Get A Laugh At My Expense!

DreamStalker wrote:Sorry you had to post such a "lengthy" (not really in my opinion) message to address an issue that was not brought up - The quality of your care by your doctor and DME staff.

I was referring to the "failure" of the healthcare system processes of not providing an APAP from the start.

Isn't that exactly what IS being referred to though by 'the healthcare system process'? Meaning the insurance companies, the doctors and ultimately the DME providers. Aren't we what the system IS?

I know I view it that way, which is exactly why I replied the way I did.

Just curious what you think.

mattman

DreamStalker wrote:Well I guess they were right then ... I should simply give up and leave poor Matt alone to preach to his flock.

Best of luck with your health and to your flock for they may well need saving.

Hey man, don't react that way. Talk to me!

I take your points very seriously which is why I gave an opinion on them one by one. Give me an opinion back!

Tell me what you think of my opinions. Disagree with me, raise points. Have a DISCUSSION!

Come on man - don't bow out. I've got zero problem talking about this as long as it's not the old 'DME companies suck' rhetoric some folks always use.

I really have zero problems with anyone thinking our industry DOES suck as long as they discuss why intelligently.

mattman

Matt, I'm going to shoot down several of your points.

1. You claim that diet and exercise would help all of us. True point, but in my case, I still needed an APAP over a CPAP. About three years ago I started walking six days a week. Within about 9 months I was up to three miles a day. Thats 18 miles a week. I am also diabetic, and take Actos. I am also 100 lbs over weight. It has been three years since I started this and guess what. I've gained probably 35 pounds from when I started. Guess what I believe the major cause of that weight gain to be today. My CPAP pressure was too low for what I needed. I don't have insurance, so I can't just call up my doc and get everything "fixed".

After about a month on APAP treatment, I'm feeling better, eating a little less, have more energy, and my blood sugars have dropped by about 15 to 30 points a day. No doctor set my pressures, I did it myself. This forum helped me in ways that I can't begin to express.

Our health care / employment system is a complete failure IMHO.

JeffH

Jeff -

Thanks for the response and I do very much understand where you are coming from. That is exactly why I worded my opinion as 'most of us'. My exact statement is below:
"Let's all face it - diet and exercise ARE two of the biggest things that would contribute to most of us finding better success with our treatment."

You are absolute proof of why it isn't the case for everyone.

I am curious though on one thing. Why do you view the healthcare/employment system as a complete failure?

Isn't the issue more how your employer and insurance work than the healthcare system in general? Do you think it's possible that if you had been able to work with a doctor your treatment would have been successful sooner?

By the way, I'm really happy to hear you got such quality help from this forum. It is a great thing!

mattman

"I am curious though on one thing. Why do you view the health care/employment system as a complete failure?"

Let's see here. To have insurance in this country you have to have a job, or be wealthy enough to afford insurance.

If you have health problems, employers won't hire you.

If you don't have a job and have health problems then you are supposed to do WHAT?

In all the so called civilized societies in the world, there is health care for all. The exception to this is the US of A and South Africa. In these two countries, we "throw away" those without.

I can tell who you voted for.

mattman wrote:

NightHawkeye wrote:Realistically though, you describe a cumbersome process which mostly delays diagnosis and treatment.
\Regards,
Bill

I find it interesting that you view this as cumbersome! To me, it's amazingly easy.

I'll grant that you find the system amazingly easy. Of course, you work within this very system, so you know not only how it's supposed to work, but also how to get it to work for you.

In the year I've been paying attention to this forum, there have been other individuals who work within the healthcare system who have indicated how well things have worked for them; folks I remember off the top of my head were Brent Hutto and Chuck-GoofyUT, although I'm sure there were others as well. Both of these guys, like you, were extremely detailed and, I believe, that worked to their benefit because they spoke the language of the healthcare system.

It may not seem like a big deal to you, but for those of us not so fortunate, it becomes a major obstacle, and a source of great frustration at times. Please don't discount this effect.

Regards,
Bill

mattman wrote:I still FIRMLY believe it is our moral obligation and fiscal responsibility to start with the least expensive treatment first and THEN work our way up to the most expensive.

mattman,

Here's one point I'm going to disagree with you on.
The amount the DME providers charge is the same......whether it's the cheapest CPAP machine or the most advanced Auto (probably similar with Bi-PAP/Bi-level machines).
If the manufacturers would make ONE machine that encompasses the whole CPAP/APAP spectrum (excluding Bi-PAPs here), their manufacturing costs would be significantly less and the cost of the machines would be able to be lowered......which would result in simpler inventorying for the DMEs and also keep their profit margins intact.

Since the patient (policy holder, group member, person who ultimately pays for this stuff) has to fork out the same amount of money, regardless of which machine they get, they should get the best quality for their money.

