New CPAP user, a few questions

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Mon Jul 31, 2023 10:22 pm

Pugsy wrote:
Mon Jul 31, 2023 8:20 pm
Here's some information on how Medicare does things when it comes to cpap equipment.

Medicare approves an allowed amount for whatever equipment and if deductible has been met will pay 80% of the ALLOWED amount. Please note that the allowed amount and the billed amount is usually entirely different.
DMEs/doctors bill out the pie in the sky amount and Medicare reduces that billed amount to the ALLOWED amount and pays from that amount. Your portion (or your secondary supplement insurance portion is 20% of the billed amount.

Medicare actually pays by the HCPCS billing code numbers.
Not by brand name or model name.
Most likely you will be given some sort of regular cpap/apap machine which is the E0601 code.
Doesn't matter the brand or model...Medicare ALLOWS the same amount for fixed cpap or auto adjusting capapable/apap machine. Doctors/DMEs usually choose and usually they want to dispense the brand and model that makes them the most money because remember....Medicare is going to pay the same no matter if it is a compact car or a big old caddy.
Now you can get around them choosing by asking your doctor to write the order for so and so brand and so and so model and then sign it with "dispense as written"...then the DME/supplier can't substitute a "cheaper" machine.
Typically regular Medicare does a 13 month capped rental so the payments are spread out over 13 months and then you own it and no more monthly payments. There are also some compliance usage requirements that have to be met for Medicare to pay....like a face to face with the doctor before the 90 th day of use and a certain minimum number of hours it needs to be used during that 90 day time period. The requirement is 70% of a consecutive 30 day time frame that you use the machine at least 4 hours. So 21 out of 30 days you need to use the machine at least 4 hours.

Be careful with Medicare Advantage plans....they will do the allowed amount as well but a lot of them are going to what we call a perpetual rental thing (not all of them will do it though) where you have to pay the 20% co pay forever and never actually own the machine. Be sure and check the Evidence of Coverage for any Medicare Advantage plan you might be thinking of. You will have to ask for this document....it's not usually part of the sales brochure stuff. I have a Medicare Advantage plan...when I first got it years ago it did the 13 month capped rental thing but a few years ago it changed to perpetual rental.

https://www.sleeprestfully.com/HCPCS/
CPAP/BiLevel Michine HCPCS Codes:

E0601 Continuous airway pressure device (CPAP/APAP)

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
BTW a lot of insurance companies (non medicare) still use the general Medicare equipment allowance schedule and that all use HCPCS billing codes.
I'll need to digest most of this over time, but a quick question is - is it generally worth it trying to work through all this, or should I just ignore the whole 'insurance' thing and go out and buy what I want 'commercially'? I don't tend to meet my deductible each year, and I'm willing/able to pay out of my own pocket if it means getting what I need/want. By way of examples - my partner wears hearing aids. She simply buys the best model available at Costco and doesn't even consider insurance. She said the models that insurance is willing to assist with are not good enough. Another example - I needed an MRI not long ago. 'Insurance rates' for various MRI's were circa $2,000 at the 'insurance billed' rate (which wouldn't get covered since I hadn't met my deductible). I called around and got 'cash prices' for MRIs that were in the $500 range. So I simply got my MRI 'commercially' and paid cash. Money spent did not contribute towards my deductible but I didn't care. So - for a CPAP machine - can I potentially buy a good machine at a 'cash price' (no insurance) that is significantly lower than the 'list price'/'book' price that the 'insurance' route would involve? Obviously, getting '80% paid' sounds attractive, but if it's 80% of an inflated price, and/or limited to only basic machines, should I just 'go outside' the system? And - "Can" I go outside the system, or am I forced to work within the 'system'?
==========================
Pugsy wrote:
Mon Jul 31, 2023 8:20 pm
Steerpike58 wrote:
Mon Jul 31, 2023 7:47 pm
I was assuming the full-face mask was there mainly for those who couldn't keep their mouths closed from a 'pressure' perspective,
No, full face masks are for people who can't breathe just through their nose and keep their mouths shut.
Has nothing to do with the pressures at all.
Mouth opening breathing can allow the air pressure to escape out the mouth and fail to proceed down the airway and this can cause sub optimal therapy because adequate pressure isn't maintained.

You might be able to "train" yourself to keep the mouth shut but only if you can get comfortable just breathing through your nose all night. It's not so easy though but it can be done or at least limited to very minor mouth breathing with a nasal mask and not a full face mask.
In my case, I seemed to have no problem using the 'nasal mask' - I was able to keep my mouth closed all the time - apparently! But - what I'm getting at is - since I'm experiencing 'nose blockage' problems, I guess I could switch to a full face mask and then try to train myself to OPEN my mouth (not keep it closed, which I'm already comfortable doing). It's the opposite of what I was thinking, but perhaps a way I should proceed given my nose issues. Hopefully I'm making myself clear!

