insurance will not pay for apap

Wulfman · Post by **Wulfman** » Fri May 11, 2007 9:54 pm

yosemitelor,

I've read that Blue Cross has worked with their insured/policyholders to do the type of thing I've described in my post in this thread.

viewtopic.php?t=17680

My employer is self-insured and the folks who manage our group are very agreeable to helping us (and the group) save money.

If you've got your prescription and your insurer will go along with it, you can get what you want without any problems or hassle.

Best wishes,

Den

yosemitelor · Post by **yosemitelor** » Sat May 12, 2007 2:32 pm

Hi Den

Thanks for the advice - i will check with Blue Cross and see if they are willing to do this.

On another note - I noticed the "hickville" comments regarding your location and the inference to the intelligence levels because of it posted earlier - I live in a "hickville" also - no elevators or stoplights in my town and the nearest fast food is a 45 minute drive away. I think any one who is smart and resourceful enough to make a go of it far removed from the big city is a pretty smart cookie That being said - "hickville" doesn't seem to have had too negative effect on my intelligence level and judging by the quality of your posts you don't seem to have suffered too much damage from it either
GO BEARS!!!!!

RachelM · Post by **RachelM** » Sun May 13, 2007 5:12 pm

Since titration was not successful during sleep study, I was sent home with an APAP w/card for a month to determine pressure needed. After a month of APAP, AND READING DISCUSSION ON THIS FORUM, I decided APAP was best for me and would increase my compliance. Dr went along with my wishes. I now find out that policy of DME (affiliated with dr) is to require payment from client for monetary difference between CPAP and APAP. Can DME make me pay?

Wulfman · Post by **Wulfman** » Sun May 13, 2007 6:59 pm

RachelM wrote:Since titration was not successful during sleep study, I was sent home with an APAP w/card for a month to determine pressure needed. After a month of APAP, AND READING DISCUSSION ON THIS FORUM, I decided APAP was best for me and would increase my compliance. Dr went along with my wishes. I now find out that policy of DME (affiliated with dr) is to require payment from client for monetary difference between CPAP and APAP. Can DME make me pay?

My answer would be "No". The insurance billing code is exactly the same for an APAP as it is for a CPAP. They will get the SAME reimbursement from the insurance provider for either......which is why they're trying to get YOU to pony up the difference that they'll lose. Call their bluff with this information.....they don't have a legal leg to stand on.

If they're THAT crooked, give them their machine back and buy one from CPAP.COM. You'll probably be money ahead anyway.

Good luck.

Den

yosemitelor · Post by **yosemitelor** » Sun May 13, 2007 7:59 pm

Hi Rachel

I am having the EXACT same problem. (A three page letter explaining why an APAP meets my needs and a CPAP does not convinced my doctor to write the letter of medical necessity for an APAP instead of a CPAP and the DME is insisting i pay the difference in the cost of machines.) Please share with the rest of us the name of your DME and where they are located so we can avoid doing business with them. If you find a DME that follows your best interests and your doctors orders please also provide us with the name and location of that DME so we can support them with our business and referrals.

First thing I would do is make sure YOUR letter of medical neccessity specifically states APAP and not CPAP because if it says CPAP there is no doubt the DME can charge you the difference. You can request a copy of what the Dr.s office sent to the DME if you do not already have it. IF it says CPAP contact your doctor , remind him of your conversation, and ask him to rewrite it specifying APAP.

In my case I called my insurance company (Blue Cross) on Friday and told them what the DME (Sleep Med) was doing. I believe it is an illegal action by SleepMed to not follow their contract with Blue Cross and try to extort extra money out of us. (Unfortunately by reading these posts it seems to be a common occurence.) We as patients need to fight back against this type of action and hope fully prevent it from happening to the next round of consurmers. I requested a form by which to file a formal complaint with the insurance company against SleepMed. I also plan to file a complaint with the Better Business Bureau and hope you do the same. I will report SleepMed's actions to my doctors office and ask them to stop referring patients to them. Hopefully if enough of us take these type of actions against the DME's who engage in these unethical and illegal practices, it will hit them in the pocketbook and then they will stop trying to rip us off. Anyone else have any ideas on further actions we can take?

