Another insurance/DME supplies question.

For those that don't remember, I was put on cpap the summer of 2017 and obtained my first Autoset through Crapria. I had issues becoming compliant within the 90 days, (partially due to Hurricane Irma) and I was warned by Crapria they would start billing me for the next period.

Basically, I got sick of their crapola, as well as the moron I had for a sleep doctor (impossible to get in touch with), and turned my machine in. Not wanting to give up on treatment, I decided to go it alone, and purchased a brand new identical machine from a well known member of this board. I have been using it successfully most of the time since then.

At this point, I have no 'sleep doctor' per se, but my GP is aware I am on cpap on my own, and thinks it's fine that way. Is there a way to get my insurance company to cover my 'supplies only' at this point, or would I need to start all over again with a new lab study by a new sleep doc? I also wonder what would happen when I need a new machine,.....I assume they would not cover a new one since I am not on record as being compliant?

It's actually not any kind of a big thing purchasing my own,....especially since I get WAY more use out of my stuff than a DME recommends. I'm basically just curious since I DO pay for my insurance in full, and feel at times that I should get the benefits as well. I have a 'high end' employer based BCBS policy if that matters. Any info from previous experience is welcome, and appreciated.

I don't have BC/BS, but can you call them and ask? I don't why they wouldn't pay for CPAP supplies. I am sure this situation happens a lot. You might have to see a sleep doctor and prescription though and put this on file with your insurance company. But I wonder if he or she will order a sleep study then? But insurance should help pay for that. I hope someone here who has private insurance comes along and can help.

Mark...You should be able to take a copy of your original sleep study and a current prescription from your PC doctor to any DME in your insurance network.
The prescription stays on file at the DME for future purchases.

I have BC/BS and they cover my supplies. Their customer service in Wyoming is very helpful, try calling yours.

I think you have to get the supplies from a source that will bill your insurance directly. I've been having issues with my current DME. I called another one to ask if I could buy supplies from them and they said yes, I would just need to send a copy of my sleep study and Rx to them.

LSAT wrote: ↑

Sat Aug 11, 2018 3:30 pm

Mark...You should be able to take a copy of your original sleep study and a current prescription from your PC doctor to any DME in your insurance network.
The prescription stays on file at the DME for future purchases.

Unfortunately I never got a copy of the sleep study itself, I only have the original prescription (which gives my AHI) that I believe is written for a 2 year period. You would think getting a study copy would be easy, but the place I was sent to is notorious for not returning phone calls. I would probably be better off requesting them via certified mail.

I'm going to try and call around to some 'small scale' DMEs, and see if they are in my network. I have not run into a doctor or facility yet that isn't, but there's always a first I guess.
Should probably call my insurance company as well, and just ask them how this will be treated since they never confirmed me as being compliant with cpap therapy before I went to self pay.

Ask your insurance co who is in network. Then send them whatever paperwork they need to ship you supplies. Keep it simple.

I would think (you know how that goes) that all a new DME would need would be a rx from the doctor for supplies.

Your primary care doctor should have a form to fill out so they can request your records and/or sleep study for you and the dme. your records are on file and you have a right to get them. When my wife and i switched sleep doctors we had to get ours from a hospital that had been closed and leveled to the ground. no problem.

Mark55 wrote: ↑

Sat Aug 11, 2018 4:36 pm

LSAT wrote: ↑

Sat Aug 11, 2018 3:30 pm

Mark...You should be able to take a copy of your original sleep study and a current prescription from your PC doctor to any DME in your insurance network.
The prescription stays on file at the DME for future purchases.

Unfortunately I never got a copy of the sleep study itself, I only have the original prescription (which gives my AHI) that I believe is written for a 2 year period. You would think getting a study copy would be easy, but the place I was sent to is notorious for not returning phone calls. I would probably be better off requesting them via certified mail.

I'm going to try and call around to some 'small scale' DMEs, and see if they are in my network. I have not run into a doctor or facility yet that isn't, but there's always a first I guess.
Should probably call my insurance company as well, and just ask them how this will be treated since they never confirmed me as being compliant with cpap therapy before I went to self pay.

Aks your doctor if they can request the sleep study results. It sounds like they are supportive, and would probably be able to get a response faster.

