DME Lies?

JayPSU · Post by **JayPSU** » Fri Jul 07, 2006 5:09 pm

So today I met with my DME, Advanced Home Medical, for the first time. I had asked my doctor to prescribe an apap for me because I wanted to be able to keep track of any pressure changes that I might need over time. The doctor said she had no problem writing me a prescription for one and would fax it over. So I get to the DME today and he says that I'm renting an apap for a month to see what pressure I need. He says my insurance won't cover an apap. I told him that when I spoke to my insurance company, Anthem, they said that as long as the doctor prescribed the apap, it would be covered. He said that they talked to my insurance and my insurance comapny said that it would have to be proven to be medically necessary for me to need an apap over a cpap, so I'd have to go with a cpap. He also said that he doesn;t know anyone who gets an apap beyond just a rental experience. Maybe he means as far as it being paid for by insurance? Anyway, I just want an apap so I can periodically make sure that my pressure needs haven't changed. He said that I'd notice a difference and at that time they'd do another sleep study to see if I need a change. I'm thinking to myself, yeah right, I didn't know I had a SERIOUS problem for 30 years, you think I'll notice a slight change in needed pressure?!

Is this guy telling the truth? All I want is an APAP, how do I get this done?

johnnygoodman · Post by **johnnygoodman** » Fri Jul 07, 2006 5:22 pm

Your DME doesn't want to put an expensive machine out on you. Visit BillMyInsurance.com, fill out the form and they'll let you know what it'd be to get an APAP of your choice through them.

Johnny

Snoredog · Post by **Snoredog** » Fri Jul 07, 2006 5:24 pm

If my insurance said they would pay for an autopap if the doctor prescribed it, I would go buy one from cpap.com and send them the bill.

a cpap machine and autopap have the same billcode. Your slimeball DME makes more money off a rental so of course they are going to tell you that.

Guest · Post by **Guest** » Fri Jul 07, 2006 5:26 pm

From what everyone here has said, there is only 1 billing code for cpaps and autopaps. What usually happens is that the insurance companies will only pay for what they see is the regular equipment and what they have the code for.But many insurance companies will let you get equipment outside of what they have coded, but it requires a lotta work.

So they are most likely saying that the only thing covered is the basic equipment that the 1 code is for, and that to get the autopap they are gonna have to get all the extra paperwork from yer doctor and then send it in for review. Also, the part about getting an auto machine for 1 month on a rental and then being switched to a regular cpap seems to be very common, if not even normal.

Guest · Post by **Guest** » Fri Jul 07, 2006 5:30 pm

Unfortunately, cpap.com is considered out of network to my insurance company.

[quote="johnnygoodman"]Your DME doesn't want to put an expensive machine out on you. Visit BillMyInsurance.com, fill out the form and they'll let you know what it'd be to get an APAP of your choice through them.

Johnny

JayPSU · Post by **JayPSU** » Fri Jul 07, 2006 5:34 pm

So they are basically being lazy? I don't get it. I told my doctor I wanted an apap and why, she sais she'd write a prescription and so I thought all was well. Then I get this crap where I can only have it as a rental for a month and then HAVE to get a cpap. How does that make sense if my doctor ok'd it and my insurance ok'd it if my doctor did? I'm confused.

[quote="Anonymous"]From what everyone here has said, there is only 1 billing code for cpaps and autopaps. What usually happens is that the insurance companies will only pay for what they see is the regular equipment and what they have the code for.But many insurance companies will let you get equipment outside of what they have coded, but it requires a lotta work.

So they are most likely saying that the only thing covered is the basic equipment that the 1 code is for, and that to get the autopap they are gonna have to get all the extra paperwork from yer doctor and then send it in for review. Also, the part about getting an auto machine for 1 month on a rental and then being switched to a regular cpap seems to be very common, if not even normal.

snork1 · Post by **snork1** » Fri Jul 07, 2006 5:47 pm

[quote="JayPSU"]..... He said that I'd notice a difference and at that time they'd do another sleep study to see if I need a change. I'm thinking to myself, yeah right, I didn't know I had a SERIOUS problem for 30 years, you think I'll notice a slight change in needed pressure?!

Is this guy telling the truth? All I want is an APAP, how do I get this done?

JayPSU · Post by **JayPSU** » Fri Jul 07, 2006 5:51 pm

So what can I do about it? What would you do to get your apap?

[quote="snork1"][quote="JayPSU"]..... He said that I'd notice a difference and at that time they'd do another sleep study to see if I need a change. I'm thinking to myself, yeah right, I didn't know I had a SERIOUS problem for 30 years, you think I'll notice a slight change in needed pressure?!

Is this guy telling the truth? All I want is an APAP, how do I get this done?

Guest · Post by **Guest** » Fri Jul 07, 2006 6:12 pm

It's kinda getting turned around backwards here for you.

