newbie needs help dealing with DME

First, just want to say I am so glad I found this forum! Such useful info.

Had a sleep study and halfway through they put me on CPAP since I was having apnea events. They titrated me to 6cm.

After reading a ton on here, I contacted several DME's in the LA area, with goal of getting an APAP machine, preferably the S9. I am on Anthem PPO in California. I finally chose a DME because they sounded honest. After speaking with them today, not so sure. I was told that because I was titrated to a certain level in my sleep study, my insurance won't cover an APAP, only a CPAP. This, despite the fact that I had my doc write a prescription for a fully data capable APAP. The DME says it's 2 separate codes for the cpap and then the auto portion and that Anthem won't cover the auto portion. I thought it was one code only, right? The DME says I will have to pay $455 over and above whatever the insurance will pay. Sounds fishy, or is it true that if I have a titration level set in the sleep study, that overrides my doctor's prescription??

Any help greatly appreciated!

Welcome!

Sounds fishy? You betcha! Unless the insurance codes have changed they are trying to rip you off. Go find another DME. It's not worth starting this adventure without the best tools. Jees, for $435 you can get an auto like mine from our hosts cpap.com.

Never, never, never, I mean NEVER let a DME tell you what your insurance company will cover. They lie like snakes.

Call your insurance company and ask. For a list of questions, see my blog here http://maskarrayed.wordpress.com/what-y ... me-part-i/

This DME has already shown itself to be dishonest. APAPs and CPAP's are both E0601 HCPC's code. 99% of the time, your insurance will cover either, and pay a single fixed amount (or monthly rental amount) REGARDLESS of what machine you get. The insurance company doesn't even CARE which type you get, because they are paying the same amount in either case.

What you especially want to find out is whether a DME may charge you an "upgrade" fee over and above the contracted allowable charge for the item. In most cases, they may not, and trying to get you to pay extra is FRAUD.

Okay, thank you!! I just got off the phone with Anthem and they basically said the same thing. They confirmed the code for a cpap is e0601. She did not know the code for an apap (she did claim it was different than the cpap) BUT she said it doesn't matter because she knows for a fact that Anthem pays the same amount for a cpap or an apap. So, yes, the DME is acting VERY shady. Interestingly, the customer service rep is now not picking up her phone.


Time to go to another DME! Going to try Western Medical which was recommended by another user on here.

Thanks all! Will post back once I get things sorted out!

Okay, just got off the phone with Western Drug (not medical). I have no deductible and my copay is 40% (Anthem pays 60%). He said that I can get the S9 autoset and mask of my choosing w/humidifier. He said my cost out of pocket will be $387, which is 40% of the cost of everything (he said it's about $967 for everything). He said if I take the mask home and end up not liking it, I have 2 weeks to return and exchange, and that my insurance provides for a new mask every 3 months anyways. I had heard of a 30 day return policy from others o here, but 2 weeks is ok with me.

Seems reasonable to me. I am scheduled to go in tomorrow.

Any thoughts?

That sounds pretty good.

The only concern I'd have is the mask return policy. THE MASK IS THE SINGLE MOST IMPORTANT FACTOR IN CPAP comfort and compliance. If the mask isn't right, you won't tolerate being strapped in it for 8 hours a night.

For most DME's, the big mask manufacturers (ResMed, Respironics, Fisher and Paykel) will take returns of masks that don't work out for the patients, and that return window for the DME's is open longer than 30 days, but they limit the patients to 30 days so they have time to return the equipment. So it's worth pushing Western on that. You should also ask them if they have samples of the masks which are provided free by the manufacturers for the express purpose of letting patients try before they buy. They are exactly like the retail masks in less fancy packaging and sometimes without the fancy box, bag, or case you get with a purchased mask. A lot of DME's sell those on the side (on the "grey market"--not to their own customers) rather than using them for their intended purposes which is to help their own customers find the best mask.

Keep in mind that if Western treats you well, they will have a customer getting replacement supplies for life. So they may make things seem like a "favor" to you, but it's really just good customer service. You can gently remind them of that too--that you've shopped around and you're willing to go elsewhere if necessary.

soulofwit1978 wrote:Any thoughts?

Keep calling. You may find an even better deal.

soulofwit1978 wrote:Okay, just got off the phone with Western Drug (not medical). I have no deductible and my copay is 40% (Anthem pays 60%). He said that I can get the S9 autoset and mask of my choosing w/humidifier. He said my cost out of pocket will be $387, which is 40% of the cost of everything (he said it's about $967 for everything). He said if I take the mask home and end up not liking it, I have 2 weeks to return and exchange, and that my insurance provides for a new mask every 3 months anyways. I had heard of a 30 day return policy from others o here, but 2 weeks is ok with me.

Seems reasonable to me. I am scheduled to go in tomorrow.

Any thoughts?

Check to see how much you will will pay if you paid out-of-pocket (oop) and bought from from cpap.com
Then you could ask Western for their very best deal, if you want to. The mask replacement is 30 days - this is offered by the mask manufacturers and there is no cost to the DME. Don't let them cheat you on this. I still don't like that they lied about that.

As for the e601 code - the insurance person (you talked to) just doesn't know it but they are the same. Call again - ask who you are speaking to so you know, take notes. You need a notebook for all you will encounter. So when you think about that fact that Ins.co, will pay the very same for apap or cpap - why would they care IF you did get an apap? Just doesn't make sense.

I have Blue Cross Blue Shield of LA and Anthem of CA. I had to pay $303 out of pocket for my S9 autoset. My DME company only uses auto set because if can be configured to assist a wide range of patients.

I would say if you were quoted $300 price range that is pretty much inline. Ask for a price sheet of cost and what the insurance pays and your part. My DME gave me a sheet with all the prices, co-pays and even the codes they use to file with. They really worked with me to help me get what I needed.