How did you end up with the XPap you have?

[Wulfman]

Lol, this is where my confusion is. The prescription is for an APAP, and saying that a CPAP hasn't failed. How would that wording, "CPAP Failed? No." be telling the DME that a lesser machine than an APAP shouldn't be dispensed?

(Sorry if I'm missing something here!)

All in Knots

I can't get into the head of your doctor.......just taking a "guess" and trying to urge you not to get panicked just yet. Be prepared but don't let it bother you.

Den

[Wulfman]

I wouldn't read too much (negativity) into it just yet. An "APAP" is still a "CPAP" (an auto-titrating/auto-adjusting CPAP) and they both share the same billing code E0601 for insurance purposes. So, in order for him to prescribe you to a Bi-Level/Bi-PAP machine, he would have had to specify in a "letter of necessity" or something (apparently he chose to write it on your prescription) that you had failed CPAP.......which you really haven't.....yet.

Den, I know everything you've said is true. Allinknots may be concerned about something in a PM I'd sent her, which is this: In spite of the fact that the same billing number is used for CPAP and APAP (and it is for my insurance company; I checked), my insurance company also requires the DME to list the make and model of the machine. They will only reimburse for APAP if the doc states on the Rx that CPAP had failed. I'm sure it's not that way with all insurance companies, but there's a chance that it could be with hers, and it wouldn't surprise me if that was a concern for her.

A hypothetical question: If I turned in a prescription that had some words neatly crossed out (totally obliterated; unreadable), do you know if an insurance company would be allowed or likely to reject it or (eek) contact my doc, asking for a new Rx?

Marsha

Doctors, DMEs and insurance providers have significant differences in the way they handle things. That's why it's usually good to work closely with your insurance provider so that everybody is "on the same page".

There MIGHT be a problem with a somewhat altered prescription......depending on who did it and who it's going to. And, I wouldn't think a doctor would alter it as they have their Rx pad handy at all times.

[allinknots]

OK, let's do another hypothetical situtation!

I have insurance with a $500 deductible. (Not sure if that deductible will have to be paid towards the sleep study I went to or not. I'm guessing it will, and the deductible will be satisfied from that, and then I'll just need to pay the 20% coinsurance on a machine.) Let's say I order the machine from cpap.com along with a healthy goodie bag: hose, mask, software, card reader, etc., pay up front and then submit the receipt to the insurance company.

Let's say I use the machine, and it ends up not working out that great for me, and I would need to go to a bi-level machine. Then what would happen? Even if the (somewhat ticked off) dr. prescribed me a bi-level machine, would I need to self-pay for it fully since the insurance company already paid for machine #1? I've heard that most insurance companies cover a machine once every five years. But what happens if the machine you use needs to be upgraded in that time period?

I called cpap.com today and spoke with a very nice lady there, but I didn't think to ask that particular question. She was so very helpful about my other questions, and frankly I just don't have the energy to run around to a bunch of DME's to see if I'll get a decent price on a machine, get a machine I want (as opposed to one they want me to have), etc.

All in Knots

[Catnapper]

I can only speak from my own experience. I had very good insurance, so that may be part of the answer. However, I had first a regular cpap, then an autopap (doctor wrote the script as I requested), then finally a bi-pap all within an 8 month span, and all covered by the insurance. I did have to have some kind of letter saying that cpap did not work well enough for the bi-pap qualification.

That at least shows it can be done. Your insurance may have different coverage, and your doctor and DME may not be so agreeable as mine were. I was lucky, most likely.

[Wulfman]

OK, let's do another hypothetical situtation!

I have insurance with a $500 deductible. (Not sure if that deductible will have to be paid towards the sleep study I went to or not. I'm guessing it will, and the deductible will be satisfied from that, and then I'll just need to pay the 20% coinsurance on a machine.) Let's say I order the machine from cpap.com along with a healthy goodie bag: hose, mask, software, card reader, etc., pay up front and then submit the receipt to the insurance company.

Let's say I use the machine, and it ends up not working out that great for me, and I would need to go to a bi-level machine. Then what would happen? Even if the (somewhat ticked off) dr. prescribed me a bi-level machine, would I need to self-pay for it fully since the insurance company already paid for machine #1? I've heard that most insurance companies cover a machine once every five years. But what happens if the machine you use needs to be upgraded in that time period?

I called cpap.com today and spoke with a very nice lady there, but I didn't think to ask that particular question. She was so very helpful about my other questions, and frankly I just don't have the energy to run around to a bunch of DME's to see if I'll get a decent price on a machine, get a machine I want (as opposed to one they want me to have), etc.

All in Knots

There should be a significant amount of information in your sleep study (be sure to get a copy)......and if the sleep doctor goes over it with you, he should be able to tell you whether you need CPAP or Bi-level therapy. For the most part, Bi-level therapy is prescribed for higher pressures.......AND a specific titration would be needed to determine the two prescribed pressures (IPAP and EPAP).

