Insurance approval

[jasper]

In another thread, Rooster mentions getting an APAP with A-flex, and the issue of getting insurance approval. Rather than get tangled in that thread, I wanted to address just that problem. I'm being told by Apria that my insurance, Aetna will not give a pre-approval for my machine. I got an M-Series Plus machine a year ago, and I was really unhappy with not getting any "real" data. (Plus there are so many other benefits from the APAP).

To cut through two months of hassle, I now have a script that states APAP with A-flex, plus a letter of medical necessity from my sleep doc. Apria wants me to sign a contract for a 10 month rental, and accept the full burden if Aetna rejects the claim. They say that Aetna will not pre-approve it.

Last time I remember getting a mask, they were able to get a pre-approval from Aetna. What gives? I really am averse to signing a contract without knowing how much I'll pay in the end. Is this really the way it works, or should I try calling Aetna myself? I don't want to unnecessarily muddy the waters, but I’m ready to do that if need be.

The funny thing is, the company I work for is self insured, and Aetna is only their TPA (Third Party Administrator).

Lastly, if I can't get pre-approval from Aetna, I intend to order on-line. Sometimes I wonder if that wouldn’t have been better anyway. I would have had my machine for 2 months now.

Any thoughts?

[Wulfman...]

In another thread, Rooster mentions getting an APAP with A-flex, and the issue of getting insurance approval. Rather than get tangled in that thread, I wanted to address just that problem. I'm being told by Apria that my insurance, Aetna will not give a pre-approval for my machine. I got an M-Series Plus machine a year ago, and I was really unhappy with not getting any "real" data. (Plus there are so many other benefits from the APAP).

To cut through two months of hassle, I now have a script that states APAP with A-flex, plus a letter of medical necessity from my sleep doc. Apria wants me to sign a contract for a 10 month rental, and accept the full burden if Aetna rejects the claim. They say that Aetna will not pre-approve it.

Last time I remember getting a mask, they were able to get a pre-approval from Aetna. What gives? I really am averse to signing a contract without knowing how much I'll pay in the end. Is this really the way it works, or should I try calling Aetna myself? I don't want to unnecessarily muddy the waters, but I’m ready to do that if need be.

The funny thing is, the company I work for is self insured, and Aetna is only their TPA (Third Party Administrator).

Lastly, if I can't get pre-approval from Aetna, I intend to order on-line. Sometimes I wonder if that wouldn’t have been better anyway. I would have had my machine for 2 months now.

Any thoughts?

You should always be able to contact your insurance provider (or TPA) and find out the REAL information. In most cases, they like to hear from their members and especially in cases where things need pre-approval. Don't just take the word of a DME.....especially the one you mentioned.

My employer is also self-insured and has another entity administer the plan.
That was how I managed to purchase my own equipment right off the bat from CPAP.COM and they reimbursed me at the 80% in-network rate. THEY wanted to save some money and so did I.....along with getting a better machine that would give me my nightly statistics. People who have these data-reporting machines actually save their insurance providers more money because the patients won't need to go back for as many trips to the doctors and sleep labs.

I was in touch with them all throughout my sleep study and subsequent ordering of equipment.....so as to keep them informed and to find out what they would cover. Unfortunately, my sleep doctor (or his office) dropped the ball as far as sending a copy of my sleep study to them, but after some prodding on my part, they finally got them faxed to my insurance provider.

Just remember......all of these people are supposed to be working for YOU. If they're deducting group insurance premiums from your paycheck, they are DEFINITELY working for your benefits.

Words of advice.....know as much about your insurance coverage as possible. Don't take the word of another party that has "making as much money as possible" as their goal. THEIR best interests are not necessarily YOURS. (Expecially when your health is at stake)

Good luck,

Den

[Guest]

Thanks Den I got the billing code for the machine, so I'll contact Aetna. Is there any other info they're going to want, besides machine name and model #?

[fidget]

They won't approve it, I can promise you that. It's coded under the same HCPC code as your current CPAP, and they won't approve the same code as the machine you already have until it's reached its expected life span of 5 years, or until your doctor orders a machine with a different HCPC code, such as a Bipap.

If it were up to me, Respironics would quit making the stupid DS100, and start out with the aflex as the basic machine.

It's not though.

[Guest]

Is the HCPC code the same as the billing code E0601? What is HCPC? Your post doesn't encourage me very much, but at least I'd like to give it a try...

[Wulfman...]

Thanks Den I got the billing code for the machine, so I'll contact Aetna. Is there any other info they're going to want, besides machine name and model #?

If you're in a position to purchase the equipment you want from CPAP.COM (and hopefully get them to reimburse you), you need to lay out the scenario to them and then ask if they will reimburse you if you purchase the equipment you want.....particularly at the in-network rate.
By the "scenario", I mean that you need to explain to them that you can purchase better equipment than you'll ever hope to get from Apria and at a lower cost than what Apria would charge your insurance. (Tell them that you want to save everybody some money)

I don't know that you need to tell them about the insurance codes at this point, but if it comes up, it's E0601 NU (for the CPAP purchase).
Also, you might be ready, just in case, and have the other codes available and some costs of the items from (I assume) CPAP.COM.

If they agree, what you'd need to do is to upload (or fax) your prescription to CPAP.COM (I scanned mine and went through their upload link to send a copy to them)
Then you'd need to charge your purchase to a credit card.
When CPAP.COM ships the equipment, they will include a copy of your invoice.....from which you can use to make an invoice FROM YOU (as the billing party) TO your insurance provider or TPA (as the party being billed).
Their invoice will have all of the appropriate billing codes on it.

