RT Hoseheads face problems too

[Vasily]

So as most of you know I am an RT and RPSGT. I have been using CPAP for about 3 1/2 years, but have been feeling a little sluggish lately. So rather than playing "Pin the tale on the donkey" with my pressure, I decided that I would go to the Sleep Doc I work for and get a script for an APAP. Got the script and asked the girls in billing (I now work as an RT in a DME) to get the pre-auth for my machine. Imagine my surprise when I came back to my office later that day and found a voice mail message from the Insurance company denying my claim for an APAP, but authorizing me for a CPAP. I thought surely they were mistaken, so I called the billing girls and they called them back. Nope, no mistaking, the Insurance would not authorize an AUTOCPAP, but were authorizing a regular CPAP.
So my manager said, no problem, you can use your employee discount (which is "cost + $1") and just buy it outright. Great idea, except cost +$1 is $85 more than it would cost me to buy it from CPAP.com!! We are talking about an "M Series" Auto with AFLEX here, core package which includes humidifier.

This all happened about 2 months ago, since that time I started tracking which patients came in with an APAP script and actually got it paid by insurance. Results, in the last 1 1/2 months I have given out 7 APAP's, 5 of which were denied by their insurance. 2 of those 5 people, actually came in and told me that they had called their insurance and asked if it was covered and had been told that it was. 4 out of the 5 had the same insurance, so I called the insurance company and asked, why they were denied. The rep told me that they were denied because there wasn't any supporting evidence that the patients were not compliant with CPAP use. Infact just the opposite, they were very compliant which made the APAP not medically necessary, because it was only wanted for comfort and they don't pay for comfort items. One of the patients even had a clause in his policy that required him to be noncompliant for 60 days or longer.

So now our manager has adopted a policy that all APAP's require a preauth from insurance prior to the patient taking possession of the equipment. Needless to say my job just got a little more frustrating today.

[rested gal]

One of the patients even had a clause in his policy that required him to be noncompliant for 60 days or longer.

Wow.

I'm curious about one thing, Vasily... autopaps are the same billing code as cpap, aren't they? How does insurance even know (or care) if the person is given an "auto-titrating cpap" instead of a bare bones cpap?

Isn't insurance going to pay whatever they've contracted with the DME to pay for "cpap"...whether it's a cpap that cannot auto-titrate, or a cpap that can auto-titrate?

[Slinky]

It would be interesting to see HOW your billing department was trying to bill these insurances.

If insurances are paying by HCPCS code E0601 and are contracted a set amount for HCPCS code E0601 there is no way the insurances even know if the xPAP is a straight CPAP or an autoPAP.

Which means your billing department is trying to bill an autoPAP under a different HCPCS code. Like trying to bill them with the HCPCS code for a bi-level for instance. Or under some miscellaneous code.

[Slinky]

On the other hand: to give some idea of how the local DME suppliers' profit margins have decreased just the last 12 months or so.

Medicare, which is "the" biggest insurer, allows a billable amount of $135 a month for 13 months for an HCPCS code E0601 CPAP. The "allowed" amount for that same CPAP is $74.96. Of this "allowed" amount Medicare pays $59.97 a month. The 20% copay from either the insured or their secondary insurance is $14.99 a month. For a grand total of $974.48 for a straight CPAP thru autoPAP. Just the machine itself. No humidifier, filter, etc. This is for the region that Michigan is in.

In October 2006 the Medicare allowed amount was $99.95. Of this allowed amount Medicare paid $79.96 and the 20% copay from the insured or their secondary insurance was $19.99. For a grand total of $1299.35 for just the machine itself. Again, this is for the region Michigan is in.

So that was a "hit" of about $320 in 2007 on the CPAP profit margin.

Of course, we have NO WAY of knowing what these local DME suppliers pay for these CPAPs as compared to cpap.com's retail prices.

