HELP HELP HELP. CPAP prescription for Auto CPAP.

[snoregirl]

Peoples opinions of what the upper range of an APAP should be set at vary. Some like it pretty close to the titration level (if they are confident that the sleep study was good, others like a little more room in case they need more pressure and aren't thrilled with the sleep study. Some feel that too much pressure (higher max) can cause more problems than it might solve. I am not an expert on this others may have more to tell you. 10 and 12 are not super high numbers, but your sleep study should tell you how you did at different pressures.

If you are happy with your titration study and pretty confident with the 8 you were titrated at, you may want to stay closer to a top of a (like 10 or so). If you question your titration study, then raising the upper pressure a bit would be good to allow the APAP to go there if necessary. With the software you should be able to see what pressures you actually are using and adjust from there if you wish. For example my titration was 13. I set 10 - 13. I haven't exceeded 13 yet. But I do spend much of the night at 10. APAP is more comfortable allowing me to be at 10 a lot. My titration appears to be farily good as the APAP has not exceeded 13 and is allowed to go to 15. I might be able to lower the bottom more, but I haven't bothered and some tell you widening the range too much can make it harder for the machine to respond to events.

Entering the setup menu on Respironics involves holding two buttons (arrows under the led display) down while you plug in the machine. You will hear a beep and you will be in setup mode. You can toggle through the menus and change what you wish. No it is not difficult and there is no secrert code. Takes 5 minutes max to toggle through and set up the whole machine. I always say programming my vcr to tape a tv show is far more complicated.

One other thing to watch out for is where you are in your insurance year. 10 months (rental period you mention) takes you through two deductable periods starting now. If you have a low deductable, or you will exceed it for other reasons, fine. But if you are like me -- $618 deductable and don't routinely make that (my regular doc visits and some other things are not subject to deductable...) then you may well pay your deductable twice on a CPAP from a Brick and Mortar DME (10 month rental). You should calculate up that total cost out of your own pocket and compare to buying cash. You have probably exceeded your deductable this year with the sleep studies but if you have to pay another come January....Check with insurance directly to make sure a 3 month rent to buy isn't possible. Mine was 3 months and then a compliance check and then buy (not BCBS) then if you didn't meet compliance they rented for another 3 month period. Everyone's insurance is different. Sounds like you did this check already but make sure before you make that financial decision. If you end up with cash and can do a shorter rental period, and you expect to meet your deductable next year, you could always have the insurance company buy a backup machine later (but not too late as you may need a new sleep study for insurance if it is too long. You would need to make that your primary machine for the compliance period though when it arrives.

You ask why our insurance companies make us buy from places that are selling for 2 x to 3 x the cost of online. The only thing I can figure is that they think they are saving money by not buying equiptment for people who don't comply. However in reality, they could buy a machine outright for everyone diagnosed and if 50% quit the insurance company would still be money ahead with the other 50% of the machines going in the trash. This doesn't even count the online savings on repeat business of masks, tubing etc. There is no good answer except the insurance companiesare narrowminded and "this is the way we have always done it..." In addition I believe that the insurance companies actually believe that they are providing better patient care and followup by requiring B and M DME's when in fact they are ignorant about the poor service and lack of knowledge that many of these B and M DME's have and are providing. For the most part insurance companies are paying a premium for nothing. In many cases the patient knows more than the DME. Not all, since I am sure that there are some good DME's out there, and some patients who can't punch a couple buttons or think logically, but from my own experience it is a total waste of money.

I attempted numerous times to bring this to the attention of my insurance company and was swatted down at every turn. They had no interest in listening to me. So, out of MY pocket my machine was about $270 out of theirs $1230 or so at least. Online total cost $709 (now $689 since the price has dropped). Yes they wasted a lot of money and couldn't care less.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, tubing, Titration, CPAP, DME, APAP

[oldgearhead]

with SW and card reader

Yes that does mean software (Encore pro) and card reader. I think
your DME was just playing dumb. They will probably not supply it to
you. because they cannot or won't support it. Furthermore, your insurance
will probably not support it either. In other words, you will need to buy it
out of pocket.

[snoregirl]

OOPS didn't see these questions. I will give them a try.


