Insurance Questions

[IkreeR]

I am new here, after being non-compliant for more than year. That's a topic for another post. Doctor wrote a prescription for a new bilevel machine and all supplies. The code is 0470 BiPap.

So this means a straight BiPap, and not an auto, correct? The scheduler at my local DME says the insurance will cover 10 months rent to own, as long as I am compliant. (My appointment is next Monday.)

Then I get a notice from my insurance that they will cover 6 units of 0470 RAD with noninvasive interface, etc., for 3 months. Why would they only pay for 3 months? And 6 units? I only need one machine.

Yes, I will call them, but have no time today. I am just looking for some possible insight into this before I jump into the insurance quagmire. Thanks.

[JDS74]

I am new here, after being non-compliant for more than year. That's a topic for another post. Doctor wrote a prescription for a new bilevel machine and all supplies. The code is 0470 BiPap.

So this means a straight BiPap, and not an auto, correct?

Not necessarily. Here is a table of insurance code for cpap equipment and supplies:
A7034 is CPAP Nasal mask
A7032 is CPAP Nasal mask cushion
A7033 is CPAP Nasal pillows
A7030 is CPAP Full Face mask
A7031 is CPAP Full Face mask cushion
A7044 is CPAP Oral Interface
A7027 is CPAP Hybrid mask
A7028 is CPAP Hybrid mask cushion
A7029 is CPAP Hybrid mask nasal pillow
A7046 is CPAP Humidifier Chamber
A7037 is CPAP tubing, long and short hoses
A4604 is CPAP Heated tubing
A7038 is CPAP disposable filter
A7039 is CPAP gross particle (foam) filter
A7035 is CPAP headgear
A7036 is CPAP chinstrap
E0561 NU is CPAP Passover Humidifier
E0562 NU is CPAP Heated Humidifier
E0470 RR is BiPAP rental
E0470 NU is BiPAP purchase
E0471 RR is BiPAP-ST rental
E0471 NU is BiPAP-ST purchase
EO601 RR is CPAP rental
E0601 NU is CPAP purchase

Notice that BiPap code 0470 does not differentiate between an auto and a straight BiPap. The scrip can get you either. Unless the doc has specified an auto machine, the DME will try to force you to take a straight one. Suggest you get back to your doc and get him to clarify which he is prescribing. Then include the terms "As Written" to apply to the cpap machine only and "Patient's Choice" to apply to the cpap mask so you can change around if needed.

The scheduler at my local DME says the insurance will cover 10 months rent to own, as long as I am compliant. (My appointment is next Monday.) Then I get a notice from my insurance that they will cover 6 units of 0470 RAD with noninvasive interface, etc., for 3 months. Why would they only pay for 3 months? And 6 units? I only need one machine.

Speculation: It is possible ??? that your insurance already partially paid for some months already and they are letting you know that you will have to pick up the tab for the months already paid.

Yes, I will call them, but have no time today. I am just looking for some possible insight into this before I jump into the insurance quagmire. Thanks.

To get clarity, you'll have to talk to your insurance company.

BTW, the term BiPap is a trademark of Philips-Respironics. The generic term is Bi-Level. Other companies have their own terms for this technology.

[Okie bipap]

If your insurance follows the same procedure as Medicare, they approve an initial three month rental during which time you must prove you are using the machine and it is treating your condition. The machine the DME will try to give depends on your prescription. If your script calls for a single pressure with pressure support, you will be issued a single pressure machine. If your script calls for a range of pressure, then you will get an automatic machine.

[IkreeR]

Thanks for the replies and my apologies for not responding earlier.

I did call my insurance, and it is covered for 3 months with compliance, and then they will renew for 6 months with compliance, and then it goes to a year.

My prescription actually reads E0470 BIPAP (not the generic bilevel). My current machine is a PRSystem One BIPAP Pro with flex. My scrip is for 16 inh/10 exh. The current prescription should get me a newer, equivalent machine from any manufacturer?

I also compared the scrip to the insurance letter. Insurance has covered a heated hose but the scrip is for a plain hose. Not a huge deal, but I predict more snafus ahead if they messed up the hose. Sigh--story of my life is fighting insurance.

[Okie bipap]

With that scrip, you will get a single pressure machine since it calls for a single pressure. If it specified a range of pressures, then it would require an auto machine.

[SewTired]

You could try asking your doc to write a script for an auto bi-level in case your needs change in the next 5-6 years before you could replace the machine. Resmed only carries an auto bilevel, but Respironics has a $300 difference between the auto and the fixed pressure bilevels. That would change what the DME gives you. The DME gets paid the same whether auto or fixed.

[Okie bipap]

ResMed makes more than one Aircurve 10 machine. The Aircurve 10 S is a single pressure machine. The Aircurve 10 ST is a single pressure machine with backup rate. The Aircurve 10 VAUTO is the auto version. They also make Aircurve 10 ASV machines.

[SewTired]

ResMed makes more than one Aircurve 10 machine. The Aircurve 10 S is a single pressure machine. The Aircurve 10 ST is a single pressure machine with backup rate. The Aircurve 10 VAUTO is the auto version. They also make Aircurve 10 ASV machines.

Thanks. I understood that the Aircure S and ST were not typical bilevel machines. I stand corrected.

[palerider]

ResMed makes more than one Aircurve 10 machine. The Aircurve 10 S is a single pressure machine. The Aircurve 10 ST is a single pressure machine with backup rate. The Aircurve 10 VAUTO is the auto version. They also make Aircurve 10 ASV machines.

