Open mind for different solutions?

snoregirl · Post by **snoregirl** » Tue Dec 26, 2006 10:43 pm

Sorry, I tried hard not to comment but I just have to.

What is really wrong is that some insurance will cover CPAP but not cover anything at all on APAP.

I would have no problem if I could have X dollars to apply to either machine. By not paying ANYTHING for apap is just plain wrong. I may choose to go with the APAP that is $200 more than the CPAP, and I am willing to pay that difference out of my own pocket, thereby costing insurance nothing more than the minimum to treat me. However many insurance companies say, if you don't take the CPAP we will contribute nothing but I will take your insurance premium anyway. VERY WRONG

mattman · Post by **mattman** » Wed Dec 27, 2006 8:42 am

snoregirl wrote:Sorry, I tried hard not to comment but I just have to.

What is really wrong is that some insurance will cover CPAP but not cover anything at all on APAP.

I would have no problem if I could have X dollars to apply to either machine. By not paying ANYTHING for apap is just plain wrong. I may choose to go with the APAP that is $200 more than the CPAP, and I am willing to pay that difference out of my own pocket, thereby costing insurance nothing more than the minimum to treat me. However many insurance companies say, if you don't take the CPAP we will contribute nothing but I will take your insurance premium anyway. VERY WRONG

What's interesting about this post is that, except for a few instances (Example - Medicare up until about 2 years ago) when you work with a DME this is exactly what can be done.

Generally, if a patient cannot tolerate a CPAP and has a need for an APAP - a DME company works with an insurance company to get the APAP covered. It's what we DO. We do the months of denials and appeals and reviews and paperwork collecting, etc.

Or if the particular plan doesn't allow for that (Which are exceedingly few and far between. I can't even think of any) or if the patient doesn't/wouldn't demonstrate a medical need for the APAP you can pay the upgrade cost and get an APAP anyways. Again, it's what we DO.

So, at least in my experience and the businesses I've worked with over the years - the situation you described is EXACTLY what the current system does.

mattman

meister · Post by **meister** » Wed Dec 27, 2006 9:10 am

Man, who was that idiot that stuck a stick in the Hornet's nest?

Happy New Year to All!! Even if some "alternative" medicine works for you!

snoregirl · Post by **snoregirl** » Wed Dec 27, 2006 10:18 am

Well mattman,

I am not talking about a patient NEEDING APAP. I am talking about choice of WANTING apap.

You didn't read my post. I am not talking about failing with CPAP and needing APAP. I am talking about a fair benefit to spend as I see fit. CPAP or APAP, my choice.

It shouldn't even be a question of a patient being allowed or not to make an upgrade with their own money.

You say that these insurance plans are few and far between. I beg to differ as my insurance is with a major company who underwrites their own and is one of the largest companies in the country/world and we all have the same benefits here in the US. So, there are an awful lot of folks out there with this plan which does indeed deny any benefits for APAP. If the patient wants to upgrade and pay the difference it is not allowed. It is take the CPAP or foot the whole bill yourself. And no, the very large DME I worked with didn't offer the upgrade option.

mattman · Post by **mattman** » Wed Dec 27, 2006 10:43 am

I did read your whole response, I apologize for not wording my response very well. I'm used to discussing this stuff in "insurance speak" since that's who I'm usually having these sorts of talks with.

When you said:
"I am talking about a fair benefit to spend as I see fit. CPAP or APAP, my choice."

That's what I was getting at with this obscurely worded comment:
"Or if the particular plan doesn't allow for that ... or if the patient doesn't/wouldn't demonstrate a medical need for the APAP you can pay the upgrade cost and get an APAP anyways."

We have in several cases setup a claim where we provided an APAP, billed a CPAP and had the patient pay an upgrade cost out of pocket simply because they wanted an APAP even though the insurance denied the Medical Review claim as not medically neccessary.

