Is this Normal? - DME Related

[BeanMeScot]

I was told by my insurance that I had to go through Homelink for my CPAP stuff to be in network. So I filled out their form and faxed in my prescription. Now they apparently want to get a copy of my sleep study to talk to my insurance company for them to certify that CPAP is medically necessary (as if my insurance would have approved a titration if it hadn't been medically necessary) and are saying they are going to contact my primary care physician. They have a prescription from a doctor. I guess I don't see why they should need anything else.

[CorgiGirl]

It's normal in my experience. My doctor faxed a copy of my prescription and my sleep study to my original DME. This also happened with my husband's original DME five years ago. When we switched to Apria, we were told they needed a copy of the sleep study for our files in addition to the prescription. We also carry copies of our sleep study with us when we travel in case we run into a problem while we're gone. (Since we're "snowbirds" we're gone for months at a time.)

I figure it's a CYA thing on the DME's parts and I don't mind providing it.

[gasp]

I was told by my insurance that I had to go through Homelink for my CPAP stuff to be in network. So I filled out their form and faxed in my prescription. Now they apparently want to get a copy of my sleep study to talk to my insurance company for them to certify that CPAP is medically necessary (as if my insurance would have approved a titration if it hadn't been medically necessary) and are saying they are going to contact my primary care physician. They have a prescription from a doctor. I guess I don't see why they should need anything else.

I agree. They have a prescription and it's their job to fill it. Perhaps they need clarification to know how to fill it. In which case, you may want to suggest to your doctor that they specify which equipment you should get. It's possible they only provided the pressure your machine should be set at, versus the actual equipment you should get such as a Bi-PAP, APAP, etc.

I asked my doctor's office to relay to the doctor (since I never did actually see him in person) that I be prescribed an Respironics AFlex with a ComfortGel mask. I really like my AFlex (because I have occasional asthma and need it for the added exhale relief feature) but have since gone on to other masks. Although for my first mask, it worked fine.

So, find out what machine will work best and which mask you want and ask your doctor to specify that in the prescription.

[BeanMeScot]

Thanks!

I have something from the sleep study but it isn't my "real" sleep study. It is basically the doctor's notes on what was found. Would the DME consider this a valid copy of my sleep study?

[BeanMeScot]

I agree. They have a prescription and it's their job to fill it. Perhaps they need clarification to know how to fill it. In which case, you may want to suggest to your doctor that they specify which equipment you should get. It's possible they only provided the pressure your machine should be set at, versus the actual equipment you should get such as a Bi-PAP, APAP, etc.

I asked my doctor's office to relay to the doctor (since I never did actually see him in person) that I be prescribed an Respironics AFlex with a ComfortGel mask. I really like my AFlex (because I have occasional asthma and need it for the added exhale relief feature) but have since gone on to other masks. Although for my first mask, it worked fine.

So, find out what machine will work best and which mask you want and ask your doctor to specify that in the prescription.

I didn't get a prescription from the sleep doctor. In fact, I have never met him. He just interpreted my results for the study and the titration. My primary care physician wrote the prescription and I told her what to write based on what I gleaned here (Respiranics M Series Auto with A-Flex, Fisher and Paykel HC 150 Heated Humidifier, and mask of my choice). The only thing I didn't specify was the mask. I figured I would be better off being able to try on a few an a B&M place before deciding which one I wanted.

[CorgiGirl]

My doc wrote "equipment per patient" allowing me to choose whatever APAP I wanted... Not quite sure how I got her to do that, but I'm glad I did.

What we carry and what was transmitted to the DME's is the doctor's interpretation of the sleep study, not the actual blow-by-blow coverage. I think that's what they are asking for when they ask for the sleep study copy.

I occurs to me that this may differ from state to state since the DME's are mostly regulated by state laws in terms of how they do business. Perhaps Washington state and others require the DME's to have a copy of the sleep study. Who knows?

[KansasRT]

It is not a state requirement, but most insurance contracts state the the DME has to have a copy of the sleep study on file. We do not have to send it in with the claim, but we have to have it in case they request it. I would bet that most DME's get a copy of your sleep study without you knowing it after they sell you the products. It is a contract issue with the insurance company. Also, the DME has to know that you qualify for CPAP. Just because you had a titration study does not mean that you met the requirements for CPAP. There are minimum time limits for untreated sleep and AHI requirements. I have a lot of patients that qualified for CPAP when they had commercial insurance ( Example BCBS) but when they became Medicare eligible they no longer met the requirements and had to have a repeat sleep study. SOME of the BS that you have to go through at your DME is not their fault. I can't account for all the other stuff that they do.