Having my GP request my records from the sleep place is a good idea,.....can't believe that didn't cross my mind!

I may give a couple of DMEs a call next week, and see if a scrip is good enough, as PR suggested.

My family has a BCBS "gold" plan offered thru my husbands employment. I won't bore you with the details, but I have been battling with my son's DME (Lincare) since 11/2017 and billing issues have yet to be resolved. After more hours than I care to count talking to DME and insurance representatives, I have learned more than I ever wanted to know about coverage for CPAP supplies. The first thing you need is a pre-authorization for CPAP supplies. Your doctor will likely have to resubmit the prescription and sleep study to a DME (maybe your PCP can do this, if not you may have to find another sleep doctor). After pre-authorization you will likely once again have to prove you are compliant. In my son's case BCBS had the 30 day hours of usage requirement and they also required a follow up with the prescribing doctor within 90 days of starting use of CPAP (the doc has to submit that there is a benefit from CPAP therapy). Also be sure to check what percentage of DME supplies your policy covers (especially if you haven't met your deductible this year).
We live in Colorado policies very by state, so your best bet is to call your insurance and ask them what they require.

One last suggestion, go to wherever you got your sleep study in person and request the report, it has been my experience that an in person visit is less easily blow off than a phone call. You have a right to your medical records.

Good idea--but have plenty of identification with you.

colomom wrote: ↑

Sat Aug 11, 2018 7:57 pm

My family has a BCBS "gold" plan offered thru my husbands employment. I won't bore you with the details, but I have been battling with my son's DME (Lincare) since 11/2017 and billing issues have yet to be resolved. After more hours than I care to count talking to DME and insurance representatives, I have learned more than I ever wanted to know about coverage for CPAP supplies. The first thing you need is a pre-authorization for CPAP supplies. Your doctor will likely have to resubmit the prescription and sleep study to a DME (maybe your PCP can do this, if not you may have to find another sleep doctor). After pre-authorization you will likely once again have to prove you are compliant. In my son's case BCBS had the 30 day hours of usage requirement and they also required a follow up with the prescribing doctor within 90 days of starting use of CPAP (the doc has to submit that there is a benefit from CPAP therapy). Also be sure to check what percentage of DME supplies your policy covers (especially if you haven't met your deductible this year).
We live in Colorado policies very by state, so your best bet is to call your insurance and ask them what they require.

One last suggestion, go to wherever you got your sleep study in person and request the report, it has been my experience that an in person visit is less easily blow off than a phone call. You have a right to your medical records.

I appreciate the story of personal experience. If it's anything like that for me,.....forget it, I'll just buy a new mask once a year, along with a couple pillows, and maybe a hose. Even full price on Cpap.com, the mask I use is less than 90 bucks.

Right now I have 3 spare/new humidifier tanks, couple boxes of filters, 2 spare Brevida masks unopened, a Simplus FFM, a new in the bag Resmed Slimline hose I got for 10 bucks and change on Amazon the other day (not counterfeit). I still have 2 Climateline hoses unused in the bag, and an unused Airstart 10 Cpap machine I bought from our sponsor on sale for 189 bucks for a backup.

After thinking of all the stuff I already have, it seems kind of silly to even go to the trouble of trying to deal with my insurance,....at least for now. Something to think about before starting what could turn into a real pain.

When I worked for county government, our BCBS plan was negotiated by management,
with the goal being low premiums--with little consideration for benefits, deductibles, and copays.
Regardless of the words used to describe your plan, the truth is in the benefits summary.
Every plan is unique--know the details and DO THE MATH.

My suggestion...go ahead and jump through whatever hoops is needed to get cpap masks and accessories covered under your insurance even though right now it's not needed and might not be for some time.

You never know when it might come in handy or you might even do what I have done in the past when I have plenty of spares ...I used the insurance to try a newly released mask so that my out of pocket isn't so much.
Now I know that cpap.com seems to now offer free return insurance on all masks now but sometimes I just don't want to fork out $120 bucks of my own money right now and sometimes I would just rather use my insurance as I never pay anything until after Medicare pays and then I get a bill for my co pay. Usually bides me about 2 to 3 months.