Just my take on that one.

Also, my beliefs on the physical fitness issue......is that in a good portion of the OSA cases (maybe half or more), the apnea is actually the cause of the weight gain and other things that throw the body metabolism out of whack.

Best wishes,

Den

matt, have you also dealt with your health insurance company to get you as DME paid during your journey? If so, how has it gone?

Kajun

mattman wrote:I've got zero problem talking about this as long as it's not the old 'DME companies suck' rhetoric some folks always use.

Alright, how about "My DME company sucks"?

Below is a condensed version of my current experience with my DME. Things I consider net positive use + as a bullet and negatives use -.

- RT came to give me an auto. I hadn't been titrated. Machine was left set at CPAP at 15. Doctor ordered Auto 4-20. I set Auto 6-20 until my range became apparent.
+ RT that left the auto gave me the mask I requested, but didn't try more than one size...Result is leaky, but cheap enough to fix on my own by ordering different sized cushions online.
- Mask refit involved getting grilled by a different RT as to why I had the audacity to have Encore installed on my computer. Chronicled here. In the end was only offered 4 different masks and got a highly uncomfortable Comfort Gel Small for my ordeal. I used it one night and it now occupies my reject drawer.
- I'm supposed to send smart cards in every 10 days for compliance. For the second time now I've had to call and ask where my card is. "Oh, it's scheduled to go out tomorrow" is always the answer, so finally this time I said, "Was it scheduled to go out tomorrow before I called?" "Honestly, no." "So if you had to prove compliance to the insurance company, would I be SOL if I didn't specifically keep track of this?" "I don't know."
- The DME has never ever called me to see how I'm doing. Not once. I'm sure they can tell I'm being compliant because I hound them for cards, but I find this strange.
- I love my doc, but they haven't called yet to tell me to move the pressure from 4-20 (lol). I was asked how I was doing (by my doc), but that was only when they thought I was turning the machine in because of the crazy nazi RT.

Ok, so given these experiences, this has been my reaction:

I wanted to try specific masks. I know I can't approach them, so I ordered online via cpap.com and ignored the fact that it's not going to my deductible.

My honest question to you is how should I approach them to get what I need? Is there some magical way I can word it so they go, "Oh, you want to order a mask and bill your insurance. Got it."? Right now I say, "I want X mask." and they say "That's not how it works."

Whenever I talk about a mask, they talk about doing a "refit". I know what mask I want, I just need them to hand it to me in a bag. Or, if they don't want to do that, I'd sit down with an RT and do a fitting with the mask I requested. If I go in for a "refit" now then I don't get the mask I want because they only have those same four crappy masks at the location they do the refits in, and at least last time completely refused to even discuss one that wasn't one of those four.

My insurance and DME are separate divisions of the same parent company, which means insurance strongly discourages you ($$) from using anyone else but their pet DME, so DME shopping is out of the question, as it's cheaper to order online than it is to order from a different DME with my copay.

mattman wrote:

DreamStalker wrote:Well I guess they were right then ... I should simply give up and leave poor Matt alone to preach to his flock.

Best of luck with your health and to your flock for they may well need saving.

Hey man, don't react that way. Talk to me!

I take your points very seriously which is why I gave an opinion on them one by one. Give me an opinion back!

Tell me what you think of my opinions. Disagree with me, raise points. Have a DISCUSSION!

Come on man - don't bow out. I've got zero problem talking about this as long as it's not the old 'DME companies suck' rhetoric some folks always use.

I really have zero problems with anyone thinking our industry DOES suck as long as they discuss why intelligently.

mattman

Unfortunately, I no longer take your points seriously. My opinion is that you enjoy confrontation and you come here to this forum to initiate it.

My point with you has always been about providing APAP technology to all apnea patients from the start because an APAP (which is easily set for CPAP mode if desired/needed) is not that much more expensive than a CPAP only machine … especially when one considers the costs associated with non-compliance and the subsequent health issues related to untreated or inadequately treated apnea.

I don’t think that all DEM companies (or doctors) suck but rather that the system processes that you preach “most apnea patients should start with a CPAP machine and then upgrade to an APAP only if needed” sucks. By the time a patient realizes that an APAP is needed, it may very well be too late because the patient has become frustrated and lost hope that PAP treatment will ever make a difference in their life.

I have made my point as best I can and you can discuss (argue) otherwise with other members of the forum … but I for one feel it is time for me to “bow” out and avoid further responses to your posts.

Have a great life!

If the manufacturers would make ONE machine that encompasses the whole CPAP/APAP spectrum (excluding Bi-PAPs here), their manufacturing costs would be significantly less and the cost of the machines would be able to be lowered......which would result in simpler inventorying for the DMEs and also keep their profit margins intact.