There's also an Aircurve10 ST-A now. so there's *five* aircurve models.

[CpapWife]

We have found that good DMEs are very hard to find (we are in AZ and our insurance agrees they are very bad in our state). However, even national companies like Edgepark have told us false statements to get more money from us than the insurance would pay.
The bad DMEs tell us things like your insurance will only cover.... when the information is blatantly false.
Some of these false statements we have been told are:

DME false statement: Your insurance will only cover rentals not outright purchase.
Truth: Our insurance does both but DMEs often charge more for rentals or think (sometimes falsely) that the insurance will pay more for a rental therefore they do rentals only (one DME actually told us they made more on rentals so they never did purchases). Note: One horrible DME said after the rental period was over we had to buy the machine when our insurance says you own the machine after the rental. Also, many learn what Medicare covers (lowest common denominator typically) and treat all insurance that way to make it "easier" for them.
Note: Most DMEs use machines for a very long time as rentals, so they earn the purchase price many times over as they rent it for 5 years to different people. So if you do rent, make sure you get a brand new machine.

DME false statement: When our older APAP, which worked fine when given to the DME rep who took it into a back room to change the setting and came back to us "broken", we were told your insurance will not buy you a new machine as they reserve the right to try to fix it first. It will take 6-9 months to fix it and the insurance only pays for one month of this so you will have to pay for the rest. [Yes, we were actually told this, luckily I knew that didn't sound right and called our insurance company.]
Truth: Our insurance (and I think most) replace machines at the 5 year mark even if they work perfectly fine and the machine. They would have done an immediate purchase of a new machine for us, needless to say we didn't buy it from the company that gave the false statement.

DME: Your insurance does not cover that mask. When I pushed back, they say our contract with your insurance does not cover that mask.
Truth: Insurance reimburses one price for any mask, they don't care which mask. DMEs, to make more money will either buy one mask in bulk to save money and offer only that one, or they will offer only a couple of masks - often older cheaper ones. The DME will sell you the more expensive mask if you pay cash for it.

DME: It is extra money if you want an Apap (or a certain machine that is newer or better).
Truth - as someone else said, insurance often has one price for any cpap/apap and the DME has a contract that supplies what you need for that price with no extra charge to you. The DME wants to make the most money and they pay less for a cpap then an appa (I am basing this info on the fact if I buy cash at a retail store like cpap.com I pay less for a cpap than an apap). So the DME is trying to charge you more, often in violation of your contract.

DME: IF you try on the mask you buy it. Or when you say the mask is not working ask to return it they say it can not be returned.
Truth: Most mask manufacturers will allow a return and refund of the mask within 30 days of purchase. But this costs the DME money to ship it back, spend extra time getting you a new mask.

DME false statement: Your insurance will only cover one disposable filter at a time.
Truth: Our insurance covered 6 months of disposable at a time.

DME false statement: You need supplies at X rate (e.g. mask so often, tubing so often, etc.). When we were first told this we called the manufacturer who was shocked as minimum the mask should last twice that long.

DME false statement: Your insurance says you a new sleep study before we do that [get supplies from them after moving to another state].
Truth: Our insurance doesn't require anything but a subscription, and certainly doesn't require a new sleep study just because we changed states.

DME: You must pay your co-pay before you receive the equipment.
Truth: The price they put on the bill is not the insurance contract price, it is an inflated price the same as Drs offices do. The insurance does their adjustment to bring it down to the contract price and after you receive the EOB (explaination of benefits) that shows what you owe then you pay that amount.
Note: Lincare, in AZ at least, makes you sign a document saying you will give them a credit card and not dispute any amount they charge to it. We said no and walked away (outrageous as billing is horrible and often incorrect in this state).

Call your insurance to see what they pay and trust that. If the DME argues, make them do a 3 way call with you to the insurance company. We have been told are pure fiction that changes continually as we catch them in lie after lie.

[IkreeR]

Thanks everyone for the information. I picked up the new equipment yesterday, and now have the Dreamstation BiPAP Pro. It is the new version of my old machine, and it is SO QUIET (in comparison to the old model).

Insurance is still not clarified, except they are covering it. It's been a bit wonky as my company decided to change carriers in April, AFTER I had already met my deductible on the old plan, and I think (but not confirmed yet) that has all been sorted. NOTE: I have a number of other chronic conditions, in addition to mild/moderate OSA, and they all include fatigue and sleepiness as symptoms. Yay me!

The paperwork seems all in order, and I have confirmation that they will cover it, but they are telling the DME one thing and me another. And past experience tells me to not fight it until I see what actually shows up on the bill, because either (or both) the DME and I are getting incorrect information over the phone. Once the insurance actually processes the claim, then I can fight once I see an actual bill, because it will just be added to the paper trail I am saving.

On the positive side, the new machine is far more quiet than the old one, and the Dreamwear mask is the most comfortable I've ever had (at least for one night ). According to Respironics software, I slept for 6.5 hours with no leaks and an average AHI of 5.5. I don't know the accuracy of the AHI or leaks, but the fact that I slept for 6.5 hours STRAIGHT without waking up or taking the mask off is a FIRST! So already this new setup is worth it.

Yes, I know about Sleepyhead, but I'm not going to bother about it until I find out why Windows decided my card reader no longer exists. I am investigating drivers and related issues, but they are continuing to give each other the silent treatment. So no Sleepyhead until they kiss and makeup.

Thanks for all the help.