Here we go with the DME...

pj1016 · Post by **pj1016** » Fri Apr 21, 2006 5:53 pm

So I tell the DME that I want an APAP.

They tell me that my BCBS insurance covers a CPAP 100%, but they won't pay for the APAP because it's not "medically necessary".

Does this sound right? I thought that the reimbursement code was the same for both CPAP and APAP machines?

The DME says that I can have the APAP if I pay the difference between the two...this just doesn't smell right to me...

pj

Guest · Post by **Guest** » Fri Apr 21, 2006 5:59 pm

Why not either call BCBS or your companies liaison to them and get the answer from the "horses mouth"?

NeurosurgeryNP · Post by **NeurosurgeryNP** » Fri Apr 21, 2006 6:25 pm

APAP and CPAP are billed the same way (same codes). The DME does not want to loose money as they get the same reimbursement for each.

snoregirl · Post by **snoregirl** » Fri Apr 21, 2006 7:33 pm

Hey, can I trade insurance companies with you?

I would be happy to pay the difference. Mine says that I can't have the APAP (on insurance) even though my doctor wrote the prescription for it and a letter. They call it "Delux equipment". They also won't pay ANYTHING on it, even what they would have paid for a CPAP. I just lost the first appeal and I am now on my 2nd level appeal (last one that I know of). Then, I have to buy it myself. I will attempt to bill the insurance company for my purchase if I lose this next appeal just for fun, and to see if it slips through. Plus make sure that they cover masks, and other supplies.

I am not trying to say that you shouldn't call your insurance and try to get it at no charge, but look at the bright side, you are doing better than I am. I would gladly trade places at this point! I am getting quite frustrated.

Guest · Post by **Guest** » Fri Apr 21, 2006 9:10 pm

Well Snoregirl,

i pay quite a pretty penny for my insurance each month...this isn't a matter of luck or entitlement.

pj

pj1016 · Post by **pj1016** » Mon Apr 24, 2006 4:01 pm

I ask the DME to call my insurance and verify that BCBS won't cover an APAP.

She leaves me a message later that BCBS will cover it in full.

OK! Now waiting for the RT to call and tell me when she will be coming to deliver and set-up.

So far...so good.

pj

3isles · Post by **3isles** » Mon Apr 24, 2006 4:31 pm

The DME says that I can have the APAP if I pay the difference between the two

thats whay my dme says about everything. apparently their contract with my insurance says that they will be paid so much for each item (ie $112.00 for a mask no matter which mask it is) so they push the cheapest product so they get the most back. And if I insist on something that doesn't allow for enough profit I pay the difference. They said that right out.

I just check out what the difference will be and then decide if its cheaper (and less hassle) to just buy myself online

I'm glad your insurance will pay for the APAP for you. Hope it works well for you.

johnnygoodman · Post by **johnnygoodman** » Mon Apr 24, 2006 5:25 pm

Greetings,

BillMyInsurance.com will give you an Auto CPAP Machine and accept BCBS as payment.

Johnny

DME_Guy · Post by **DME_Guy** » Mon Apr 24, 2006 9:59 pm

The billing code and reimbursement is the same for both CPAP and APAP. They really are different machines and should have separate billing codes. There are seperate billing codes for a standard wheelchair and a light-weight wheelchair when the only difference is about 5 lbs. I don't know why the same doesn't apply to CPAP equipment.

Many DMEs will absorb the cost if the reimbursement justifies it. Many HMO insurance companies don't pay enough for the DME to be able to afford to put out an APAP or even an S8 Elite or Remstar Plus with C-flex. Some companies pay the DME less than $45.00 for a mask, especially if there is a medical group involved.

Sure, we all pay a lot of money for health insurance. That doesn't mean the insurance companies are passing that money on to the actual providers of care.

Having said that, many DME companies don't understand the cost of unhappy customers. Years ago, I switched our standard mask to the Ultra Mirage from the Comfort Classic. The initial cost of the mask was twice as much but it reduced the number of complaint calls and additional RT visits by about 80%. That alone made up for the additional cost of goods.

Here's a litte secret. If you call your DME company to complain, you're just one individual. If the referral source calls the DME company to complain on your behalf, the DME risks losing all of the business from that referral source and will be much more motivated to make you happy.

rested gal · Post by **rested gal** » Tue Apr 25, 2006 10:20 am

DME_Guy wrote:Here's a litte secret. If you call your DME company to complain, you're just one individual. If the referral source calls the DME company to complain on your behalf, the DME risks losing all of the business from that referral source and will be much more motivated to make you happy.

Excellent hint, DME_Guy!

Folks, if you don't receive the kind of help you need from your DME after politely asking for it a couple of times, sic your doctor's office on them.

pj1016 · Post by **pj1016** » Tue Apr 25, 2006 4:13 pm

DME calls...

DME: "Respironics doesn't make an Auto with C-Flex."

Me: "Yes they do."

DME: "No they don't".

Me: "Yes they do."

DME: "No they don't. Even if they did, we wouldn't have it in stock and we would have to order it. Then you are talking five more days."

Me: <sigh> "What's your email addy? I'll send you a link from Respironics website to show you the machine."

Fast forward an hour, and the DME leaves me a message that they have the machine in stock and expect the RT to call me to set-up in-home appt.

She calls a few minutes later and says she'll be over on Friday.

To be continued...keep your fingers crossed!

pj

Wulfman · Post by **Wulfman** » Tue Apr 25, 2006 4:34 pm

pj1016 wrote:DME calls...

DME: "Respironics doesn't make an Auto with C-Flex."

Fast forward an hour, and the DME leaves me a message that they have the machine in stock and expect the RT to call me to set-up in-home appt.

To be continued...keep your fingers crossed!

pj

GOOD GRIEF!!!

Beware of the EVIL DME!

Good luck.

Den

Here we go with the DME...

Here we go with the DME...

I would be happy with that

Just as I thought

Update

Re: Update