Bottom line for DMEs is that they make the same profit for cpap or apap. Which do YOU think they will recocmmend??? Voice your concerns to the sleep doc, have him write you an APAP script and then visit the DME. I wouldn't worry too much about the insurance company until you get this other issue straightened out. I didn't know better when I first started out with a rented cpap but by researching and this forum I decided the auto was what I wanted. I convinced my doc to write the script (months later he agrees that the apap WAS the right move|) I took my new script to the DME and was firm in what I wanted. Came thru and the insurance paid for it. The only one unhappy was the DME, they made a lot loss profit. So stick to your guns, be firm, polite and arm your self with knowledge. After you have the machine in your possesion, then you can thumb your nose at the DME, well maybe just smile knowingly at them....
Good luck.

[Rastaman]

The only reason I'm having the wife call the insurance company is that's what she does for a living all day long. I'm the one calling the DME or going to see the doc. It sounds like he might've only prescribed a CPAP and since the DME is part of his office, I don't know what to expect on an APAP prescription. In addition to these other factors I'm also on the Atkin's diet and losing weight rapidly. So, I can see where I might, and I say might, need pressure changes based on that as well.

Thanks for all the input. It really does make me feel better.

[Linda3032]

Rastaman,

I assume you contacted billmyinsurance.com to find out if they will deal with your insurance company.

If so, get a copy of your current cpap prescription, buy a Remstar auto at cpap.com, and have billmyinsurance.com handle the insurance claim for you.

If you haven't done this yet, do it NOW. (in my humble opinion, of course).

[snoregirl]

A couple things. If you decided that you really want the APAP I would keep working all angles (Dr, DME, and Insurance). I think that the insurance company is your least concern, since if the Dr prescribes and the DME gives, it is the same billing code and Insurance will never know and have no reason to care. Since insurance is covering 100%, if you can't get anyone to approve an APAP take the CPAP anyway for $0.

If nothing else it is a backup machine or an asset to sell when you buy your APAP. Since it cost you nothing, look at it like insurance coverage for part of your apap if and when you sell it. Just make sure that since they are covering 100% that you OWN it so you can dispose of it.

Get your prescription from you doctor hardcopy. Doesn't matter that it is CPAP. If you decide you want to buy an auto later with your own money then you can use that CPAP prescription and not have to fight the doctor.

I question any DME that is associated with a doctor's office. Too much room for kickback...

Your humidifier will work if you buy the M series auto I believe. So if you buy one later yourself you only need the machine. Don't need supplies either since I assume everything on M series is interchangable.

Do you have a pretax medical option at work? I have one where we can set aside money for medical purposes and then the purchases or copys etc are paid with pre-tax money. If so in the next benefit year put aside enough for the APAP. That reduces the effective cost.

Whatever you decide good luck.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): humidifier, CPAP, DME, Prescription, auto, APAP

[Wulfman]

Bottom line for DMEs is that they make the same profit for cpap or apap. Which do YOU think they will recocmmend???

I THINK what Bonnie meant to say was that DMEs can only charge the insurance providers the same amount for CPAP or APAP (since it's the same billing code). Consequently, they're losing (at least) a couple of hundred dollars by selling an APAP over a CPAP. Why would they WANT to do that??? After all, it's only AIR......right?

Den

[Rastaman]

I called the DME just now and got her voice mail (lunch time) and let her know that I would be willing to pay the difference to get a Remstar Auto w/C-flex. I reiterated everything I mentioned previously and said if it's possible I'd like the remstar auto w/ c-flex even if it's not the m series and even if it's heavier (which she mentioned). I said If I need a different prescription, I'd like to request one from the doctor. (If that's even necessary since I'm paying out of pocket $200 to $300) And I said please call me back today with out of pocket totals. Wish me luck!

[Rastaman]

I do have a pretax medical option at work. But I need more information about it since I don't use it currently. We use my wife's and it has a cool little MasterCard that comes with it.

I'm WILLING to pay the difference. The wife has OK'd that. I learned along time ago if she doesn't OK something I'm going to pay for it later She wants, she gets. She says we can afford it. $300. And I'm a very very non-confrontational guy with most people. I get myself all worked up. And I'm liable to pound someone if I get too mad. And I don't want to even walk down that road. I know this is probably just as simple as being a thorn in someone's side for long enough but it's not really in MY nature to do that. I'd rather just pay the money and be happy with my new purchase. I'll feel like "I" bought the machine for a disount at $300!!!!

My guess is that I'll have to give back the entire machine because, according to my DME, the M series of the APAP might not come out for 6 months. I'll bet she's wrong. I might just rent the CPAP for 1 month and then buy the APAP auto m series with c-flex. Time will tell. It depends on the phone call I get back from this DME. My guess is the fix is in IF the DME is in the same office as the sleep doc. They're not going to approve an apap unless it's absolutely medically necessary, which it is, but that's hard to prove without taking an apap machine home for a month.

Does anyone see any objections to me paying for the difference? I thought I couldn't afford it but we're going to squeeze our pennies and come up with the dough. Thank god we don't have a cable bill. Can't really afford it yet. But I feel lucky to have high-speed internet

[Rastaman]

Is an Remstar Auto w/ C-Flex (Non-M series) pretty good by comparison to the new M series? Should I wait? I COULD rent the current model for a period of time. But how long can I get away with that and still change machines? Is the "M series" worth all the trouble?

[Rastaman]

They've agreed to switch me out for a Resmed S8 Autoset Vantage. All I have to pay is $35 for the water chamber. I know this is probably an older unit but that's ok, as long as I get the features that I need. Does anyone have any input on this particular unit?