Navigating the maze?

I went to the pulmonologist last week to try to get another sleep study. Someone on this board suggested to me that if it has been some time since my last study and as I haven't been using the CPAP, that my settings may have changed (e.g., due to weight gain, etc.).

To recap, I have been non-compliant with using my CPAP for a few years now. What was scary was that I mentioned that the new /technology machines might help me become more compliant and I mentioned "APAP", the pulmonologist didn't seem to know what that was! I explained the auto pressure settings on both the inhalation and exhalation sides (although he did mention bi-level).

I am scheduled to do another sleep study on Friday. Here is my question: If I want an APAP, does this doctor have to write the perscription for one? Or does he give me a perscription for some type of CPAP machine and can I then talk to the insurance company to get a APAP? Can I take the scrip and go to cpap.com to buy an APAP?

Ultimately, I want the latest technology to help me be as compliant as I can be. Otherwise, I may have to seriously consider doing the surgery (see previous post).

Thanks.

According to the person I spoke with at cpap.com, a prescription for CPAP is a prescription for CPAP, they can sell you an Auto. (Auto being short for Auto Titrating CPAP).

Many DMEs don't see it that way (because the Auto costs them more, but the insurance company doesn't PAY them more), but as has been discussed elsewhere, when they're charging you 2-3 times what a FAIR and profitable outfit like cpap.com can charge you, I'm not that concerned with cutting into their 200-300% profit margin.

Liam, who still doesn't have his own auto, but would like one.

Some follow-up questions, I am a newbie to this whole insurance thing so I have lots of questions I hope you will entertain.

1. Am I able to speak to the DME to indicate a preference on type of CPAP machine (I didn't know a patient can intervene like this)? Why would they honor my request for an APAP if the insurance company only reimburses them for a regular CPAP?

2. Can I take the scrip and go to CPAP.com to buy an APAP? If so, I guess the disadvantage is that someone doesn't come over to go over how the mask should be fitted, etc.

3. If the DME is not getting reimbursed for more than a regular CPAP, can I pay them money out of pocket to get a APAP over a CPAP?

Thanks.

1) If your script only says CPAP, getting the DME to provide APAP is going to be like pulling teeth.

2) Yes, you can take the script to CPAP.COM and buy an APAP. They will charge you MUCH less than the DME will, but may not be reimbursable under your insurance policy. Note that you should pay CLOSE attention, because you may very well find that your out of pocket, paying CPAP.COM directly and cutting out the insurance entirely, is less than your out of pocket paying just your deductibles and copays and such through the DME.

3) I don't know but keep in mind, an APAP *IS* a CPAP. It just has some extra features, but from a medical claim number standpoint, it's the same thing. It's not the difference between a motorcycle and a car, it's the difference between a Toyota and a Lexus. They don't want to give you the Lexus because they're going to charge you the same as they'd charge for a Toyota, or a Hyundai, or even a Kia. They'll try to give you the cheapest thing they can, because why accept a 175% markup when you can accept a 400% or more markup?

I think that's everything you asked.

Anyone who thinks I'm mistaken, please correct me!

Liam, who wants a rolls royce.

For number 2, that scenario is an out of network with no coverage. It is also possible that your insurance company will want compliance data (or so I have heard) before they authorize a purchase. If I were you (but I am not cuz I already have an APAP ) I would contact my insurance company and pin them down to your exact coverage.

I agree, except that pay CLOSE attention. Although many insurance companies have an in network and an out of network, you will probably find your out of network deductible is quite high, very possibly higher than your total out of pocket cost from cpap.com. (Mine is $1000 out of network).

Also, many insurance companies insist on RENTING the equipment (or rent-to-own), which you can't do through CPAP.COM, so that even though it's a covered expense, they'll refuse to cover it on the grounds that your policy specifies a rental.

Just be aware of the possible pitfals, so you can expressly ask when you call, because at least with my insurance company, the customer service drones don't know crap, and if you go based on what they tell you, you can get royally screwed.

Liam, who wants to go get royally hammered.

I remember not paying a dime for my previous cpap equipment. It comes down to what the scrip says.

If it says CPAP, I can get a CPAP or an APAP if the DME chooses.

If it says Bi-pap, I can only get a bi-pap.

What I don't get is how and when I intervene with the DME/ insurance company to indicate a preference as to what they are going to give me. For example, after the sleep study, I will visit my pulmonologist to review results. I'm sure he'll write a scrip. Then, do I ask him or the insurance company which DME they will be dealing with? Then, do I need to tell them that I will call them to see if I can indicate preference?

How many DMEs even hear from the patient? I'm sure most of them don't (e.g., doctor/insurance company contacts them, they order the equipment and arrange a meeting with the patient).

Ed

The time to ask is to ask that it be specified on the script. The DME is highly unlikely to let you ask for that Lexus if all that's been specified is "car". Your insurance company may have specific standards (mine specifies the Remstar Pro-2), which may upgrade you from Kia to Hyundai or Toyota.

But if they're not TOLD to give you a Lexus, you're not likely to talk them into one. Again, because the price they charge is constant, whether they sell you the bottom of the line (aka cheapest) machine or the most expensive APAP. And since based on their pricing, they're CLEARLY just in it for the money (most, that is), the likelihood that they'll voluntarily give up any of it without being so told by the doctor is slim at best.