You ask
____________________________________________________________________
Question: I am not sure what “auto-titrate” means. Allow me to re word it to see if I understand it correctly. With example of 6-10 pressure setting, does that mean the machine will start at the INHALE base-line pressure at 6 cm. If this pressure does not improve the sleep numbers, it will gradually adjust the pressure from 6 all the way to max 10 and will try to find the pressure setting that will yield the lowest number of events of the optimal condition? In this case, what is the incremental pressure step that the machine will take?
____________________________________________________________________
Your basic idea is correct. I can't tell you the incremental pressure steps though.


You ask
_______________________________________________________________________
On the other hand, the “EXPIRATORY RELIEF” will NOT be adjustable by the user ______________________________________________________________________

No, the user can adjust the exhale relief (even without the "special" manual that the DME's withhold. Instructions are in the patient manual. Resprionics Cflex can be used in APAP mode, Resmed's version is only availale in CPAP mode.


You ask
______________________________________________________________________
The Auto Cflex will pick the best one out of the 3 pre-defined expiratory pressure drop which is not controllable by the DME or the user.
_________________________________________________________________

No, you pick the level of pressure drop. It is not picked automatically. 1 is the least pressure drop and 3 is the most. I would pick 1 or 2 with a pressure range like yours. Just set the one you think you want. Try it and change if needed. Just reenter setup mode and pick a new setting 0, 1, 2, 3.

[Moogy]

If you want to know if your insurance will pay for an online purchase, DON'T call the insurance. Instead call http://www.billmyinsurance.com. They will figure it our for you, and it will be much easier and more accurate than any telephone benefits advisor.

(My BlueCross telephone advisor told me that I should take the worn-out mask to my DME to see if it could be REPAIRED when I asked how often they would buy me a new mask. She had no idea what cpap equipment is or how it works, apparently.)

Billmyinsurance is NOT exactly the same as buying through cpap.com. They have to charge the amount that the insurance will allow. Typically, that is more than the normal cpap.com price, but they earn it, since they have to do all the insurance paperwork and make the phone calls.

I was able to use my Texas BCBS insurance with billmyinsurance.com


Moogy

[RachelM]

Two things caught my attention:

BCBS Rent to Buy-I've already bought the APAP I wanted (had to insist!) from my sleep doctor. I intend to keep on keepin' on so the purchase was probably the right way to start.

I thought that if I wanted the Respironics software I would have to purchase it myself. Do sleep drs really prescribe the software for a patient to insurance would then cover it? My sleep clinic already knows that they have an informed, demanding client on their hands.

[Wulfman]

I thought that if I wanted the Respironics software I would have to purchase it myself. Do sleep drs really prescribe the software for a patient to insurance would then cover it? My sleep clinic already knows that they have an informed, demanding client on their hands.

No. It would be taking food out of their mouths and keeping them from making payments on their BMWs and SUVs. Also, in order to be able to get your insurance to pay for it, there has to be a billing code....and there isn't one for the software.
The way I look at it is the cost of the software and reader is very cheap compared to paying for repeated trips back to the doctor and follow-up sleep studies to find out what the software will tell you.

Best wishes,

Den

[pcisuser]

THANKS THANKS THAKS a million times.

Since yesterday, there have been more follow up responses to my questions. Besides the people I have thanked in my last post, I would like to add my appreciation to the following people who have responded to my follow up questions.

Many many thanks to the very detailed response from Snoregirl and bdp522. I also appreciate the extra inputs/thoughts from oldgearhead and Moogy. Of course, please refer to my prior post for the long list of people who have helped me out.

Following is my status so far:

(1) I have contacted with http://www.billmyinsurance.com as suggested by some users here. Unfortunately, they said my insurance dictates the term rent-to-own and they can't even tell how many month of renting until I commit the purchase and a bill is sent to my insurance. The cost of the Remstar Mseries Auto CPAP with full setup (no software) is around $1340. What is funny is this: They told me that regardless of what machine I pick, the insurance goes by a generic billling code E0601. That means the machine will cost $1340 for a bottom of the line to the top of the line. I think the insurance is treating the cost of this machine like the "allowable specialist office visit of $80 per visit".... This $1340 is closely the same as what a local DME will charge because they all are smart and go by what the code allows them to charge (but not what the machine actually costs).

