I Read The Guides, But I'm Afraid I'm Getting Horrible Support From Medi-Cal, My Doctor, And A Potential DME

Hi everyone!

I'm a new user here, and I have recently been diagnosed with OSA. I had a AutoPAP machine once before when I had private insurance. My DME was awful and I hated dealing with them. I had a very hard time adapting to the machine, and the company provided no help whatsoever. They also could not getting their billing straight. I gave up after three months and just returned the machine out of frustration. I don't think I ever used it consistently enough to feel any benefits.

My insurance recently changed to Medi-Cal (California's version of Medicare) and I visited a clinic, which I guess is also my primary care provider now. I provided them with my in home sleep study results from less than a year ago, which were used to diagnose me the first time. They said that was enough to hook me up with a DME. I have been determined to make sure I get a great DME this time, so I have been following the advice from these two blog posts:

Adventures in Hosehead Land - Advice for those newly diagnosed with OSA
https://adventures-in-hosehead-land.blo ... -with.html

Mask Arrayed - WHAT YOU NEED TO KNOW BEFORE YOU MEET YOUR DME Part I
https://maskarrayed.wordpress.com/what- ... me-part-i/

Following this advice, I contacted my insurance to answer questions like:

1. Does Medi-Cal cover any CPAP machine I request since they are all billed with the same code?
2. How often can I get a replacement mask if one is not working and I need to try a new one?
3. Can you give me a list of DMEs that I can contact in my area?

They responded to question 1 by telling me that every CPAP machine has a different code and they didn't know what I was talking about. They answered question 2 by saying they didn't know; it is all based on medical necessity that I need to discuss with my doctor. They answered question 3 by saying they didn't know, and that my doctor should just contact a DME for me.

These responses do not align with either of the guides I have been reading. Are these guides outdated, or did I just talk to someone at Medi-Cal who doesn't know what they are doing?

After this, I contact my doctor's office and told them that I was having a hard time finding my own DME and they can just go with whatever they recommend. However, I said they could only do so if that DME will provide me with the machine that I want. On my first go-around, I had a Respironics Dreamstation. I still have a heated hose and some filters for that, so I'd like to be able to use them. The office person at my doctor's office just said that the DME will call me and I will have to sort that out with them. Again, this is not the response I was expecting after reading the guides I linked above. Did I just encounter another person, this time at my doctor's office, who doesn't know how to do their job?

I'm really afraid to get into a mess with a bad DME and terrible support from a doctor again, but I honestly don't know what to do. I have severe depression that has been resistant to over a dozen medications and my psychiatrist thinks sleep apnea is a likely source. It took a lot for me to make all these appointments, and I really need a machine. Any help to make this easier would be appreciated. Thanks!

Up here even I know the codes are the same for Cpap or Apap... they're just trying to get rich. Also you'd be much better off calling your own insce. co. re what they cover and not try to get anywhere thru DME's who... just want to get rich and don't generally know zip about zap.

The response you got is typical. That is why the two sites you went to exist, to help prepare people like you for what you experienced.
Medi-Cal is the same as Medicaid not Medicare.
Most of the folks at the Medi-Cal offices are minimum wage disinterested people who know less than you and only care about 2 things, quiting time and payday and maybe lunch break.
It will take much patience and perseverance to get what you need in that invironment.

Can I assume you don't have much money to pay for your equipment yourself, even used.

Keep asking questions here and you will get through it all successfully.

Are you aware of Secondwindcpap.com? The equipment's all refurb'd, you don't need a script and they are terrific to deal with, stand behind everything and will replace if there's any problem.

Good luck, and get ready for a fight..

OK, fasten your seatbelt. Learning curve ahead.

First, as already pointed out, Medi-Cal is the equivalent of Medicaid in other states, NOT Medicare. The rules for Medi-Cal are VERY different than Medicare, private insurance, and even Medicaid in other states. They are very convoluted and confusing.

Most Medi-Cal programs funnel you in to some sort of managed care program. All the referrals need to come from your provider, and in most cases you must use a DME provider contracted with your health care provider. So you need to ask your primary care clinic which DME to go to. If you aren't in some sort of managed care program, you are going to have to find a DME that accepts Medi-Cal. I wish you luck, because the reimbursement rates are low and it's hard to find providers that will accept it.

You may not have a choice of machine or even mask. If you are in a managed care system, they may have a "formulary" and you can only have what is on their formulary for masks and machines.