Den

[smurf]

The other newbie on the block chiming in here.......I have read what a lot of people have said (especially like reading what Slinky has to say) and decided I want the ResMed AutoSet II and toys to go along with. I then found all the DMEs in my area and visited each one. I found a lot of difference in them. I then, and should have done this first, found which DME was on my preferred provider list and went to that one.

TOUCHDOWN!!!!!!

I have yet to get a perscription but found a DME on the magical peferred list willing to give me what I want and for the same price. He explained that he only gets one price. He will give me a 14 day trial on any mask I want and can return it for another for no charge. He has already told me he will give me the auto even if my scrip calls for a straight CPAP (he said he would only set me up in straight CPAP mode, not the auto mode unless the Dr. ordered it.) I have already had my hands on an ResMed AutoSet II and he has put it aside for me until the scrip come in next week. I'm finding my DME is killer compared to the stories I've heard here...

GO SHOPPING NOW!!!! DO NOT WAIT TO TAKE WHAT COMES TO YOU!!! FULLFILL YOUR OWN WISHES BY FINDING SOMEONE THAT WILL GIVE YOU WHAT YOU WANT!!!!!

[allinknots]

OK, here comes more craziness!!

I decided that I would just go ahead and by my stuff from cpap.com. I called my insurance company to see if I could self-file the insurance claim, and let them know that buying the equipment this way would be a savings even over what their agreed-upon price is with the preferred provider DME's. (Wasn't entirely sure on that one, but I made an educated guess.)

Insurance told me I could do so, HOWEVER cpap.com would be considered an out-of-network supplier, and subject to that deductible and reimbursement benefits. Our out-of-network deductible is $1,000 with 60% insurance payment afterwards.

Since our in-network benefits are $500 deductible, 80% coverage after meeting the deductible, it looks like I'll be going with an in-network DME, if I can find one that has the equipment I'd like.

This is so crazy! The insurance co. is basically encouraging me to spend more (of their) money than I would need to.

Silly me, I thought that the first preferred DME I'd call would have the equipment I wanted. I ended up calling about 6 preferred DME's yesterday, and none of them had the equipment package I'd like. (One of them had the Respironics M Series with C-Flex in, but no software and card reader, etc. And even that DME only had one of those units, since they mainly deal with Fisher-Paykel.) Looks like I'll be spending most of today on the phone, instead of just being able to order everything from cpap.com and then doing something else with my life.

All in Knots

[Wulfman]

OK, here comes more craziness!!

I decided that I would just go ahead and by my stuff from cpap.com. I called my insurance company to see if I could self-file the insurance claim, and let them know that buying the equipment this way would be a savings even over what their agreed-upon price is with the preferred provider DME's. (Wasn't entirely sure on that one, but I made an educated guess.)

Insurance told me I could do so, HOWEVER cpap.com would be considered an out-of-network supplier, and subject to that deductible and reimbursement benefits. Our out-of-network deductible is $1,000 with 60% insurance payment afterwards.

Since our in-network benefits are $500 deductible, 80% coverage after meeting the deductible, it looks like I'll be going with an in-network DME, if I can find one that has the equipment I'd like.

This is so crazy! The insurance co. is basically encouraging me to spend more (of their) money than I would need to.

Silly me, I thought that the first preferred DME I'd call would have the equipment I wanted. I ended up calling about 6 preferred DME's yesterday, and none of them had the equipment package I'd like. (One of them had the Respironics M Series with C-Flex in, but no software and card reader, etc. And even that DME only had one of those units, since they mainly deal with Fisher-Paykel.) Looks like I'll be spending most of today on the phone, instead of just being able to order everything from cpap.com and then doing something else with my life.

All in Knots

I think either you or they are misunderstanding the process. YOU should be considered "in-network" to your insurance provider. YOU have to submit an invoice to your insurance provider (and I believe CPAP.COM includes the paperwork with your order to do that). Yes, if you just send in the invoice from CPAP.com to your insurance provider, they'll consider it "out-of-network"........that's why YOU have to submit the invoice to get the "in-network" reimbursement.

Den

[Bookbear]

This is so crazy! The insurance co. is basically encouraging me to spend more (of their) money than I would need to.

Well, in actual fact, it's YOUR money they are encouraging you to spend. Who pays the premiums (and the deductables)? Even if it's your employer who is paying the premiums, it's really you, through your labor for them now; and later on, reduced wages and lower benefits for you due to increased health insurance costs.

The point remains of course that health insurance costs so much in large part because of such behavior on the part of insurance companies.

You (speaking to your insurance company rep.): I can save you nearly half what you would pay the DME for exactly the same equipment (or maybe even better equipment). Just reimburse me for my on-line purchase.

Insurance company: Not listening....lalalalalalala.....in-network only.....lalalalalalal....$1,000 deductable......lalalalalalla....not listening.........

You: Grrrrr....