[Vasily]

RG,

Good point, I asked the girls in billing about that when they denied mine. The short answer is, insurance does not pay a dime no matter how often they are billed until they recieve the script and a copy of the sleep study from us. Once they recieve the script and the sleep study, they then pay or deny the claim. My wife and I have known one of the billing girls for over 15 years, so being the skeptic I went to her after I heard this and she confirmed it. She also went on to state that, about 75% of the time they call for a preauth on CPAP's the insurance rep will ask them if it is a regular CPAP or an Auto.


Slinky,

Believe me they ARE billing by HCPCS E0601, these girls have been doing this for a long time, they know what they are doing.

I'm curious why you would think that I should find another job?
Is it because of the cost of the APAP?
CPAP.com probably sells hundreds of those a month, we barely move 30 CPAP's total of all kinds in a month, who do you think Respironics is going to give a better price point too?
I mean honestly find another job? I love my job, I could have worked at the local private sleep lab and made $9 more an hour, but I felt that helping the patient on the treatment end was putting my skills to better use than on the diagnostic end.
To each their own I guess.

[Vasily]

Ahh I just wanted to post this example of why i love my job.


About 2 weeks ago I setup a 94yo lady on CPAP, sharp as a whip and understood everything I told her. I called her last Friday for a 2 week followup (my secretary does the 72 hour and 1 week), she said she was having some problems with the mask, so I made her an appointment to come in on Monday morning and we would work it out. She came in and brought her mask, after about 5 minutes we had the problem straightened out. We then sat and talked about everything from politics to gardening and fishing for the next 30 mins. Why? Becaused I realized that she didn't really need help with her mask, or need my years of experience fed to her. She just wanted to get out and talk to someone. THAT is why I love my job, because I made a difference in atleast 1 patients life that day!!!

Oh and before she left she asked if I would come over to her house and pull the weeds in her garden without my shirt on. Hehe I told her I had to see if my wife would approve of that. To which she replied, "Honey she's a woman, she knows at 94 I'm not a threat to her, but she also understand that women are never to old to window shop!!" LMAO

So as you see, my patients can also make MY day!!!

[Slinky]

Vasily, my apologies. That comment didn't come out the way it was intended. Nor did the tongue in cheek avatar that was supposed to have been at the end of that sentence. I was trying to dig out my Medicare info and submitted that post too soon.

It still makes absolutely no sense that insurance would give a rat's rear one way or another whether the patient is given a straight CPAP or an APAP. That insurance is going to pay the same amount regardless which type machine the patient is given! Its absolutely no skin off the insurance's nose which machine the patient is given. It is ONLY the DME supplier who feels the difference. I'm sorry, I don't buy this story.

What I do see tho is that the DME supplier shells out the cost of the machine, whatever amount it is, up front or w/in 30 days, yet their reimbursement is strung out piecemeal over 13 months.

[Slinky]

And, Vasily, I certainly hadn't intended to be critical of you personally in any way. Its obvious you care about patients or you wouldn't be spending your time here.

[Snoredog]

One of the patients even had a clause in his policy that required him to be noncompliant for 60 days or longer.

Wow.

I'm curious about one thing, Vasily... autopaps are the same billing code as cpap, aren't they? How does insurance even know (or care) if the person is given an "auto-titrating cpap" instead of a bare bones cpap?

Isn't insurance going to pay whatever they've contracted with the DME to pay for "cpap"...whether it's a cpap that cannot auto-titrate, or a cpap that can auto-titrate?

What she ^ said HOW are they going to know you are getting an autopap? Your billing department TOLD them you were and billed them for it.

I call it the blind leading the blind...

You got hosed on your autopap purchase because your OWN billing department hosed you, had they simply given Insurance company the CPAP bill code they would have paid for the machine like any other CPAP.

All they would have had to do was program the machine into "CPAP mode", used that code, and hand you the machine in that mode. Then I bet they would have paid for it like any other cpap machine.

Once you get home, you reprogram it into Auto mode and you have your autopap.

Autopaps have separate bill codes, which one is used depends on which mode you program the machine in. What is even funnier (sorry it is at your expense), your Manager changes your policy, meaning they don't know either, reason I say blind leading the blind.