I hope I worded this out a little better. I'm not always good at this!

mattman

Goofproof · Post by **Goofproof** » Wed Dec 27, 2006 11:30 am

mattman wrote:I did read your whole response, I apologize for not wording my response very well. I'm used to discussing this stuff in "insurance speak" since that's who I'm usually having these sorts of talks with.

When you said:
"I am talking about a fair benefit to spend as I see fit. CPAP or APAP, my choice."

That's what I was getting at with this obscurely worded comment:
"Or if the particular plan doesn't allow for that ... or if the patient doesn't/wouldn't demonstrate a medical need for the APAP you can pay the upgrade cost and get an APAP anyways."

We have in several cases setup a claim where we provided an APAP, billed a CPAP and had the patient pay an upgrade cost out of pocket simply because they wanted an APAP even though the insurance denied the Medical Review claim as not medically neccessary.

I hope I worded this out a little better. I'm not always good at this!

mattman

The cost at a rate much higher than the difference in the cost of the machines. (More Profit) Jim

mattman · Post by **mattman** » Wed Dec 27, 2006 12:24 pm

Goofproof wrote:
mattman wrote:I did read your whole response, I apologize for not wording my response very well. I'm used to discussing this stuff in "insurance speak" since that's who I'm usually having these sorts of talks with.

When you said:
"I am talking about a fair benefit to spend as I see fit. CPAP or APAP, my choice."

That's what I was getting at with this obscurely worded comment:
"Or if the particular plan doesn't allow for that ... or if the patient doesn't/wouldn't demonstrate a medical need for the APAP you can pay the upgrade cost and get an APAP anyways."

We have in several cases setup a claim where we provided an APAP, billed a CPAP and had the patient pay an upgrade cost out of pocket simply because they wanted an APAP even though the insurance denied the Medical Review claim as not medically neccessary.

I hope I worded this out a little better. I'm not always good at this!

mattman
The cost at a rate much higher than the difference in the cost of the machines. (More Profit) Jim

I had this really ascerbic reply all typed out to that lovely little comment before discretion won out and I deleted it without posting.
Thanks and have a nice day.

drbandage · Post by **drbandage** » Wed Dec 27, 2006 1:03 pm

As a newbie, I am trying to do due diligence on all my medical and medical equipment decisions. I have seen a number of excellent posts that have a summary of links to discussions about a particular topic, e.g. mouth breathing. Many of them seem to have been posted by Rested Gal, BTW, and thanks for that!
Is anyone aware of a post that provides such a collection of links regarding the use of dental devices?
Thanks in advance.

snork1 · Post by **snork1** » Wed Dec 27, 2006 1:19 pm

[quote="drbandage"]As a newbie, I am trying to do due diligence on all my medical and medical equipment decisions. I have seen a number of excellent posts that have a summary of links to discussions about a particular topic, e.g. mouth breathing. Many of them seem to have been posted by Rested Gal, BTW, and thanks for that!
Is anyone aware of a post that provides such a collection of links regarding the use of dental devices?
Thanks in advance.

drbandage · Post by **drbandage** » Wed Dec 27, 2006 2:33 pm

[quote="snork1"][quote="drbandage"]As a newbie, I am trying to do due diligence on all my medical and medical equipment decisions. I have seen a number of excellent posts that have a summary of links to discussions about a particular topic, e.g. mouth breathing. Many of them seem to have been posted by Rested Gal, BTW, and thanks for that!
Is anyone aware of a post that provides such a collection of links regarding the use of dental devices?
Thanks in advance.

Snork1 wrote:

I would suggest going over to the talkaboutsleep.com forum, "dental sleep medicine" sub-forum, where you will encounter a lot less hostility on the subject and can read about the good and the bad, so you can make an informed decision for your apnea treatment path.

blarg · Post by **blarg** » Thu Dec 28, 2006 9:41 am

mattman wrote:I had this really ascerbic reply all typed out to that lovely little comment before discretion won out and I deleted it without posting.
Thanks and have a nice day.

Alright, I've been staying out of this one thus far, but here goes.