Besides my machine and humidifier, I also got extra filters, an extra 10' hose and an oxygen supply connector listed on my invoice and they paid for it (well, 80% of it). The only thing they wouldn't reimburse me for was the software and cardreader package.

Den


.
Here's a full list of the billing codes (I've bolded the ones I used):

* E0601 RR is CPAP rental.
* E0601 NU is CPAP purchase.
* A7034 is CPAP nasal mask, including all nasal masks, Nasal Aire, Breeze, Spiritus.
* A7032 is CPAP nasal mask cushion.
* A7030 is CPAP Full Face mask.
* A7031 is CPAP Full Face mask cushion.
* A7044 is CPAP Full Oral Interface.
* A7046 is CPAP Humidifier Chamber.
* A7037 is CPAP tubing, long and short hoses.
* A7038 is CPAP disposable filter.
* A7039 is CPAP gross particle (foam) filter.
* A7035 is CPAP headgear.
* A7033 is CPAP nasal pillows.
* 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.

Other CPAP items are listed under E1399, which is miscellaneous.

[Snoredog]

I would just take your Plus machine back to Apria and set it on the counter, tell them they can keep it.

Take your AFlex script and order the machine online from CPAP.com, you will never look back.

The other option is buying the AFlex outright, selling the cheapo Plus machine on craigslist or elsewhere (you may get $50-$100 for it).

It all depends on what your copay is and if you use those idiots for your replacement masks. Don't tell them you got rid of the machine, let them keep supplying you with masks if you don't have any copay.

But just keep in mind, if you for example would lose your current job/coverage you may be stuck with making those monthly rental payments that your insurance may now be making. Then you'll be paying out of your own pocket for that garbage machine they gave you and if you don't pay it they have your SS# and won't hesitate to zing your credit file.

[fidget]

He could take it back, but he's had it for a year, and probably owns it in another month or two. Aetna rents to purchase price. He'd be better off keeping that one for a back up machine, or travel machine.

Their criteria for replacement of the machine is 5 years.

The HCPC code is the billing code, initiated my Medicare, and used by all insurance companies. A CPAP is a CPAP to your insurance, it's the code that counts.

Aetna follows Medicare guidelines pretty closely as far as replacement supplies and equipment.

[Wulfman...]

He could take it back, but he's had it for a year, and probably owns it in another month or two. Aetna rents to purchase price. He'd be better off keeping that one for a back up machine, or travel machine.

Their criteria for replacement of the machine is 5 years.

The HCPC code is the billing code, initiated my Medicare, and used by all insurance companies. A CPAP is a CPAP to your insurance, it's the code that counts.

Aetna follows Medicare guidelines pretty closely as far as replacement supplies and equipment.

Yeah, I agree.....I just noticed that myself on re-reading his post. I was focused on the issue of getting insurance approval/reimbursement.

Jasper, if you really want an Auto or something better, you'd be better off purchasing out-of-pocket for a primary machine and keeping the one your insurance is buying for a backup.

Den

[MidnightOwl]

Do NOT sign anything agreeing to make full payments if Aetna denies it. If nothing else that will leave you making payments at their full cash rate which could easily be 7 or 8 times what Aetna pays and what a reasonable price is. Even if you are resigned to paying yourself you should do it at the cheapest rate.

If you are self insured your coverage is determined by your company's contract with Aetna. Ultimately your employer pays. And your employer has way more clout with Aetna than any individual ever can. The terms of your coverage may not be identical with the rest of Aetna's insured but probably neither their customer service nor processors will be aware of that. You need to check directly with your employer's benefits department.

Either ask for a copy of the policy or, if you trust them not to misuse your medical information, you can ask them more specifically about your problem. Or if you're very lucky for help.

Good luck.

[darthlucy]

Just remember......all of these people are supposed to be working for YOU. If they're deducting group insurance premiums from your paycheck, they are DEFINITELY working for your benefits.

I have to disagree with this statement. As far as the insurance company is concerned, their client is your employer, not you. If your employer is not satisfied with the cost of the service provided by the insurance company, they will not continue to do business with that insurance company. One individual's happiness is not a factor in that decision. Therefore, the insurance company's actions will always be based on what their client, your employer, wants.

[Wulfman...]

Just remember......all of these people are supposed to be working for YOU. If they're deducting group insurance premiums from your paycheck, they are DEFINITELY working for your benefits.

I have to disagree with this statement. As far as the insurance company is concerned, their client is your employer, not you. If your employer is not satisfied with the cost of the service provided by the insurance company, they will not continue to do business with that insurance company. One individual's happiness is not a factor in that decision. Therefore, the insurance company's actions will always be based on what their client, your employer, wants.

Jasper's employer is self-insured and the insurance plan is being managed by a third party (TPA).

In this case, the insurer is the employer and it all depends on what's written in their group policy rules.

I still stand by my statements.

Den

[Guest]

We have a sign on our office wall...

There's only one bos.....

The CUSTOMER!

And he or she can fire everybody in the company,
from the Chairman on down,
simply by spending his or her
money somewhere else!

'nuff said

[jasper]

Called Aetna, and they want to know the HCPCS code and dx code... Hate to admit it, but I think fidget is correct. I'll go through the motions anyway, then go down to Apria and pick up my script and order online. My co-pay is only 50% anyway (yeah, I know).

I do now own the Plus machine, so I'll keep that for a backup. I didn't own it when all this started, but they've managed to drag it out long enough. I figure at least I can keep it by the couch where I might want to doze off. That way, I'll have it available for naps.

BTW, I looked up HCPCS for myself. It is officialy Health Care Finance Administration Common Procedure Coding System (basically Medicare).