(2) Yes, I am aware of the annual deductible. Just for your info, my annual enrollment starts in Mid year from July this year to June next year. That's why I wait until now to do. The problem is that my old prescription didn't detail what model and the local DME had refused to give me what I wanted. That's why I have to go to my family doctor..... with all the backward forward runs.... Here it's almost the end of October. What is worse is that my Rent-to-own term is 10 months (some DME told me and the others like billmyinsurance don't even know what my ins policy allows). That means I will have to pay deductible in July and August 2007. Anyways... I need to use my insurance every year and that's the basic health care cost.

Trust me, I have called my BCBS illinois so many times to find out about the rent-to-own duration and COULD NEVER get that info. They don't even want to tell me how much is the allowed amount and said: "We are in Illinois and you are in California. Everything has to be referred to the BCBS in California (not directly insured through California) and we don't have the info you ask. At one point, I get the insurance and the DME billilng staff on the phone all together, the insurance person suddenly agreed to everything the DME biller said. Apparently, she must realize that the DME staff is familiar with my policy and said yes this yes that, yes, the rent term is 10 months. That's how I believe it's 10 month now. However, no one will know until the final bill comes. In engineering world, people specifies things clearly. In real world, people try and error. In this case, people must commit to the purchase/rent before knowing what the terms are.... How silly this is. Very frustrate!

One more interesting thing to share. In several instances while talking to billmyinsurance.com or the local DME's, I insisted on trying to find a much shorter Rent-to-Own term so that I don't have to let it run over beyond June2007. They would say: We would love also a shorter term so that we can collect the money soon. Your insurance just wants to pay us in installment and that's a lot of paper work. I then said, if I buy it outright and pay in cash now, how much it would be? They said "It would be whatever you pay monthly times the number of months". I then argued that this is not logical, if you charge me the same amount for either an out-right purchase or over a 10 month period, everyone in this world would then want to pay you in installment. There must be a difference between them because it involves interest, maintenance obligation.... They said "NO", the amount reflects the cost of the machine and none of the interest stuff..... I then argued using the buying a car vs lease-to-own a car. They said: "Buying a car is different than buying a CPAP machine"

I gave up. These people just had a different mind set. They think of the $1340 amount (as opposed for the $750 online price) as the actual cost because it is the so called "ALLOWED" amount. They just like to forget all other factors like "ALLOWD interest, ALLOWED maintenance fee, ALLOWED possible return after 2 months...

What's more amazing is this. When I brought the same subject with one of the BCBS staff on the telephone, she presented an argument quite similar to what the DME people said. That is, the price is an ALLOWED amount, whether you pay it today in full or you pay it in 10 months, it's the same price, sir.

So much for that. While these DME's people who try to sell us the machines may not have the sleep disorder like us, I think our mind is still a lot clear sober here.

Again, I SINCERELY appreciate everyone who has put in the extra time to type and to help me out. Tomorrow, I will have to go back to my doctor office to get another prescription that must include:
Min =6 Max=12 Cflex at 2 as suggested by Rested Gal.
This info must be on the prescription or APRIA DME will not sell me one.

I will keep you all informed as what my experiences will be (with the DME and the CPAP machine itself) after sleepless nights, I deserve to get treated better.

[rested gal]

after sleepless nights, I deserve to get treated better

Amen.

[Wulfman]

I'm guessing that there's other things that they didn't tell you they're probably going to charge you for.....like the heated humidifier (about $400)......mask (about $250).....hose (about $50)......and probably a bunch more things that'll be charged separately that'll bring your total cost to around $2000 or more. They'll charge the maximum allowable for each item and in the end, it'll be close to three times what a single setup would be.
This is why our insurance industry is BROKEN! The foxes are guarding the henhouses (so to speak).

Do you have a co-pay? If you do and you "do the math", your portion of the payments will probably come pretty close to the amount of what you could buy one outright.....from CPAP.COM....especially since it'll go past your insurance's fiscal year end.