Blue Cross told me it is their policy to pay 80 % of what ever the doctor prescribes whether it is an APAP or CPAP and as the patient. I should not have to pay the difference in the cost of the machines as long as that is what the doctor prescribed. I called SleepMed to tell them this, and they told me my Dr.s nurse told them it was patient choice and not mandatory. (You might want to check and see if something similar happened in your situation.) Anyhow I again called Blue Cross and asked them if it was their policy to have their approved DME's take a nurses opinion over a doctors written medical orders. They said NO, only a doctor and not a nurse or DME can decide what is medically necessary or mandatory. They are opening an investigation into the matter. I will also contact my insurance company Monday and see if they will let me do what Den has suggested in the post just prior to yours.

Anyhow I am livid that the DME takes a nurses opinion over the phone as to what is medically necessary and places more weight on it than a Dr.'s written letter of medical necessity that says an APAP is mandatory. I suggest you ask your Dr.s office for a copy of the letter of medical necessity - it should contain wording to the effect that this equipment is mandatory, or an absolute medical necessity and ask the DME what part of that wording they do not understand.

One poster on here suggested to change DME's until you find one that will not fight you on this. If you can accomlish that problem solved - i sincerely hope it is that easy for you. However as you are already renting from that DME i am afraid from what i have read on this forum you may be locked into doing business with them now for the purchase. So far from my experience it is not easy to find a DME that will not hassle you on this, as i have not yet been able to find a DME anywhere near me that is not playing this game. However, I will update you tomorrow on what my doctors office says once i confront them with the nurses actions which i believe violate a law as she is not able to legally tell a provider what is medically necessary or mandatory for a patient (this is the net effect of what she has done). I also believe my written correspondence with my doctor is confidential and protected by privacy laws which she has violated, and i also believe her actions are a violation of medical ethics by a registered nurse. I will confront her tomorrow morning with these facts and insist she immediately rectify the situation. I'll let ya know how it goes.

yosemitegal · Post by **yosemitegal** » Sat May 26, 2007 10:42 pm

Just to update you on what happened with my situation. I went to see the nurse and she told me the DME had lied to me. They were just trying to force me into getting a CPAP or paying the cost of the APAP. She told my Doctor and he was not happy about it and he called a different DME personally and they issued me an APAP right off the bat. So I will still file a written complaint with the insurance company about the DME's actions, but I found for me the solution was using a different DME. So therefore i highly recommend you do NOT use the services of SleepMed.

THier · Post by **THier** » Sun May 27, 2007 4:41 am

[quote="yosemitegal"]Just to update you on what happened with my situation. I went to see the nurse and she told me the DME had lied to me. They were just trying to force me into getting a CPAP or paying the cost of the APAP. She told my Doctor and he was not happy about it and he called a different DME personally and they issued me an APAP right off the bat. So I will still file a written complaint with the insurance company about the DME's actions, but I found for me the solution was using a different DME. So therefore i highly recommend you do NOT use the services of SleepMed.

dllfo · Post by **dllfo** » Mon May 28, 2007 11:33 am

Still Learning,
My pulmonologist ordered the Respironics Auto Bipap for me (thank goodness),
but when my wife went in, the tech actually told me she didn't need the Auto Bipap when a cheap cpap would do it.

We made sure my wife's dr. had a piece of paper with Respironics Auto Bipap with heated humidifier on it. I showed him her scores on the Auto Bipap and
he was pretty impressed. She got the Auto Bipap. I gave him enough "ammo"
that he was comfortable writing the prescription.

IF you do the same thing, at least you will have tried. Print out an ad for it from CPAPTALK.COM or something.

They also titrated her at...I think it was 6........and her numbers still run higher than that every night.

insurance will not pay for apap

Thanks for the idea!

SleepMed insists patient must pay differance in cost of APAP

Had to switch DME's

Re: Had to switch DME's

Machine	Humidifier