If you are not in a managed care situation, this is what you are up against: https://files.medi-cal.ca.gov/pubsdoco/ ... a04p00.doc
"Per Title 22, California Code of Regulations (CCR), Section 51321(g): Authorization for durable medical equipment shall be limited to the lowest cost item that meets a patient’s medical need." So that means that the DME provider is not going to be motivated to give you more than the most basic machine.

Your provider may have to complete a "Treatment Authorization Request" (called a "TAR") in order to get the DME to provide the equipment.

You are going to have very little luck making the billing code argument with Medi-Cal DME providers. Medi-Cal may actually pay different amounts for a basic CPAP vs. a fully auto data capable machine with heated hose. It's not Medicare.

You can try asking the doctor to write the prescription for an "auto adjusting CPAP machine with full efficacy data and a heated hose". If the doctor writes the prescription, that's an argument for "medical necessity" but expect pushback from the DME, i.e. requiring a range of pressures and other justifications on the TAR. Don't hold your breath expecting a particular machine.

Expect a long wait. There are layers of bureaucracy and the wheels turn slowly.

If you possibly can afford your own machine (Secondwind.com, perhaps, or Craigslist) you will save yourself a lot of annoyance and stress. But if that's not possible you are going to have to go with the flow. Be patient with yourself and the process because getting yourself all worked up hoping for a good and supportive DME is likely an exercise in frustration. Get your support here, it's free and we don't care what your insurance is.

With the low income plans, the resources are spread thin, and quality comes last.
To get optimum care, you may need to self-pay (online, used, etc.)
or have a TON of charm.
Just a hint: bilevel machines are all full data, so if you have really bad aerophagia . . .
(You never heard it here)

Julie wrote: ↑

Tue May 08, 2018 9:15 pm

Are you aware of Secondwindcpap.com? The equipment's all refurb'd, you don't need a script and they are terrific to deal with, stand behind everything and will replace if there's any problem.

Julie...FYI...This is what it says on their web site...
If you are unable to purchase a replacement CPAP or BIPAP machine because you have lost track of your prescription, have an out of date prescription, or 'pre-existing' clause in your policy, we may be able to help with our physician authorization

Thanks for the tips everyone. It's been 3 weeks since my appointment with my primary through Medi-Cal. I've called several times to figure out why I haven't been hooked up with a DME provider, and they just keep giving me the run-around. I decided to purchase a used Respironics DreamStation Auto CPAP from Secondwindcpap.com since so many people here recommend them. I can't wait to get my machine!

I think you'll be much happier NOT dealing with the DME. They are still probably processing your TAR.

If you do get a machine under Medi-Cal you will have a backup. Win:win.

It is best to have backups.
Murphy works double shifts on the weekend and after hours.

Janknitz wrote: ↑

Wed May 23, 2018 7:47 pm

I think you'll be much happier NOT dealing with the DME. They are still probably processing your TAR.

If you do get a machine under Medi-Cal you will have a backup. Win:win.

I think so too! I already feel so relieved knowing I wont have to deal with a DME again. Last time was a nightmare.

sucramnella wrote: ↑

Wed May 23, 2018 8:37 pm

Janknitz wrote: ↑

Wed May 23, 2018 7:47 pm

I think you'll be much happier NOT dealing with the DME. They are still probably processing your TAR.

If you do get a machine under Medi-Cal you will have a backup. Win:win.

I think so too! I already feel so relieved knowing I wont have to deal with a DME again. Last time was a nightmare.

One caveat--there are compliance requirements to keep a Medi-Cal provided machine--every four months if rented . I found the provider manual and here is what it says:

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) EQUIPMENT

Authorization (for CPAP device) As medically necessary:
• Authorization for rental may be granted in increments of up to four months, both for the initial authorization and for reauthorization.
• Authorization for purchase may be granted for one device every three years.
The provider of the CPAP unit cannot be the same provider that performs and/or interprets the polysomnogram. These two providers must be financially separate from one another.




Reimbursement of accessory replacements for CPAP devices for HCPCS codes A4604, A7027 – A7039 and A7044 – A7046 (listed below) requires a TAR every 12 months. Documentation of the following criteria must be submitted with the TAR:
• A new detailed written order obtained prior to delivery of accessory replacements
• Documentation of a face-to-face re-evaluation by the treating medical provider within 12 months prior to the date of the order which states that CPAP continues to be medically necessary, and the patient continues to use the device
• Documentation that the replacement of specific accessories or furnishing of new accessories is medically necessary and essential for the effective use of the device

Medi-Cal will also cover supplies if you own your own CPAP machine, the provider just has to document that you own your machine.