My point with you has always been about providing APAP technology to all apnea patients from the start because an APAP (which is easily set for CPAP mode if desired) is not that much more expensive than a CPAP only machine … especially when one considers the costs associated with non-compliance and the subsequent health issues related to untreated or inadequately treated apnea.

..what they (Wolf & Stalker) said...plus, for me, OSA has been a self-treatable
condition.....

First I am the one who posted:

Second, you guys gotta layoff Mattman. He is making observations from his perspective. Disagree if you feel the need, but lets not take every opportunity to take out our bad experiences with DME's on poor Matt .

I never meant it to mean don't discuss and disagree. I just thought several were taking "potshots" at mattman and his profession without actually providing substance.

That being said, I think Mattman is off base on several points. He obviously overstaed when he said the process was simple. It might be for him, but certainly not for everyone, and I am guessing "not" for most. Here is how my attempt to get an auto rental went:
1) call and ask to talk with sleep doc. Told he won't change treatment (ie order an auto trial) without seeing me. First appointment is 4 weeks out, but I could see the PA in one week. I see the PA and convince him I know what I am talking about and that recent neck surgery really meant I needed an auto for awhile. He calls sleep doc and gets it ok'd.
2) DME takes over a week to "prepare" and deliver an auto. I ask if I can get any info from the machine since I track my AHI and such daily, and am told no. I found out here that I can turn on a menu setting that allows for daily readouts on the LED. I kept track of every number for 3 weeks. DME was ticked when they found out I was doing that.
3) Insurance refuses to pay for 3 week rental because the code being billed is for a cpap and they already bought me one of those. Took lots of calls, paperwork, etc to convince them to pay.
4) Made appointment to see sleep doc well in advance to get results, but instead the PA walks in. (Doc is in the mergency room - understandable) PA tries to tell me everything is hunky dory until I make him get out the report and stop looking at just the summary page. He calls Doc on his cell phone and they decide I need to be put on an auto full time. From there the process gets worse much worse and more complicated.

Now I am a very competent person (and humble). I in no way found this process to be simple. Maybe I am the exception, but I doubt it. I am guessing Mattman's "simple" process is more of the exception.

I still FIRMLY believe it is our moral obligation and fiscal responsibility to start with the least expensive treatment first and THEN work our way up to the most expensive.

I strongly disagree. I am all for keeping costs down, that is what I do for a living in another field. That is what I pay doctors big $'s for, to help "guide" me in the BEST treatment possible for my condition, not the "least expensive and go from there." In addition, I have been around long enough to see that starting with the least expensive ussually means spending more in the long run.

Just my 2 cents worth.

Just like everything else in life , it sorta seems to boil down to who u know and who you don't know. And how high and mighty your insurance company is I'm guessing.

- My dme gave me a machine, has 8 masks to choose from, puts one on ya, reclines ya back in an old recliner, waits about 1 mins and then says okay no leaks? feels good? that'll work for ya..

- Nobody has ever called me to check on my progress.. dr, insurance, dme...

- Dr. hasn't a clue about therapy of sleep apnea, but at least she admitted it to me.

Don't hate mattman or be jealous cuz he's got a great relationship with his Dr. in the fact that he can call her up and ask/talk to her without waiting or having to have an appt.

He made this post because he now has to WAIT on his dme and his Dr. to figure out the next step... something many of us have posted complaints about.

mattman has been a great source of information for me recently with a problem and I THANK HIM. Yea he's a dme guy which everyone seems to find dme=evil but he's not. He's honest with how that end of the business works and people should just respect that, not hate it because its not to your liking.

mattman,
In another thread, I said I thought the same billing code was used for both APAP and CPAP. Your response was:

mattman wrote:There is a little bit of a very common confusion in what you are looking at and what you are asking.

As is commonly referenced, Insurance Companies do not have a specific code set up for an APAP. CPAP has a code of E0601. Insurance Companies do not as a rule cover an auto unit due to the insurance companies considering it to be a luxury/not medically neccessary.
However, since an APAP *DOES* fulfill the defination of the code E0601 it CAN legally be provided as a E0601. There is a little bit of an important distinction there. It's not that they just don't have a seperate code for the autot, it's that they have deemed it not neccessary but since it also meets the criteria for the other unit it can be billed that way if the provider wishes to do so.

The reason that distinction is important to this is the statement that you copied above:
"More sophisticated machines ... may be covered with a specific physician prescription and documented failure to respond to standard CPAP."

This statement refers to the workaround for an auto unit not having a HCPC code. There is a catch-all code - E1399. This is the code used for something that doesn't have another code. It (generally) requires going through the insurance companies Medical Review board and is MUCH more labor intensive and time consuming.
In cases where a patient has a documented failure to respond to CPAP therapy and Bi-Level doesn't seem appropriate an attempt could be made to bill an Auto unit as an E1399 and go through the review process. This could potentially result in coverage for the Auto unit and with reimbursement determined by the insurance company.