What you've posted thus far is that your DME is a good one, and that if the insurance company are jerks that won't pay a cent for the APAP, you'll let the customer pay the difference regardless. That's a good thing, and I'm glad you guys do that.

My question though, is why does anyone deserve an acerbic reply for noting that your prices are higher than what one could find online? People can make informed decisions. If your prices are higher, it should be easy for you to describe what the reasons are for the price increases. DMEs provide much more service than online companies. People can make their own decisions. If there are no reasons, then greed comes to mind. You're not the CEO of the company mattman, and I for one don't expect you to fix every problem in your company. Companies have to be at least somewhat greedy or they're not companies. Getting mad at patients who raise issues, though, will not help your case.

The original issue raised by snoregirl remains. You note that "that's how the system currently works" without the disclaimer that that's how the system currently works if a patient is using your DME. That's fine, just realize that because it's solved in your corner of the world doesn't alleviate the issue entirely. Since you work in the industry, are there any solutions you see out there that would actually eliminate the issue industry-wide?

-SWS · Post by **-SWS** » Thu Dec 28, 2006 10:13 am

drbandage wrote: Is anyone aware of a post that provides such a collection of links regarding the use of dental devices?

Sorry we missed this request. See Rested Gal's post on the following message board (currently fourth posting from the top): http://www.apneasupport.org/forum-11.html

And Rested Gal's post on this message board as well:
viewtopic.php?t=2836

muld00n · Post by **muld00n** » Thu Dec 28, 2006 10:37 am

drbandage wrote:
Is anyone aware of a post that provides such a collection of links regarding the use of dental devices?

Does this help?

cpaptalk-faq.php?FCID=15#15

neversleeps · Post by **neversleeps** » Thu Dec 28, 2006 11:08 am

Okay, let me throw this out there:
How many people give up when they can't tolerate CPAP and never make it to the battle for the APAP? This therapy isn't easy to adjust to and as we've seen written on this forum so many times, DMEs often don't follow up with their customers. Would it increase the odds of successfully sticking with it if everyone started out with an APAP?

Aren't the technological advances making straight CPAPs obsolete? After all, APAPs can be used in CPAP mode if desired. I'm kind of surprised the manufacturers don't capitalize on this and phase out straight CPAP machines altogether (ala the gaming industry). They could make more money. Their product has improved, so why continue to manufacture the outdated machines? Then we wouldn't have to deal with the battle for the APAP anymore and customers would be starting out with the greatest possible advantage. We know less than half the people prescribed CPAP stick with it. Doesn't it make sense to give them the best equipment possible in the hopes they'll actually use the thing? DMEs would benefit because they'd get the repeat business they're missing from the majority of people who quit and never come back. The manufacturer wins, the customer wins, the DME wins.

I'd be curious to know how many knowledgable DMEs (putting aside their interest in profit margins for the moment) would give their customers an APAP as their first machine if they could.

KansasRT · Post by **KansasRT** » Thu Dec 28, 2006 4:01 pm

I would agree with giving patients an apap to begin with, but not always having it be set as an apap. I am not convinced that everyone needs apap settings. But I do agree that having that technology available would be benefical. I do not agree with a DME company billing an insurance company for a cpap and providing an apap and making the patient pay the difference. The billing code is the same for both machines, but you still have to provide the insurance a description of the equipment. Not giving the appropriate description to an insurance company is not a practice I would feel comfortable doing. Also, if you are a contracting provider with an insurance company it is a touchy issue in billing a patient for something that technically should be covered by insurance. How I handle this situation is we would provide a patient with an apap and bill the insurance for an apap. Most generally they will not cover it, but will reimburse for a cpap. I would be responsible for writing off the difference, not billing the patient. Until I was on this site, I had never heard of billing a patient the extra for an apap. $200 seems like alot to me for the difference anyway. I guess I have different view of things.

Open mind for different solutions?

Stirring up the pot

alt treatments, dental

Re: alt treatments, dental