My Quest for Autopap has begun

[DerekB]

OK, I just called my primary doctors nurse (doc is out of town till tues.) and explained that I received the Remstar Plus and would like to return it and get the Remstar Auto due to its ability to record data an allow me to review my response to treatment. I would like the doctor to write a prescription for the Remstar Auto w/cflex. As I have been having some restless nights and some tired days I would like the option of the Auto feature to help provide a more flexible treatment. I have been on therapy since April and the Plus machine was the one given to me by the DME on a 12 month rental, after which I get to keep. I know the Plus and the Auto have the same billing code so there should not be a problem with the insurance company. I think?? The DME would just have to pony up the new unit and except the difference in cost. I can see where I might have a struggle with the DME but if I go there with the new prescription for a Remstar Auto w/cflex I don't see where they can deny giving me one.

Will this work?

Any advise or suggestions appreciated!

Derek

_________________

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

[rested gal]

Derek, you're absolutely right about cpap and autopap having the same insurance billing code. It should make no difference at all to most insurance companies which "cpap" machine the DME gives you. The insurance companies usually have an agreement with certain DMEs to pay only X number of dollars to the DME for "cpap." "CPAP" includes autopap...same billing code because Medicare regards an autopap as just another cpap machine (an "auto-titrating cpap"), unlike the separate billing code they give to bi-level machines.

As for whether the DME will be cooperative about it or will try to throw up roadblocks and give you misinformation, it just depends on the particular DME.

First thing is, as you said, get the prescription that specifies "autopap" and a range of pressure to be set (like 5 - 15 cm H20, or whatever range you and the doctor decide on.)

If you have a particular brand/model of autopap you want, I'd go a step farther if I were you, and have the doctor specify that exact brand/model of autopap on the Rx.

For example:

Respironics REMstar Auto with C-flex
Pressure 5 - 15 cmwp (or cm H20)

Do a search for snorgirl's posts about "insurance." She's given a lot of good sound advice about stepping your way through the hassle of dealing with DMEs over insurance issues.

Of course, with a bit of luck, your DME will glance at the new Rx and bring the autopap you want right out to you. That happens, too.

[snoregirl]

Derek,

I just want to comment on a quote from you post


You say........

"and get the Remstar Auto due to its ability to record data an allow me to review my response to treatment."

Just be aware that the Remstar Pro2 (old version) and the Remstar M Pro also record data and allow you to review your response to treatment. The difference between these machine and the Auto is the ability of the AUTO machine to adjust to your need for higher or lower pressures. Higher without you having to read data and tweak, and read data again and tweak. Lower pressures to make you more comfortable (and compliant) when you don't need the full pressure for which you were titrated.

If I was a DME or Doc and being stingy and you told me the quote above, I would agree to swap your plus for a Pro2 or M Pro. So you need to be clear about what you expect to get from an AUTO if you are asking for one. And make sure that what you expect to get can only be gotten from an AUTO.

On the question of insurance. Really hard to say how that will go. In my experience and numerous converstions with my company, the Insurance denied paying ANYTHING for what it considered a "deluxe" machine. That included even paying what they would have for a lesser machine and letting me pick up the difference. However, when it came down to it and I got the DME to give me the auto (since I did have a prescription for one), the insurance company didn't look twice at whatever the DME submitted as a name for the machine, they just paid the E0601 code and that was the end of it. Even though they were so adamant that they wouldn't pay for a "deluxe" machine and I (in their doctor's opinion who never met me) I didn't need it.

So if your insurance is with you for the AUTO you may be able to use that with the DME to get the machine. If they are not with you, you have to get your script and convince the DME to give it to you. They may tell you your insurance doesn't cover it. They may be technically right. But the loophole lies in the coding and payment. Really a fine point.

I hope you are lucky and you get the script you want and the DME doesn't give you any trouble.

If you are on your own with the DME (no insurance support for AUTO), then you have to decide what you want and be ready to hand back their machine and walk to the fax machine to upload you prescription to buy online. That is probably the only leverage you have at that point -- the threat of no continued business from you for that DME.

And you willingness to do this may depend on how good your insurance coverage is and how badly you want the APAP.

[DerekB]

Thanks RG and snoregirl for the great advise.

I am going to print the description of the Auto and give it to the nurse.

I will keep you notified on this thread of my progress.

Thanks again!

Derek

[Snoredog]

you got some good advice above, other reasons I prefer the autopap besides the data reporting:

1. I sleep on my stomach, side and supine, pressure requirements differ at each position.

2. With GERD, I sometimes end up with aerophagia, with the autopap supplying pressure only when needed this helps relieve the painful condition.