Now, all that being said... the typical reasons an insurance company might consider an auto claim would be for things like uncontrolled aerophagia, etc.
Insurance companies will almost never consider it for things like potential future weight loss (Future possibilities generally don't matter to them), desire for monitoring (Smart-Card CPAPs will do this), less future titrations (Again, future possibilities don't matter and a low percentage of people need regular re-titration).

The easiest option is to work with your doctor and your DME provider. Talk to them. It's not uncommon for a DME company to be willing to provide an Auto unit under the E0601 code. This mostly depends on what the reimbursement for your particular policy is. Sometimes they will be willing to provide it under that code and bill you a small upcharge. Some policies allow upcharging, though many do not.
Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.

Some questions for you:

1) -Some DMEs use the same code for both APAP and CPAP, accept the allowable amount from the insurance company and then write off the additional cost of the APAP. Is that correct?

2) -Some DMEs use the same code for both APAP and CPAP and then bill the patient an upcharge for the APAP. You're saying this is legal and this upcharge is determined by the insurance policy and not the DME. Is that correct?

3) -Some DMEs use the miscellaneous code E1399 for APAP. You're saying this is legal even though the existing code for APAP is E0601. Is that correct? Does using the misc. code result in a higher allowable amount from the insurance company than using E0601?

mattman wrote:Don't EXPECT the company to be willing to do it, regardless of what the doc writes on the prescription. The old addage is that your Doctor could write a prescription for a Ferrari but it doesn't mean anyone is going to fill it.

4) -Are you saying the DME is not required by law to fill the prescription for an APAP, even if that is what the doctor specified on the prescription?

My father said to me more times then I can count "The road to hell is paved in good intentions".

Though you post in jest that your being delayed and that the 9 months was because you played around with other things I have to ask a few simple questions.

If you where issued on auto-pap from the start and fine tuned your treatment in a few nights or so even say a month like you suggest, and because it reacts to nightly changes in your needed pressures, would it have helped your tiredness?

I know after I got my apap in just 3 days I can feel a difference from my Cpap that is night and day and I was on the cpap for almost a month. My ranges have been from 14-19 cm H20 and the machine answered those needs fast enough for me to have the best sleep I can remember in years. As far as my mental outlook goes I can now look to the future as something other then blank.

Maybe your diet failure and exercise failure wouldn't have happened in the first place? Maybe if you weren't so tired you would have packed lunchs of good food instead of the cheeseburger thing? Maybe you would have had the energy to shop and cook for those lunches? Maybe if you weren't so tired you could have researched a bit and formed a lifestyle diet that works for you instead of the easy fast food stop? I also have to wonder how much easier things would have been for your body with the tumor thing if it was fully rested, at full strength from exercised, and not had those cheeseburgers?. How much better could you have performed at work?

Next point, you say use the least expensive cure ok. Whats more expensive when you DON'T have insurance? pay $3200 for 2 sleep studies pay $1200 for a cpap, pay $300- $500 in hoses, tubes and masks, and pay $40-$75 per doctor visit say like 5 total to get it all setup. Keep in mind this is a normal joe without the aid of this site and https://www.cpap.com.

Then 9 months of feeling tired, physically drained, mentally drained, and trying to eat right, exercise, and get a job. Then figured out its not working and have to buy another machine, lose the investment in the first one, and have to go to the doc yet again 2 or 3 more times?

Or 1 sleep study to get the report $1600, 2 or 3 $40-$75 Doc visits to order study. review, and follow-up, buy 1 Apap or bi-pap if the pressure needed is higher then apap can do $1200 and $300-500 for hoses, tubes, and mask. Then if the Doc knows about https://www.cpap.com and is not motivated by greed tells you to get it there, its even less.

My friend, I think your OSA is effecting your mental outlook and thought processes even more then you know or your trying to justify having people make more visits then they really need, in order to increase profits.

I am glad your job lets you have the time to play with treatment for 9 months to a year and affords you the ability to play with whatever mask and machine setup you like and wait for them. But there are some of us that time and money are not on our side and we need the fastest and BEST solution to our issues.

I have said it before and will bring up the point again I wonder how many people have been put off and have had their quality of life ruined and or more serious issues because of this attitude that people have all the money and time in the world to treat their medical issues, on the part of medical professionals and the systems related to the medical field.

I do believe you wish to help people but your attitude and mis-guided good intentions might seriously hurt someones life and you would never know it.

And although its easy to think I am flaming here but I am not, I am asked hard questions and making strong points in the hopes that they be taken seriously.