But it still doesn't change the fact Insurance is so STUPID, if they had a half a brain, they would know that autopap would save them money over the course of therapy in doctor visits, PSG titrations etc., but they are banking more on the statistical failure rates of this therapy, if >40% or more fail on therapy why buy you a more expensive machine.

[Slinky]

SnoreDog, are you saying that IF the pressure setting ordered by the doctor is just ONE pressure the DME suppliers are billing at the CPAP code BUT if the doctor specifies TWO pressures for a pressure range the DME suppliers are then billing it as a bi-level with the bi-level HCPCS code??

[Vasily]

Nope, honestly the story is the truth, I know it doesn't make any sense to me either. But I know the girl that I verified the story with wouldn't BS me. Like I said, we have known her and her husband for over 15 years. Her husband and I deployed in the military together twice in the same unit, so my wife and her and our kids (theirs are only 1 year apart from ours) became very good friends.

I think the sad reality is that the top 8 DME providers in the US have banded together and lobby hard on Capitol Hill to push their agenda. This is not always the same agenda that the smaller companys have or always in the best intrest of the patient I believe. I think this same group has been pushing hard to get the CPAP HPCPS changed for APAP's, thus prompting a change in the way Insurance Co's are starting to look at them.

Oh and yeah sorry I just get a little steamed when people start talking about my job. I don't care about slamming DME's in general, because I feel basically the same, however I think that the manager I work for does the best she can to provide the best for every patient given the guidelines she has to work under.

So no ill will taken.

[Snoredog]

SnoreDog, are you saying that IF the pressure setting ordered by the doctor is just ONE pressure the DME suppliers are billing at the CPAP code BUT if the doctor specifies TWO pressures for a pressure range the DME suppliers are then billing it as a bi-level with the bi-level HCPCS code??

No I didn't say that at all. I said there are two bill codes in the auto-cpap, which one used and billed depends on which mode it is programmed in. Exact same machine, different bill codes.

It is not like Insurance is doing us any favors keeping premiums down.

[Slinky]

I'm only finding the billing code for CPAP and the billing code for bi-level.

[Snoredog]

[quote="Vasily"]Nope, honestly the story is the truth, I know it doesn't make any sense to me either. But I know the girl that I verified the story with wouldn't BS me. Like I said, we have known her and her husband for over 15 years. Her husband and I deployed in the military together twice in the same unit, so my wife and her and our kids (theirs are only 1 year apart from ours) became very good friends.

I think the sad reality is that the top 8 DME providers in the US have banded together and lobby hard on Capitol Hill to push their agenda. This is not always the same agenda that the smaller companys have or always in the best intrest of the patient I believe. I think this same group has been pushing hard to get the CPAP HPCPS changed for APAP's, thus prompting a change in the way Insurance Co's are starting to look at them.

Oh and yeah sorry I just get a little steamed when people start talking about my job. I don't care about slamming DME's in general, because I feel basically the same, however I think that the manager I work for does the best she can to provide the best for every patient given the guidelines she has to work under.

So no ill will taken.

[Vasily]

What she ^ said HOW are they going to know you are getting an autopap? Your billing department TOLD them you were and billed them for it.

I call it the blind leading the blind...

You got hosed on your autopap purchase because your OWN billing department hosed you, had they simply given Insurance company the CPAP bill code they would have paid for the machine like any other CPAP.

All they would have had to do was program the machine into "CPAP mode", used that code, and hand you the machine in that mode. Then I bet they would have paid for it like any other cpap machine.

Once you get home, you reprogram it into Auto mode and you have your autopap.

Autopaps have separate bill codes, which one is used depends on which mode you program the machine in. What is even funnier (sorry it is at your expense), your Manager changes your policy, meaning they don't know either, reason I say blind leading the blind.

Snoredog,

I would like to know where you are getting the info about different codes for APAP's. I will look again tomorrow in the 2007 HPCP code book, but i'mm 99% certain that CPAP's, CPAP's/Cflex, CPAP's/EPR, APAP's etc. are all the same code E0601.