Good luck with the system,

Den

[snoregirl]

Yes, I share you frustration. I ran into someone higher up than a regular phone operator at my insurance company (maybe called customer service rep or some such thing) whose job it was was to help get through the confusion and actually interpret the policy. I didn't find this until after I had experienced the run around like you are getting and completed my purchase and collected my benefits though. I would try to call a supervisor or find someone (other than the initial person who answers the phone when you call) to try to pin down your benefits (specifically the rule on rent to own time). Someone there has to know. You have to get the right person and ask the right questons. "When is the earliest the company will approve a purchase?" "What defines compliance for the purpose of purchasing the rental?" Etc. "Can I talk to a benefits supervisor?" And on and on.

I agree with Wulfman totally that you have to do the cost analysis. What does it cost online to purchase outright, then what do I expect to copay if I use the rent to own DME. Really depends on your deductable and copay amounts and rental timeframe. With my copay of 20% (I think mine was) I ended up paying about $270 (deductable already done with sleep study in same year so I didn't count that) vs $709 at the time for my regular Resprionics auto (now it is $689).

I also agree that you need to not forget to look at the humidifier cost and mask. Both of these will most likely be a "purchase" as opposed to a rent to buy. These are considered something that can't be sold to another person. I seriously doubt the $1300 or so number included anything but the machine. That number is all too familiar and too low. Use Wulfman's numbers for your cost analysis (or ask specifically for humidifier and pick a full face mask and ask for a number on that too).

I know it is easy to sit here and say buy cash. It is not my money, but depending on your copay percentage and deductable for next year if truly you have to rent a full 10 months, it may come out to be the thing to do.

I don't recall you saying what your copay percentage is. BUT as I recall from this issue with others, it generally starts breaking even around 50% copay (not considering an additional deductable).

I will tell you that if you are close to break even, you will get your machine faster, less hassle with what machine etc by buying cash. I was almost there until I got the DME to give me the AUTO. I had a different issue. I had a prescription for Auto but the DME didn't want to give it. But that is a totally different story. But since I got the auto for around $270, I put up with the DME hassle so I could keep my other $440.

Also remember what you just learned -- E0601. If the DME tries to talk you into "you only need CPAP" your cost analysis changes. They get the same amount but you have to compare for cash against a lesser number. And if they suddenly change their tune about whether or not your insurance will pay for an auto that is another ball game too. Then you need to see how close to break even you are cash vs. DME and decide how much the fight is worth to you. Sometimes they conviently "don't have the machine you want" so why don't you start with this one and we will upgrade later. Once you let them bill your insurance company you may have trouble if you want to switch DMEs.

Good luck and let us know how it is going. And what is your copay percentage??? Curious minds want to know.

[pcisuser]

Hi everyone!

On last Friday, I wrote a detailed description about my health plan situation to answer some of the questions that some of you had asked. Unfortunately, after submitting the post quickly and neglected to check the status carefully before closing the window, I realized much later that my posting was never successfully submitted. So was my time and effort also lost in the cyber space.

There has been new and interesting development so far. Before going farther, let me describe my medical plan status.

PPO plan year: 7/2006 to 6/2007: In-network $500 deductible (been met) copayment 10% while out-of-network deductible is $800 and 40% copayment.

PPO plan year: 7/2007 to 6-2008: same if PPO but I may switch to EPO.

So far, I have met the $500 deduct for 2006-2007 because of another medical expenses. Knowing the full system cost is about $13xx, the monthly rental should be about $100 per month (other items like heated-humidifier and mask are not recurring and so the monthly rent out of the total $13xx is expected.
That makes my in net-work cost about: $10 month (10% of $100) and out-of-network is about $700 ($300 additional deductible plus 40% of $100 for 10 months). The difference is pretty obvious that I must stay in-network. If I don’t join the same PPO next year, I may have to pay one more extra rental month. But that $100 monthly after June 2007 can be applied to the annual deductible and serve some purpose there.

All these time, every DMEs and the BCBS staff I have contacted have suggested that I will have a 10-month rent to own with system price at around $13xx including the http://www.billmyinsurance.com.

Now something unbelievable is following; yes I said unbelievable because what happens next is conflicting with what I have been told so far including the xyz DME supplier from which I am acquiring the system.