It's not that anyone is being lazy, or trying to screw you over.The more expensive option simply isn't accomodated by your insurance.They only made 1 code for all the equipment.Depending on your insurance the amount they pay may not cover the cost of the more expensive unit. I'd say try the auto for a month and see how you do.Worst comes to worst, talk to the company and ask them about borrowing one or offering to pay cash for one a couple times a year and see what they say.

Or talk to your insurance company and find out what it would take to get special coverage for that auto unit. From what they guy at the dme told you it sounds like it would be if its sent in for review.

From how it's been described here though it doesn't really sound like anyone is trying to screw you, it's just that the system isn't setup well to cover different types of machines.Insurance companies sure wanna take our money but damn if they want to give any of it back!

JayPSU · Post by **JayPSU** » Fri Jul 07, 2006 6:20 pm

Ok, I must be missing something here then. My insurance company told me that they WOULD pay for an apap as long as my doctor prescribed it. So I asked my doctor to prescribe it, and she did. Things got all messed up when I got to the DME today and I don't get why. Insurance was a go, and the doctor was a go for the apap. What's the problem?

[quote="Anonymous"]It's kinda getting turned around backwards here for you.

It's not that anyone is being lazy, or trying to screw you over.The more expensive option simply isn't accomodated by your insurance.They only made 1 code for all the equipment.Depending on your insurance the amount they pay may not cover the cost of the more expensive unit. I'd say try the auto for a month and see how you do.Worst comes to worst, talk to the company and ask them about borrowing one or offering to pay cash for one a couple times a year and see what they say.

Or talk to your insurance company and find out what it would take to get special coverage for that auto unit. From what they guy at the dme told you it sounds like it would be if its sent in for review.

From how it's been described here though it doesn't really sound like anyone is trying to screw you, it's just that the system isn't setup well to cover different types of machines.Insurance companies sure wanna take our money but damn if they want to give any of it back!

NightHawkeye · Post by **NightHawkeye** » Fri Jul 07, 2006 6:33 pm

JayPSU wrote:What's the problem?

I think you already know what the problem is Jay. The facts have been clearly stated already. The only other thing I can think of which really needs to be said is that some posters here have a better grasp on reality than others. And you get to choose whom to believe, just like in real life. .

Regards,
Bill

Guest · Post by **Guest** » Fri Jul 07, 2006 6:34 pm

Because, according to the insurance, they do pay for it. They pay for anything labelled a xpap machine. This happened to me a bunch of time with certain things too. Its like asking them if they pay for a cpap mask.They are gonna tell you they do. It's only when you try to submit a claim for 2 in month that they go OOOoooh, you meant do we pay for one now!!Well no, we don't. You can only have 1 every 6 months.

So yes, they pay for an autopap, because they pay for anything with pap in the name.They just may not pay enough to cover the actual cost of it!!

Or to put it simply (the way the therapist lady actually explained it to me):

It's like if your insurance covered the cost of your car. If you call 'em up and ask 'Do you cover my car' they will say yes. What they aint telling you is that all they are gonna pay for is a 2 door Kia with no air conditioning and a manual transmission. They aint gonna pay for the nice new Cadillac!

JayPSU · Post by **JayPSU** » Fri Jul 07, 2006 6:42 pm

So essentially there is nothing I can do? Is that what all of you are saying? I can only get a cpap even though my doctor prescribed an apap? Is there a way that I can get an apap and pay the difference in price between the cpap and apap? Please be patient with me as I have ZERO experience with insurance companies. All I have ever needed before this in the past is checkups, blood tests, and twice x-rays. I don't really have experience working with insurance companies.

Guest · Post by **Guest** » Fri Jul 07, 2006 6:56 pm

Worst comes to worst, talk to the company and ask them about borrowing an auto or offering to pay cash for one a couple times a year and see what they say.

Or talk to your insurance company or the dme and find out what it would take to get special coverage for that auto unit. From what they guy at the dme told you it sounds like it would be if its sent in for review.

inacpapfog · Post by **inacpapfog** » Fri Jul 07, 2006 7:03 pm

JayPSU, your case kinda sounds like the same ordeal I went through to get my apap through insurance. I wanted an apap from the very beginning for the same reasons as you. When DME told me the same story you got, I argued the same points you stated! After I left the DME office, I called insurance (BCBS) and got it from the horse's mouth, IF THE DOCTOR WRITES APAP AS A MEDICAL NEED (via the prescription) DME will fill the prescription! I called my doctor after 1 week and reported excessive aerophagia and inability to breath with the mask on at random times through the night. He documented this in my records and wrote the specific prescription for the apap w/ humidifier ! I had my apap within 24 hours after that! Moral of story, if the front door sticks, try the back door! (Heck, I'll climb through the window if needed!)

DME Lies?

DME Lies?

Re: DME Lies?

Re: DME Lies?