GrumpyHere
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Re: New CPAP user, a few questions

Post by GrumpyHere » Tue Aug 01, 2023 1:43 am

Steerpike58 wrote:
Mon Jul 31, 2023 7:47 pm
Is this pretty typical or do some machines also analyze the condition? If so, can you give me just one sample machine to read further on?
There aren’t any CPAP machines that analyze untreated condition. Any pressure is treatment so they can only provide info on treated condition.
I've been reading here that there are various elements to the problem - central apneas, regular apneas, hypopneas, etc. Will my sleep specialst be able to see which of these (how many) I'm experiencing with the ResMed Airsense 10 Autoset? If not, how will my condition be diagnosed if all I started with was a WatchPAT session and a composite AHI of 30.3?
The WatchPAT has already diagnosed you with sleep apnea.
Your sleep specialist will likely only care about treatment compliance and the treated AHI.
Their standard will likely be pretty low: 4 hours of use per night and AHI below 5.
Forum members recommend at least 7 hours of sleep and treated AHI below 2.

The composite AHI of 30.3 doesn’t tell us much.
The forum experts need more info.
Please scan and redact personal info from your WatchPAT test report and post it for additional analysis.
Please use offsite image hosting because the site is out of storage space.

Low levels of centrals aren’t considered harmful so don’t be too worried.
If you have low level of centrals, you may be adequately treated with lower priced machines (AirSense 10/11 AutoSet ~$700/1k cash price).
High levels of centrals may respond to bi-level CPAP machines (AirCurve VAuto ~$2k) or require even more specialized ASV bi-levels (~$3-4k)
There are frequently low hour machines put up for sale by forum members (LSAT has good reputation. palerider has ASVs available.)

The AutoSet can identify and react to obstructive apneas, hypopneas, flow limitations, snores.
It can identify centrals but its algorithms doesn’t react to them except by recording them.
You need to use the OSCAR software along with the data recorded on the SD card inserted into the CPAP to optimize your treatment.
I found both masks I was given (F&P Vitera for 'full face' (referred to as 'Simplus' in paperwork), and 'ResMed Airfit N20' for nasal mask) to be surprisingly comfortable, from a pure 'fit' perspective. I did notice that, with the full face Vitera, at high pressures, there was a constant 'whistle'/'whine' with air escaping around the seal, no matter what I did with the straps (but that could be an excessive pressure thing). (I generally have smooth skin, no beard). Neither mask did well with my 'breathRite' strips, but that seems somewhat understandable.
Great that you’re happy with them.

If the whistle/whine disrupt your sleep, then mask liners might help you.
They don’t necessarily stop the leaks but may muffle the noise down to acceptable levels.
Pad a Cheek ones are highly rated.

Code: Select all

 https://www.padacheek.com/
I guess I could switch to a full face mask and then try to train myself to OPEN my mouth (not keep it closed, which I'm already comfortable doing)
BTW nasal breathing is healthier.

Code: Select all

https://pubmed.ncbi.nlm.nih.gov/8971255/#:~:text=Abstract,inspiration%2C%20especially%20during%20nasal%20breathing.
The vasodilator gas nitric oxide (NO) is produced in the paranasal sinuses and is excreted continuously into the nasal airways of humans. This NO will normally reach the lungs with inspiration, especially during nasal breathing.
ResMed Lumis Tx - VAuto mode

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ChicagoGranny
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Re: New CPAP user, a few questions

Post by ChicagoGranny » Tue Aug 01, 2023 5:30 am

Steerpike58 wrote:
Mon Jul 31, 2023 10:22 pm
try to train myself to OPEN my mouth (not keep it closed, which I'm already comfortable doing).
No, no, no. Mouth-breathing is unhealthy. GrumpyHere mentions one of the reasons. Your mouth can also get very dry from mouth-breathing. This can lead to very bad oral health. Many people here train very hard to exclusively breathe exclusively through the nose. I use a FFM but I train to keep my mouth closed all night. Should it inadvertently open, the FFM will ensure the CPAP therapy is still effective.

As far as insurance, your MRI example shows you have experience maneuvering through the insurance morass. I recommend you do it. Self-pay should be a last resort. On the other hand, the funds seem to be no problem for you. If there are delays in getting insurance to act, you could buy self-pay. If you are like most of us, you are going to want a backup machine. You can never know when a machine, even a new machine, will fail just as you get in bed.

Before you take delivery of any machine, run it through this thread for comments. Currently, the only machines I would recommend are the ResMed AirSense 10 or 11 AutoSets.

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Pugsy
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Re: New CPAP user, a few questions

Post by Pugsy » Tue Aug 01, 2023 5:59 am

Steerpike58 wrote:
Mon Jul 31, 2023 10:22 pm
a quick question is - is it generally worth it trying to work through all this, or should I just ignore the whole 'insurance' thing and go out and buy what I want 'commercially'? I don't tend to meet my deductible each year, and I'm willing/able to pay out of my own pocket if it means getting what I need/want.
I guess it all depends on what is most important to someone.
I have been on cpap since 2009 and on Medicare that whole time...yet I have never used my insurance to buy me a machine.
I have always just bought my own machine and usually private purchase. For me the first machine was a wash in cost anyway. Meaning my out of pocket cost for my first machine was about what my 20% copay would have added up to over that 13 month capped rental. BTW I have bought several machines over the years this way and now that my Medicare Advantage plan has gone to perpetual rental I will continue doing what I have been doing for years and just not expect my insurance to provide a machine. I usually buy privately and slightly used machines at a discounted price. I accept the fact that I probably won't have any warranty if I run into problems and will be on my own if the machine breaks but I have never had that happen....yet.

