Doc caved in S9 autoset Rx order DME Battle next!!

[vince32837]

hi-
doc had refused an autoset script saying cpap all I needed.. I said please make copies of my 2 sleep studies, I'm leaving the practice. Doc caved in said ok, I give you Rx for Resumed s9 autoset... she faxed it to DME that rented me the S9 elite cpap.

they called...left VM, once I pay $250 up charge they will order me S9 auto...Aetna compliance team researching if this allowed.
DME told us doc prescribed top machine, they need order for me...$250 extra...

I might return the elite unit and call other Aetna DME local suppliers see no upcharge??

Vince

[LSAT]

They are NOT ALLOWED to charge you an up charge. Call your insurance company and tell them. The insurance company will deal with them.

[Wulfman...]

What LSAT said.
Insurance companies pay from the insurance billing code. Both straight CPAP and Auto CPAP (APAP) have the very same billing code.......E0601.

They can't legally upcharge you. Either threaten them with turning them into the authorities for insurance fraud or dump them and find another one. Be sure to get an original or copy of your prescription. It will come in handy in the future.


Den

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[Wulfman...]

By the way, ResMed also makes an "Escape Auto". Do NOT accept that one (if they try to pull a "switcheroo" on you).
It isn't as full-featured as the "Autoset". The "Autoset" is the one you want in the ResMed line. It can be set to straight pressure CPAP mode if you have a fixed pressure prescription.


Den

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[HerbM]

Aetna has been VERY GOOD to me.

Call them -- ask for clarification (and help.)

That is what worked for me on my mask.

DME warned me I could not return my special order mask for another before I committed to it.

When it didn't work at all, I played fair. Called Aetna and ASKED them the POLICY on when I could get a new mask if mine did work.

CS rep made two trips to talk to the supervisor but came back and said, "Order another mask, we'll pay for it."

At no point did I ASK for ANYTHING except information on the actual rules of *my* insurance plan with Aetna.

Aetna stepped up.

[ubnoxus]

Yeah Aetna has been amazing to deal with with any issues I have had. Unless there are drastic changes we will never switch to anyone else

[HerbM]

I had a similar deal with Symmetra (not nationally well known, from the Pacific Northwest) for 20 years until ObamaCare forced them to cancel our policy.)

Symmetra was great -- the main advantage was that there was NO "In network", "out of network".

They paid their part no matter where or what medical treatment we received.

Aetna is great too -- maybe a little better or a little worse but certainly seems to be comparable to Symmetra so far.

And despite the "network" issues, Aetna has approved ALMOST all of our health care providers as "in network" so in practice it is not TOO BAD.

(Symmetra would have let us use CPAP.com -- that would be the main difference I have seen so far -- but they would be "out of network" for Aetna.)

[Janknitz]

Aetna doesn't care if you have an auto or a straight CPAP. They are both the same HCPCs code. They may have something to say about your DME trying to upcharge you for a covered unit. Don't rely on the DME to tell you what Aetna's "decision" is. They are not contacting Aetna because Aetna doesn't care about which machine you get. Call Aetna yourself and find out if Aetna allows the "balance billing".

How long have you had the Elite from the DME? If it's been a short time (less than a month) you MAY be able to convince another DME to provide an Autoset instead. But if you've had it for a while, nobody will want to provide the Autoset, which has a low profit margin when they can get the money for the entire rental period, no profit if less than the entire rental period is available.

Since you already have the humidifier and hose, you can consider buying just the blower part on your own and return the DME's blower to them. You might be able to find a good unit from secondwind.com or on Craigslist.

[vince32837]

Thanks for the guidance and support....

I have had the Elite 10 days...I'm dealing with Aetna compliance directly. My DME is in bed with Respironics, the FL Resmed rep not allowed on property, Resmed mails all products from CA...worker-bee told me.

I called Resmed Corp asked operator for reseller support in CA today, They said what is your dealer ID#, I said I'm originally from Brooklyn, that's my ID....Pressured the guy not to hang up....I pressured them to find out their DME return policy? He said "we are not in the used Resmed machine business", we will not take back from the dealer a perfectly working elite unit." They can take it back from me , get it sterlizied locally and resell to someone else" Thats between you and them" Resmed not in your game.

I am doing the Aetna 10 month rental into ownership thing- My co-pay is $6/month for an elite rental...I might tell them tomorrow keep my $6 and here is your machine back. I read the 12 pages of docs they had me intial and sign, talks about warranty, damage etc..1 yr etc..nothing about absolute return.. I will call

stay tuned- plus Aetna said they will call Thurs too...

Vince

[Kenwood]

I had a similar problem getting my BiPap Pro switched to an Auto BiPap. DME said insurance company wouldn't allow it. I called Aetna....and they really couldn't care less what the doctor prescribes me.....a CPAP machine is a CPAP machine. No matter model or brand. The DME then claimed that my sleep study results do not indicate a need for an Auto. So my sleep doctor had to call them and remind the DME who the DOCTOR was and to issue the RX as prescribed. Then surprise...my Auto was approved that day and shipped it to me.

[HerbM]

Also, when Aetna told me to just "buy a mask" they gave me "Edge Park Medical" as an in network provide by mail order. (800 321 0591)

Now, I would rather we were able to use CPAP.com but this was Aetna's suggestion.

Called Edge Park, and they told me any of three masks at $120, $160, and $240 would cost me $19.

Today they called and told me the mask is on the way.

So if you have your prescription, know what you want, then try calling them. (You might call Aetna to make sure that its on YOUR network and my insurance isn't somehow different. I doubt it is different but why take a chance?)

[chunkyfrog]

Good to know; I have Aetna as well.
I haven't paid a dime for cpap supplies, but have to pay in advance for diabetes testing supplies,
after which I am reimbursed. This puzzles me, unless they are trying to get me to use mail order (yuck!)

[archangle]

Even if the DME isn't allowed to upcharge, they're not required to give you a specific model. They can say "nope, we only supply model x CPAP for patients using insurance company y." It depends on the contract with the insurance company.

[StuUnderPressure]

I have had the Elite 10 days...I'm dealing with Aetna compliance directly. My DME is in bed with Respironics, the FL Resmed rep not allowed on property, Resmed mails all products from CA...worker-bee told me.

It actually is very common for a DME to deal primarily in 1 brand.
If they sell only 1 brand, they sell more of that brand & can get a larger volume discount that way.

They can, of course, still order a ResMed, but chances are "their" cost will be larger because they buy very little from ResMed.

If you go to a DME that sells primarily Respironics & you instead want a ResMed, you WILL have an uphill battle.

Your best bet might be to find another DME who sells primarily ResMed who is also an approved provider for your insurance company & start all over again.

[teachcsg]

Stu is correct.
Most DMEs deal with one manufacturer due to volume discount. The company I work for deals primarily with Respironics as well. Unfortunately, with lowering reimbursement rates some products are too expensive for the company to provide. It seems like Resmed prices their machines and mask quite high-they know they have a very good product and dont allow for much discount. There was a lawsuit going on recently where a small manufacturer of cpap mask was in a fight with Resmed over their mask and pricing-they priced their mask very low. I did not read too much into the lawsuit but the small company had taken out a full page ad in an industry magazine showng that it typically cost all manufacturers (including resmed and respironics) a very small amount (I forget the figure) to make a mask it seemed like Resmed had a problem with that.
So, all that to say-some DMEs have to be exclusive to stay in business.