CPAP therapist,machine coming tomorrow - questions

MichaelM wrote:As it stands, I cannot just get a script and buy the equipment online. I tried that. My doctor will give the script but the insurance co will not pay, even after I went over the numbers with them and demonstrated they would save about 40% of the cost.

Look at the numbers carefully, Michael. Depending on your insurance company and your plan, you may find (like I did) that buying the whole thing lock stock and barrel from cpap.com (or the online retailer of your choice) will result in the same or less out of pocket for you than going with the 3x markup you're likely to get from the insurance company's choice. For me, I have 100% coverage, but only up to $700. I can buy from their company, for a total outlay of $1850, or $1150 out of pocket and take whatever crap they give me, or I can buy the best machine, humidifier, mask, etc available on CPAP.COM and come in under that out of pocket number.

MichaelM wrote:It really galls me that I cannot try anything before its a done deal. How is it people are able to try masks and machines before a final commitment?

Well, apparently your DME sucks rocks. I still hate the pricing structure and everything, but I've said before, I have an awesome medical equipment representative. So far I've had four different appointments with her, for between 30 and 45 minutes each time, trying to find the right mask.

Liam, who can't sleep again, and is ready to give up on the whole CPAP thing, because he just can't get to sleep with the thing on his face.

From what I have seen, all insurance companies will only buy a new mask every 6 months.

Nasal pillows are not uncomfortable. Where did the RT get that?

The FP "new" mask she is suggesting is the one I think that has not received very good reviews, so you will probably hate it

Why can the sleep labs sterilize masks but the DMEs can't??? so people can try several and find one they really like?

Do many sleep doctors perhaps write CPAP when they mean xPAP, using it as simply a generic CPAP. Maybe these things are preprinted to have CPAP. My dr. prescribed a APAP (I love him!), heated humidifier, and "mask".

My head RT who is now my regular RT after a big fracas with the home DME over my customer "service", says he will exchange the new 420 integrated humidifier for my FP heated humidifier! Too cool! Thought I would have to order one and pay for it myself.

Only this RT at the DME seems to really know anything about all the masks, even though I've introduced him to the SNAPP which he said was very comfortable and the Swift. The other RT is also a CPAP users but like Debbie a real zero on knowledge.

She came, and now she's gone.

Here's how the RT visit went:

She brought three masks. One I had not reviewed but two were mentioned in this forum as not recommended by some users.

A mask that I seem to note had good reviews, the Resmed Ultra Mirage, she could not supply.

She brought a Fisher PayKel 220. I asked about the 221, and what the differences were. She told me there was no difference. After a few minutes of that conversation I found, in my notes gleaned from this site, the 221 has complaince software, while the 220 did not. She him/hawed about then came up with a story how "compliance software" can sometimes be detrimental as far as insurance companies are concerned.

I also asked about the Remstar C-Flex. (during my first sleep study I seemed to have problems exhaling) While she did not try to disuade me, she kept steering me to the Fisher Paykel. Its hard to describe how she was "downplaying" C-Flex but it was as if she was dismissing it almost as a gimmick. (my words not hers) She pointed out it has only been out two years. I pointed out, it must have been made as C-Flex for people who had trouble exhaling, as I seemed to.

She also pointed out the Remstar Pro C-Flex uses a complinace card, again something that could be a detriment as far as insurance is concerned. (what does this woman think, I am trying to stick it to the insurance co? Do I want this just for show??)

I asked which might be quieter, and she responded, the FP. Wonder if this is true or another steer? (quiet is important to me)

Another point was that on the "contract" she brought, it showed the machine as a rental. I inquired as to the procedure if I was unable to adjust to that particular machine.

Her answer was that it would be mine for five years, that the insurance would not cover another within that periodand that they would not take a return. (similar to the mask policy)

Told her I would make some more inquiries and get back to her.

After she departed I contacted Direct Blue who explained the "rental thing". They said they would pay rental up to their purchase price ($720 for the machine) then the rental would cease and the machine would be mine. Anyone experience this?

I am contacting another supplier (they have Remstar but no FP) who told me once they would "fit me" with a mask. Will keep you posted.