I decided to deal with a local DME (say xyz) because it’s a very large company and has local offices in a lot of places, including one near my work company. Rewinding back to early this year when I have the previous general CPAP description (CPAP @ 8cm H2O with humidifier), I went to them for the user/buyer training session and was given a basic Remstar model that has no “heat” unit. At that time, I looked at other patients around the table, it appeared like everyone was having a heated unit and some fancy mask. I asked the staff why mine was so basic, and I was told we go by what the doctor prescribes. My prescription didn’t spell out bell and whistle and therefore, I got the cheapest. The cost of that basic system at that time was:
Remstar CPAP $76/month rent (recurring, DID NOT specify how many months either)
Mask $85
Humidifier $79 (one time cost, not recurring)
Headgear $28

I was also told, “You have met your annual deductible and you owe us nothing, just take it with you today”, (remember owe NOTHING). Well, I was aware that I only have met $2xx something deductible and must have 10% copayment. I didn’t trust what they said but denied the machine and walked away. Later, I realized that it’s better for me to wait until 7/2006 to get the machine because I will have a new full plan year and I was planning to have colonoscopy procedure and so it made more sense to wait until I July this year after my $500 deductible has been met.

This time, thanks to the generous and wonderful helps from some of you and the help of my family doctor. My prescription reads explicitly like this: The Mercedes Benz rated “Auto CPAP with Cflex and heated humidifier with software and care reader”. Like I have said, everyone couldn’t quote the exact rent-to-own duration and the final price but the informal conclusion is this: About $13xx and 10 month rental period.

I have decided to deal with the same xyz DME that I had back in March mainly because they have a nearby local office and they are large and therefore should have everything ready in case there is a need to exchange/repair…

Last Friday, I was surprised that they told me my order has been in place, my doctor office has signed a re-confirmation letter about the prescription, AND I can buy it outright at a total cost of around $11xx. I DIDN’T believe it but I had nothing to loose if I go along. They told me I may have to wait for a week because it’s a brand new model that they have only started to give the to patients since mid-September. I was a little disappointed because I will waste one month rental for this plan year. However, I had no choice and can’t switch to another DME since the doctor office has done a lot more so far for me.

Today (Mon), I suddenly got a phone call from this xyz DME who told me that an M-series Auto CPAP machine is available in the office. I was shocked and I went there this afternoon to pick it up. As of this moment, this is what I had:
Remstar M-ser Auto CPAP with C-flex $ 650
Heat Humidifier $ 190
Mask $ 75

There is NO MENTIONING of Rental period or monthly rental cost. The invoice indicates therefore an outright purchase (unlike last time which shows a recurring monthly rental cost but not the 100% cost). Remember the statement “You owe nothing, the deductible has been met”? They said the same this time. However, I know I have truly met the $500 deductible except the no copayment statement is questionable.

It is UNBELIEVABLE that all these rent-to-own confirmation from everyone/everything (all DME’s, insurance company staff, my almost-get-it rent-to-own paperwork for a basic machine earlier this year…) is suddenly replaced by an outright purchase with a more reasonable system price ($11xx as opposed to the anticipated $13xx price). I have a strong feeling that someone at the xyz DME verification department is not doing his/her job thoroughly because they had said similar thing in the past “You have no copayment and owe us nothing”. They even told me that the SW and card reader is still on order and I will get it later. I told them “I only want it if and only if the insurance company covers it” and they said “yes”. I said, “Then I am waiting for it”.

If this turns out to be wrong, I still have an invoice on hand with a reasonable price to back up to.

Anyways, I am very happy to have the machine on hand and will try it out tonight.
Just some observation I have about the Auto CPAP machine at the user training room.

Some users had complained that the M is noisy. I noticed the machine of the patient next to me was very very noisy. However, he was also complaining that his mask was leaking. I then tried to intentionally lift my mask up to create a gap for air leakage, immediately my machine became significantly noisier. I can understand and accept that fact. Have you ever heard of a tire that has a severe leak or a leaked balloon? The same phenomenon here.