Liam, who didn't used to be this cynical and jaded. Well, yeah, I guess he did.

I'm definitely in the minority, here, as I do not believe that all DME's are "evil". The sleep DME's I have worked with here in Chicago will work with the patient on the choice of equipment and mask. Ten years ago, that wasn't the case with my initial DME as I was given a machine and a mask (on an emergency basis,though) without any choice of either. Luckily I was able to adapt to them with no problems. But the companies I know of today (about 4 or 5 here) do things differently.

Yes, they do charge more money, but for that they put up with the insurance hassles and Medicare hassles (which can delay payment for months, while you are using the equipment) and they can offer support in person. Keep in mind that they rarely receive the full amount of the billing from your insurance and you, because of the negotiated rates. The same thing happens with hospitals, too. Five years ago, my hospital bill for quadruple bypass surgery and 4 days stay in the hospital (not counting surgeon and anesthesiologist) was $40,000. The final net payment from me and my insurance company was $14,000. Insurance payments are definitely a major issue in how our healthcare system works.

Bi-paps have a separate billing code and reimbursement schedule, I think, as compared to CPAPs, but as of now an APAP is reimbursed at the CPAP rate, so the insurance companies are limiting their payment for the APAP. Since the manufacturer's cost is higher for the more complicated machine, a DME is eating that extra cost differential.

If you are running a business, you have to cover your operating costs of staff, office location, travel, cost of goods, cost of money (waiting for insurance), etc. Whether you feel you get the same benefit for your money from a given DME provider is up to you, but by saying that all DME companies are evil is saying that all small (or even large) business is evil

CPAP.com has its own operating efficiencies and may well be a better place to buy for many people, but there are also many others who prefer to buy locally or who may be forced to buy locally due to insurance. If those persons see some perceived value in the offerings from their DME, let them make that choice.

Dave

Dave,

I respectfully disagree. Yes, they don't receive "full" payment, they receive their "negotiated" price with the insurance company.

I can't speak for anyone else's DME or insurance company, but the full package that I have right now would be about $800 from CPAP.COM. The same full package at the "negotiated discount" from my DME is $1850. And the same full package at the "regular prices" is about $2500 or more.

I understand the hassles and stuff they go through, but when, with my copays and coverage limits, it becomes cheaper to buy the equipment outright from cpap.com than it is to buy it through the insurance company, SOMEONE is gouging. It just makes no sense to me that with my limits and such, my out of pocket going CPAP.COM is $800, and my out of pocket going through my DME and my insurance is $1150.

You can't tell me that they're taking less money, because they're taking more OUT OF MY POCKET than CPAP.COM does, even assuming my insurance pays NONE of the $700 my policy is limited to for DME.

I don't believe there's sufficient overhead to justify more than DOUBLING the cost of the equipment. It's got to be greed, pure and simple.

And then there's the whole idea that there is a "standard price" for "a cpap" and a "negotiated price" for one. Not for each model, but one price no matter what CPAP machine you get. So if they give me the little cheap Puritan Bennett (model number is out of my head right now, and by cheap I am strictly speaking cost) or whether they give me a Remstar Auto, the cost to me is the same. That's price fixing, and in any other field, it's ILLEGAL. But for some reason in the medical field, it's status quo.

The people who WORK for these companies may not be greedy and gouging, certainly my DME rep is a joy to work with. But working with her is not worth the amount her company gouges me (or my insurance) for.

Liam, who doesn't begrudge someone earning an honest living, but there's nothing honest about these business practices.

Dave,

The point that many people on the forum (including me) try to make regarding the local DMEs is that the outrageous prices they charge can not be justified by the insurance hassles or the supposed extra service. The insurance premiums we pay are grossly inflated by the wasteful overpaying to the DMEs. I a patient can get the same equipment for 1/4th the cost that means the insurance premiums can also be 1/4th what they are now. Until people realize that health insurance in not a bottomless pit of money, our rates will keep rising and insurance will become unafordable for more and more people.

As a side note, have you ever taken advantage of calling the cpap.com help line? The people on the phone there are much more helpful and friendly than any local DME has been to me. They are also there till 10pm Mon to Sat... try to get that kind of service from the Local DME.

We are just trying are "darndest" to get people to look at things in a different light. We all have the benefit of the innovations brought about by the cpap.com folks...it's a new world and it's getting better everyday.

Ditto Wader.
Wasting insurance $$$$$$$ just makes it cost more for all. The leading cause of bankruptcy is medical costs. If we lost our insurance today how many of us might be in the poor house by years end. It only takes 1 serious accident or illness to wipe us out. Lets save where we can. The internet offers us a great way to save everyone a few $$. Yes , even our insurance carrier. Horray for cpap.com !

Waverly

The bigger picture is for the same dollars out of your pocket, What kind of equipment are you getting? Are you getting a Yugo or getting a Mercedes? Or even worse, are you paying for a Yugo and getting a Mercedes? If we weren't talking about medical equipment, I doubt this discussion would happen...