Anyone else had their insurance company tell them this?

[Sharrykb]

Yesterday I had to call my insurance company about something else and then I asked where I can find information about what my insurance will cover and when as far as CPAP supplies. The woman told me that because of changes brought about by the Affordable Health Care Act, they no long go by a schedule, they go by medically necessary and the DME has to get prior authorization for any supplies prior to providing them to me. So I asked her a few questions and according to what she told me, if something goes wrong with oh say my nasal pillow and I don't have another one, I can't get another one right away and have to wait until the DME gets prior authorization from the insurance company. And apparently there is no such thing as getting a new or different mask unless the one you have actually breaks. So I guess that means I don't get to try a different style of mask after 3 months like I had hoped to.

Has anyone else been told this by their insurance company? This is private insurance telling me this, not Medicare or Medicaid.

[Pugsy]

And apparently there is no such thing as getting a new or different mask unless the one you have actually breaks. So I guess that means I don't get to try a different style of mask after 3 months like I had hoped to.

So it gets "broken" or the dog chews it up or you step on it and break something.
I don't think that you have to produce the "broken" mask as proof. No more than someone has to prove that a cushion is worn out and a replacement is needed by physically returning the worn out part.

[Sharrykb]

And apparently there is no such thing as getting a new or different mask unless the one you have actually breaks. So I guess that means I don't get to try a different style of mask after 3 months like I had hoped to.

So it gets "broken" or the dog chews it up or you step on it and break something.
I don't think that you have to produce the "broken" mask as proof. No more than someone has to prove that a cushion is worn out and a replacement is needed by physically returning the worn out part.

I sure hope you are correct but the insurance lady was quite insistant that the only way it would be medically necessary for it to be replaced is if it is broken and then I couldn't get a replacement until after the DME went through the prior authorization process. This makes no sense to me at all and I sure hope it isn't true!

[library lady]

It seems to me that if you have a valid, unexpired prescription that is the indication of medically necessary and no prior authorization should be necessary until it expires. My prescription is good for 99 years.

[Pugsy]

Prior authorization doesn't necessarily mean visually inspecting the "broken" part or verifying cushion/nasal pillow/or whatever is worn out.
Check with your DME to find out exactly what is involved with this new "prior authorization" thing as in what are they going to need to do to comply with this new requirement.
I seriously doubt DMEs will want to visually inspect anything as that opens up a whole new can of worms.

[Sharrykb]

Pugsy, my husband suggests that I call them back and ask to see the policy in writing because the policy as explained to me over the phone makes zero sense to us. I'll let you know what I find out.

[Julie]

I can just see each individual DME tech, possibly poorly trained to begin with, making decisions about how damaged each individual tiny component is on each individual mask, etc. and reporting their subjective findings to the insce. co... who won't even look at it anyhow! I think your tech's taking it too literally!

[Sharrykb]

I can just see each individual DME tech, possibly poorly trained to begin with, making decisions about how damaged each individual tiny component is on each individual mask, etc. and reporting their subjective findings to the insce. co... who won't even look at it anyhow! I think your tech's taking it too literally!

I agree! This sounds like a nightmare and I'm really hoping the woman at the insurance company is wrong. I've tried calling this morning but keep getting a message that all employees are in a meeting.

[chunkyfrog]

Sherry: Sometimes you have to bring in the big guns.
If your insurance is through an employer, contact personnel directly, or the benefits manager;
and ask them to get you a certified copy of the "rule", and an written explanation of how it is to be satisfied.
If you are insistent, but polite, your request will be honored.
--{{even faster, if there are tears}}

[BlackSpinner]

I can just see each individual DME tech, possibly poorly trained to begin with, making decisions about how damaged each individual tiny component is on each individual mask, etc. and reporting their subjective findings to the insce. co... who won't even look at it anyhow! I think your tech's taking it too literally!

LOL send all those "broken " parts to the insurance company instead - by registered mail preferably.

[Sharrykb]

Sherry: Sometimes you have to bring in the big guns.
If your insurance is through an employer, contact personnel directly, or the benefits manager;
and ask them to get you a certified copy of the "rule", and an written explanation of how it is to be satisfied.
If you are insistent, but polite, your request will be honored.
--{{even faster, if there are tears}}

I might have to do just that before this is over.

I just got off the phone from talking to another woman at the insurance company and she told me something completely different. And she is unable/unwilling to provide me with any proof that her answer is any more or less valid than the information I was given yesterday. I did, however, convince her that I need to speak with someone who is more familiar with CPAP supplies so she is going to try to find someone more knowledgeable and have them call me back. I'm not holding my breath on that one...

[JDS74]

My insurance has always been medical necessity. However, they recognize a schedule that is a little more strict than the Medicare schedule.

Mask and hose - 6 months, machine - 5 years, etc.
I don't have a mask with cushions so I've never inquired.

All insurance companies require pre-authorization from a DME but the process isn't too onerous.
Don't get all worked up. It's just some under paid clerk's comment.

[Sharrykb]

My insurance has always been medical necessity. However, they recognize a schedule that is a little more strict than the Medicare schedule.

Mask and hose - 6 months, machine - 5 years, etc.
I don't have a mask with cushions so I've never inquired.

All insurance companies require pre-authorization from a DME but the process isn't too onerous.
Don't get all worked up. It's just some under paid clerk's comment.

I'm really not that worked up about this. I just want to get a straight answer from the insurance company about what I can expect as far as replacing supplies. Just trying to prevent future problems, over which I might actually get worked up over. I'd rather prevent the problem so as to avoid needing to get worked up over it.

[RandyJ]

Talk to your DME... they will know what your insurance requires and what the replacement schedule is. They will also want to sell you as much as they can, so if your insurance allows new nasal pillows every month, or every 3 months, they will do what they can to get them to you on schedule and collect their money.

Pillows are cheap ($20-30) for a set for most masks, the ones for the P10 are $19 on cpap.com; ebay and cpap.com are great direct pay options to buy a couple of pillows to have as extras for emergencies. Once you start replacing through DME on schedule many people find they get too many and end up stockpiling, which also allows you to always have a few ahead.

[Sharrykb]

Talk to your DME... they will know what your insurance requires and what the replacement schedule is. They will also want to sell you as much as they can, so if your insurance allows new nasal pillows every month, or every 3 months, they will do what they can to get them to you on schedule and collect their money.

Pillows are cheap ($20-30) for a set for most masks; ebay and cpap.com are great direct pay options to buy a couple of pillows to have as extras for emergencies. Once you start replacing through DME on schedule many people find they get too many and end up stockpiling, which also allows you to always have a few ahead.

Thank you RandyJ. I know eventually this will all be okay because I'm sure I will be offered more supplies than I actually need. It's just a bit scary when you first start and only have 1 and don't understand when you are allowed to get another one and how that process works. Then when everyone you talk to tells you something completely different, it is confusing.

The latest is that my insurance company's "resident expert on all things CPAP" called me back. He says that the prior authorization rule only applies to the actual equipment and does not apply to supplies at all. He said this whole prior authorization thing is relatively new and since most of the customer service reps don't really understand the difference between an actual CPAP machine and a nasal pillow, they are confused and unfortunately give out incorrect information. I'm a little hesitant to post how lenient their actual supply replacement policy is though. It seems too good to be true...