3. Today you may have a job and insurance coverage, tomorrow that job could be outsourced where you can possibly end up with no medical coverage. Then what are you going to do with the monthly rental? Purchasing your machine is always the best option in my opinion.

4. You can save money on deductibles, followup PSG's and doctor visits with an autopap as it will nearly always supply the correct pressure needed (don't tell your doctor this, they will use that excuse to deny your request).

Getting an autopap is harder if you want insurance to pay for it. If you are willing to pay out of your own pocket then you don't need to go through the hassle, just take your current cpap script (you do have a copy of it correct?) and purchase the autopap you want on-line then fax over a copy of the cpap script. Buy it from cpap.com and it will come with all the manuals.

[DerekB]

No problem getting script from doc. Wrote it up as: RemStar Auto CPAP w/CFlex.

Went DME, showed them my prescription, and they said no problem, come on in here we have this one right here. At this point I was thinking I was dreaming. Then she said "You use it for 7 days, bring it back, then we set you unit for the pressure found from the 7 night sleep study". I said no I want to keep it, turn in my Remstar Plus and keep the Auto. I have a prescription for it. That's when things changed - Big Time. They went on to tell me that they don't offer the Auto machine to the public, that it is only used for 7 night (loaner) sleep studies to determine pressure. Well after a little back and forth she figured out that I knew what I was talking about concerning the billing code and they only wanting to provide a machine that will yield them the highest profit. I said that the problem with the insurance company is not my problem, it yours (theirs). She said they are having a meeting the next day and they would discuss this issue as there was another patient making the same request as I. I said OK, i'll be back.

OK, two days later (today) I went in and she said they had their meeting, and that she called the insurance company and was told that they are not allowed to charge the patient any up cost to cover the difference between the Plus vs Auto and that it was at their own discretion whether they wanted to provide the Auto machine. Then went on to tell me that at their meeting they decided that it was their policy to only provide the Plus model and that was their decision. They would only provide the line of machines that they have. As if saying the Auto is not in the line of machines they have. I pointed out that they are a Respironics dealer that includes the Auto machine. She said still that they do not offer the Auto machine to the public. I said does Respironics know you are not offering the complete product line to the public. Well there was a little more back and forth and I finally said, "So you are telling me that your profitability rates higher than (my) patient care?" She stopped talking right there and I turned around and walked out.

10 minutes after I got home I got a call from the boss of the DME and she said while she still supports her employee, and their policy will remain the same, they are going to provide me with the machine that was prescribed. I was to call my tech and set an appointment. I called, went right away and picked it up this morning. Not a new one, one of their loaner machines. The tech said they zeroed out the hours. The display did show 11.1 hours after start up. During startup is shows 482 blower hours. If this is true than it is newer than my Plus that had 1380 hours.

I am happy happy! I hope this will improve my therapy and I am now in a search for the reader and software.

Thanks to all here that offered advise and knowledge!

DerekB

[rested gal]

Wow, Derek. Interesting post. What an inside look you got at how that DME makes decisions about what a doctor has prescribed.

Hope you get very comfy, effective treatment with your almost new machine. Good job!

[Wulfman]

Congratulations on getting an Auto.

My question is whether they are going to get you a NEW machine?
I was under the impression that if a machine has over a certain number of blower hours on it (maybe like 40), they aren't supposed to sell it to a customer (and bill insurance) as a NEW machine.....which is what a patient is supposed to get.....a NEW MACHINE.

Den

[snoregirl]

What is the warrenty on the "used machine" and does your insurance company know it is used? Is it rental or purchase? Do you have all the items that come with it? Manuals, extra ring (humidifier to machine, filters...)

Your choice how to go. But you can see how a little waiting pays off.

[DerekB]

I didn't ask about warranty. I do have a dated receipt that says new and the serial number is listed. The DME boss said it would be an even exchange in place of the Plus. I have had the Plus for 7 months and the insurance pays 10 months for the rental (80% Ins/20% me) then the machine is mine. So in three months this machines is mine. I think this is an internal swap at the DME, the insurance company probably won't be informed of it.

We only swaped the machine and user manual. I kept everything else from the Plus. The travel bag, the filters the two rings (for the humidifier connect) the power cord etc...

If this machine were older and had thousands of hours use then I might push the issue but I think all is well and I don't want to open a can of worms with the insurance company. Who knows what they might decide to do.

Thanks for all the concern and support.

This is truly a great place to air this stuff out.

DerekB

[rested gal]

Derek, please check your private messages...button at upper right.