[allinknots]

I think either you or they are misunderstanding the process. Den

LOL, Den, your statement is a little too logical here. I completely understand the process, as I have occasionally self-filed forms (with a different insurance co.) in the past. And the insurance company understands, too.

YOU should be considered "in-network" to your insurance provider.

Well, since my name isn't in their booklet as in-network, I'm not. I even asked, "Even if I purchase the equipment online, and it would cost you (meaning the insurance company) *less* than your contracted amount with one of the in-network providers, you will still consider this as out-of-network?" They answered, "Yes, since you are purchasing this from an out-of-network company it would be subject to your out-of-network benefits schedule."

All in Knots

[Wulfman]

I think either you or they are misunderstanding the process. Den

LOL, Den, your statement is a little too logical here. I completely understand the process, as I have occasionally self-filed forms (with a different insurance co.) in the past. And the insurance company understands, too.

YOU should be considered "in-network" to your insurance provider.

Well, since my name isn't in their booklet as in-network, I'm not. I even asked, "Even if I purchase the equipment online, and it would cost you (meaning the insurance company) *less* than your contracted amount with one of the in-network providers, you will still consider this as out-of-network?" They answered, "Yes, since you are purchasing this from an out-of-network company it would be subject to your out-of-network benefits schedule."

All in Knots

SO.......if you purchase ANY medical prescriptions, supplies or services out-of-pocket, there is no way for you to get reimbursed or have it apply to your deductible?
As I mentioned in a post the other day, we accumulate my wife's chiropractic bills (paid out-of-pocket) throughout the year and then fill out a form to submit them to my provider.....which then get applied to our deductible. It's not enough to meet the deductible, but it contributes to it.

Den

[allinknots]

Well, in actual fact, it's YOUR money they are encouraging you to spend. Who pays the premiums (and the deductables)? Even if it's your employer who is paying the premiums, it's really you, through your labor for them now; and later on, reduced wages and lower benefits due to increased health insurance costs.

The point remains of course that health insurance costs so much in large part because of such behavior on the part of insurance companies.

You: I can save you nearly half what you would pay the DME for exactly the same equipment (or maybe even better equipment).

Insurance company: Not listening....lalalalalalala.....in-network only.....lalalalalalal....$1,000 deductable......lalalalalalla....not listening.........

You: Grrrrr....

Yes, Bookbear, you've got it. It certainly doesn't make logical sense. When I was discussing this with my hubby, his thought was that perhaps the insurance company has agreed to the "policy" (pun not intended) of holding firm to their definition of in-network suppliers in order to be able to have in-network suppliers. Maybe the DME's have told them "We'll only agree to your in-contract price if you agree to cover internet purchases at the out-of-network rate, thereby discouraging your clients from purchasing their equipment from the evil, under-cutting internet ."

If that is the case, I can see their point. If everyone were to price compare the way I do and see that they can get a better selection, better price, and free delivery to their home from buying online--and then receive the same benefits from their insurance co., then everyone would do that. The ripple effect would be the closing-down of the Mom and Pop local DME's. Guess you really can't fault them for wanting to stay in business. Now if I could only find one that will offer the equipment I'd like.

All in Knots

[allinknots]

SO.......if you purchase ANY medical prescriptions, supplies or services out-of-pocket, there is no way for you to get reimbursed or have it apply to your deductible?

Yes, it would apply to my out-of-network deductible, if they are purchased out-of-network. And the out-of-network deductible on our policy is separate from an in-network deductible. In-network is a $500 deductible, then insurance pays 80%. Out-of-network is $1,000 and then insurance pays 60%. So, if I were to purchase $999 of equipment from cpap.com, insurance would not pay out one cent--but my deductible would be just about satisfied. Which wouldn't matter one way or the other if I didn't accrue more medical expenses that are out-of-network. And I really try to stay in-network any chance I get.

As I mentioned in a post the other day, we accumulate my wife's chiropractic bills (paid out-of-pocket) throughout the year and then fill out a form to submit them to my provider.....which then get applied to our deductible. It's not enough to meet the deductible, but it contributes to it.

Den

As long as you eventually meet your deductible with other expenses, then it's worth your time to do so. But if all your wife's chiro bills do not add up to the deductible, and your other insurance claims don't apply to satisfying that same deductible, then you're wasting your time.

All in Knots
(Been handling most of the family finances including medical insurance issues for 28 years now and counting)

[Wulfman]

That sucks......having separate deductibles for in and out of network.

Den

[marshaeb]

That sucks......having separate deductibles for in and out of network.

Absolutely, Den. But it is that way with some insurance policies. Although the $$ amounts for the deductibles are different, Allinknots' story is mine exactly. I could be missing something, Allinknots, but it sure seems to me that you're asking all the right questions. And you're right, it's nuts. And infuriating. You have my empathy and the sure knowledge that you're not alone in this. I know that doesn't help your pocketbook one little bit, but there you are.

Marsha