Sorry this is so long.

Michael,

Sounds like you handled it well. Here's a couple points of info for you re: the "visit"

cpap.com sells the HC220 for $399 as compared to the $720 you were quoted by the RT (note the RTs price is nearly double)

Believe it or not the HC221 (with compliance software) is $419. Your RT is feeding you a line about the insurance companies "problem" with compliance software. No insurance company is going to even notice the $20 difference. Most DMEs carry the non-software models. I guess they are afraid if you know too much about your treatment you won't need them.

Regarding the downplaying of C-flex, I have noticed from many previous posts that when a Doc/RT/DME is trying to talk you out of what you want, they seem to always claim that item does not function as represented. One of these times I would like to see these people get sued by the company they are erroneously slaming. It's apparent that these DME/RTs have some sort of exclusive contract to supply a particular brand of equipment. If they would be honest and tell you that, you could choose to go elsewhere. Instead they lie about the quality of the equipment you request.

Do you know what your copay amount will be? If you pay several hundred dollars out of pocket and get equipment from the RT that doesn't work for you, as they said, you are stuck with it and will be paying again to buy on your own. unless you can find an RT that will give you the equipment you want, it may be better to just skip the RT and buy yourself. Sounds like a rip-off but I think if you do the math you will see how that works.

Keep up the good work.

My co-pay is 10% regardless of the price.

What the RT was getting at about the compliance software was that if the insurance company found non-compliance they would not continue to pay. She said they (the provider) didn't have that problem when THEY kept track of the time used. (since it was cumulative, not four hours per night)

My provider also said if I opened a mask it was mine. It could not be returned. When I called my insurance company they did not know anyhting either. But after lots of hollering and screaming I got an RT to come out and fit me for a mask that fit instead of just sending masks shot gun style. I am begininning to think that you need to keep at them to get the care you should be receiving. I told my provider that I was the least important peice of the process - I was only the patient. That seemed to get everyone attention including my insurance company. But I am finally up and running with a mask that fits and am getting a good nights sleep - it is wonderful to wake up int he morning rested and ready to meet the day.

Boy, I'm appreciating my DME and my sleep lab more and more. They have a big vat of sterilizing solution, and so they'll let you try mask after mask, and then they toss them into the solution and (if they've found one for you to keep) give you the new pristine one to go home with.

So far I've had 3 masks at home, only one of which was mine (and that, if it doesn't work out, she said she could take back and do a swap on), the other two were ones they use in the sleep lab that they allowed me to take home to demo for a few days, rather than running into the "You opened it, you bought it" scenario.

Of course, with the markup I'm paying on this stuff, they could afford to throw away a couple of masks and still come out ahead, but... by comparison to what many of the rest of you are dealing with, my DME is a joy.

Liam, who hopes his wife (who lurks on the board) doesn't accuse him of having a thing for his DME.

Boy, this is even frustrating me and I'm one of the blessed ones! Just to throw a positive twist into this, there are quality docs and dme's out there. Both of mine have been super although I did notice that the dme charged the insurance plan twenty seven bucks for a chin strap! Geez!

HappyHoser, my insurance company seems to pay $720 (to the provicder) regardless of the brand and model of the unit. Something they term "allowed amount". Of that I pay 10%.

Yet another reason I am doing as much research as possible.

Do not know about the masks but I suppose they are paid for along the same lines.

I mentioned to them I could find lower pirced equipment from places such as cpap.com but that did not fly.

If you are having probelms with an insurance company I think you should go up the chain of command. Eventually you will get to the right person.

Not really having any problem with the insurance company per se. The insurance co CS people I have talked to cannot understand why the providers are as they are. The inability for me to buy one on my own and get re-imbursement is just that way the policy is.

As far as the $720 allowable, regardless of what the providers retail price is, they have to accept the insurance amount of $720 to be one of their providers. Since that is still inflated, I am sure the providers have no problems accepting the allowable amount! Probably jut one more reason why they are happy to try to give me older models!

Well, since your are going to be using the unit 1/3 of your life, get the best one you can afford. Its well worth it.