[Lilluanu]

My sleep doctor automatically sent a copy of my sleep study to the DME along with my prescription before I ever got there. I've been extremely fortunate with my GP (who paid attention to the symptoms I listed and immediately referred me for a sleep study); my sleep doctor and his clinic staff who have been prompt, efficient, and supportive; and my DME's RT who has gone above and beyond in working with the constraints of insurance co-pays and authorization needs to get my equipment the way I want it - they've all been very knowledgeable and easy to work with throughout the entire diagnosis and treatment process, whenever I had questions or wanted to try something different. My RT even tends to throw in little extras like spare nasal pillows for masks (including the Swift II mask the sleep clinic gave me free after my titration study) and the nifty bags for the equipment (again including for the Swift II the sleep clinic gave me). She's offered candid advice and feedback based on her own experience and what other customers have told her of theirs to help me choose my equipment and set it up, and I've been quite satisfied with her recommendations thus far.

From what I've read here and on other OSA sites I know my experiences with these providers are extraordinarily unusual and I can only say I'm grateful and will happily provide their contact information to anyone in the triangle area of NC should you wish to have a similarly smooth process.

[BeanMeScot]

So I still don't have anything.

I called the person assigned to me at HomeLink and she said she had just gotten in the approval for "a basic CPAP machine". I will be working with a local DME, from what I understand (whenever they happen to call me) but I don't like this "a basic CPAP machine" crap. My prescription specified a Respironics REMstar M Series Auto w/A-Flex. What rights do I have to get what was prescribed (if they try and downsell me)?

[Wulfman]

Don't accept anything less than what your prescription says. If they normally carry Respironics machines, then they should HAVE to give you what your prescription says. Otherwise (in my opinion) it's "fraud".

Den

[BeanMeScot]

Don't accept anything less than what your prescription says. If they normally carry Respironics machines, then they should HAVE to give you what your prescription says. Otherwise (in my opinion) it's "fraud".

Den

How would I threaten them if they try to give me a cheap machine?

[gasp]

Don't accept anything less than what your prescription says. If they normally carry Respironics machines, then they should HAVE to give you what your prescription says. Otherwise (in my opinion) it's "fraud".

Den

How would I threaten them if they try to give me a cheap machine?

Very nicely I would say "I can't accept a substitute machine and that my doctor and I had an understanding on what he was prescribing and this is not it." If that fails, then adding "I will have to contact my doctor and let him know that you want to substitute another machine than what he wanted and have him get back to you. I'm certain he'll want to speak to the manager. Whom should I say he should call?"

[Wulfman]

Don't accept anything less than what your prescription says. If they normally carry Respironics machines, then they should HAVE to give you what your prescription says. Otherwise (in my opinion) it's "fraud".

Den

How would I threaten them if they try to give me a cheap machine?

You could have your doctor add to your prescription something like "Do not substitute" or "Fill as prescribed"
Make sure that you physically have possession of your prescription (preferably the original). Make copies and do NOT give them your original.
ALL CPAP machines (both single pressure and Auto adjusting) use the very same insurance codes:
* E0601 RR is CPAP rental
* E0601 NU is CPAP purchase

AND, there should not be any additional charges for the better machine. The insurance reimbursement is the same for all CPAPs and that is why the DMEs don't want to give you a better machine......they'll make more profit off of selling a cheap(er) machine. They put THEIR profits above YOUR therapy.

If they do not fill the prescription as written, you should notify your insurance provider (and also tell the DME that you're going to do this) that this DME is refusing to fill the prescription as written by the doctor and that you want to have them dropped as a recommended provider for your insurance provider.

Money talks!

And again......do NOT accept or sign an agreement unless or until you get the machine you want and which you were prescribed.

Den

[BeanMeScot]

I do have physical possession of my prescription(s). I'm the one that told the doctor what to write (gleaned from here, of course)! I guess it is too late on the no substitution thing though. Homelink is in some other state so I faxed them a copy.

[feeling_better]

Both DMEs I have dealt with in the last 2 months, required a copy of the sleep study from the doc. Apparently this was required by my ins. company; and the AHI does drive the coverage of cpap.