As for the water tank, some users here had complained that it is kind of hard to push it in and it is susceptible to leakage. I tried it and the M-series water tank was inserted in or pulled out quite smoothly. Let me back up a little bit in time. One of the big reason I hesitate to take home the prior Remstar machine earlier this year was this: The water lid is at the bottom when in use. This is totally like having a bottle of water and store it upside down in the cabinet. This layout is totally against my practical mind. The quality of the silicon seal is the only thing that can stop any leakage. I was contending to acquire another CPAP machine that my friend has but the water tank design of his unit was designed the same way. That was one of the reason that turned me off for the CPAP design quality. Guess what this M-series do? Its water tank has been designed with the practical mind: “Lid on top”. Boy, finally it satisfied my engineering mind. Judging from the look and feel, I really like this M-series.

Well, I will continue to post my experience with this machine after I have a chance to use for a few days. For now, I really really want to express my sincere appreciation to all of you who have helped me out and have shown quite an interest in the insurance matter.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): cpap machine, auto cpap, humidifier, C-FLEX, cflex, CPAP, DME, seal, Prescription, auto

[snoregirl]

WOW

It looks like it turned out great for you!

You have a nice insurance policy (10% copay)..

You got the machine you wanted at a really reasonable price.

Good thing you waited and didn't take the other machine, since most likely your insurance company wouldn't have bought another so soon.

Happy papping.

Great to hear a success story.

[Mile High Sleeper]

Lots of good advice here. For others reading this thread, remember the basic info for the CPAPer and their doctor: click the yellow light bulb/our collective wisdom and read the articles on CPAP machine choices and CPAP pressure settings.

[Snoredog]

pcisuser wrote:

(3) I will call BCBS tomorrow to find out if I can purchase the machine from CPAP.com. The only issue I have is because I am a NEW NEW user and the BCBS’s 10 month rent-to-own policy may helpful in allowing me to have a low risk try-out period. On the other hand, judging from the red-tape procedure (not allow me to understand the setup. Not all patients are incompetent and most of us here are far far from that, need a prescription even for a mask. My prior prescription didn’t have the word “heated humidifier” and they didn’t want to give me that feature….), I am not sure how good is this 10 month period. Comparing the rental price (from my old prescription) with CPAP , the price difference is like $500 at cpap.com vs $1200 at DME. This is too big a difference and I am not sure why BCBS would have us stick to the contracted DME. I think this is a fairly new science (not exactly the science but the ever-more-popular use of the CPAP machines)

Insurance likes to see the jacked up price from the DME because it costs YOU more. If they get billed that $1200 for that $500 machine you may have a 50% deductible for DME equipment. So $600 you have to pay, insurance may have a contract with that DME where they only have to pay $500 for it so they save $100 and you pay the rest.

They may also put you on some kind of 10 month rental so they can hide the costs from you even more. In the end you end up paying for it either thru higher premiums, copays or deductibles. Any way you look at it it is a crooked system, a legal license to steal.

you have to do the math to figure out which way costs you less because your insurance and DME are not going to make suggestions on saving you money. Right now is a bad time of the year for getting equipment if you have fullfilled your annual deductible, might be better postponing the purchase until after January when a new year begins, but then they may put you on a 10 month rental and you'd be back to square one.

[judys02]

Hi- My DME problems aren't quite as bad as yours, but I have found what seems to be another SECRET trick to limit the patient-- I hope someone can help me get around it. You might also need this info.

I have the Remstar M Auto with Cflex. Originally the DME disabled the AUTO part. After a lot of argument, I got a new prescription and had it set so that it auto-titrates. But they set it at 4-20 somehow. I know I should be able to use the + key to make it start at 6, but they seem to have disabled that!!!! (I gasp at 4 and it is taking forever to get to 9).

I also (on my own) bought the Encore sw and card reader. So, I wrote a new DEVICE PRESCRIPTION with a 6-20 range. When I put the card back into the apap, it beeps continuously and flashes the card symbol.

So there is something set in the machine at 4-20 that I can't change. ( If I take the card out, it works at 4 again, but without any recording capability).

The card isn't "corrupted" as the manual says. I can read it on my PC and all the data is still there and it specifies 6-20.

Does anyone know how I can make it start at 6? AND read my card again?

And yes, I've called my DME, gotten voicemail on all choices, and no call backs. I haven't tried Apria, but Pulmonary Solutions in Santa Clara is not very responsive either.