For myself...buying privately eliminated the "hassle factor" meant I got what I wanted when I wanted it and without big brother being involved in any of it. That "hassle factor" has been fairly important to me but it may not be so important to someone else.

Since you aren't on Medicare as of yet and have private insurance with a high deductible you have to do the math and figure out how important the "hassle factor" is going to be to yourself.
I suggest that you first wait to see what is offered by your insurance in terms of equipment and costs to you so that you can make the best decision for yourself. They will be prescribing something based on the data that this week long trial shows them.

Is your Kaiser plan an HMO plan or PPO plan or something else? If Kaiser is the equipment supplier they may offer a very good machine at a very good price point. Check out your options so you can best figure out what you are most comfortable with doing.

As far as nasal mask vs full face masks....Start out using what is most comfortable for you and what allows you to sleep the easiest and the best. Without sleep none of this stuff matters much.
You know you can always change mask types later....don't have to get it perfect right off the bat and in fact most people don't anyway. Start with nasal mask first and depending on just how much the nasal congestion impacts the actual therapy itself then we decide if a change is needed or not.
Having a humidifier working with your machine may or may not help relieve the congestion...worth trying for sure.
Maybe with added moisture your nasal congestion gets reduced and take the need for a full face mask out of the equation.
Plus a lot of people have both kinds of masks available just in case something happens like they get a bad cold and simply can't breathe through their nose so they bring out the full face mask for the time they are ill.

Whatever Kaiser offers...don't accept a Phillips Respironics machine. Several reasons for that statement that I don't have time to go into at this time.

Assuming you won't need anything special in terms of therapy like treatment for centrals or needing much higher pressures....you probably will be needing a machine like your trial machine AirSense 10 AutoSet or the AirSense 11 AutoSet version. Lets see what is prescribed first.

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Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Tue Aug 01, 2023 11:23 pm

GrumpyHere wrote:
Tue Aug 01, 2023 1:43 am

The WatchPAT has already diagnosed you with sleep apnea.
Your sleep specialist will likely only care about treatment compliance and the treated AHI.
Their standard will likely be pretty low: 4 hours of use per night and AHI below 5.
Forum members recommend at least 7 hours of sleep and treated AHI below 2.

The composite AHI of 30.3 doesn’t tell us much.
The forum experts need more info.
Please scan and redact personal info from your WatchPAT test report and post it for additional analysis.
Please use offsite image hosting because the site is out of storage space.
Here's the watchPAT report from June - https://i.imgur.com/Mk11Hkm.jpg
And here's the ResMed report from this past week - https://i.imgur.com/qKQf68Q.jpg
GrumpyHere wrote:
Tue Aug 01, 2023 1:43 am

Low levels of centrals aren’t considered harmful so don’t be too worried.
If you have low level of centrals, you may be adequately treated with lower priced machines (AirSense 10/11 AutoSet ~$700/1k cash price).
High levels of centrals may respond to bi-level CPAP machines (AirCurve VAuto ~$2k) or require even more specialized ASV bi-levels (~$3-4k)
There are frequently low hour machines put up for sale by forum members (LSAT has good reputation. palerider has ASVs available.)
Seems like my initial AHI of 30.3 from the WatchPAT has now dropped to 11.9, made up of 11.1 AI and 0.8 HI. So I guess that's progress!
Also, I see 'Centrals' are at 8.2, 'Obstructives' at 2.7. Shouldn't these two numbers add up to 11.1? I guess this constitutes "high levels of centrals' ...
GrumpyHere wrote:
Tue Aug 01, 2023 1:43 am
The AutoSet can identify and react to obstructive apneas, hypopneas, flow limitations, snores.
It can identify centrals but its algorithms doesn’t react to them except by recording them.
You need to use the OSCAR software along with the data recorded on the SD card inserted into the CPAP to optimize your treatment.
Based on these results and our first review meeting, the sleep specialist gave me the humidifier attachment for the device, and removed the 'ramp up' altogether. He reduced maximum pressure from 20 to 15, and removed the EHR setting. Min pressure remains at 5. I got the machine back for another 30 days, and he explained how I can reach him in order to make changes should I need them.

Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Tue Aug 01, 2023 11:31 pm

ChicagoGranny wrote:
Tue Aug 01, 2023 5:30 am
Steerpike58 wrote:
Mon Jul 31, 2023 10:22 pm
try to train myself to OPEN my mouth (not keep it closed, which I'm already comfortable doing).
No, no, no. Mouth-breathing is unhealthy. GrumpyHere mentions one of the reasons. Your mouth can also get very dry from mouth-breathing. This can lead to very bad oral health. Many people here train very hard to exclusively breathe exclusively through the nose. I use a FFM but I train to keep my mouth closed all night. Should it inadvertently open, the FFM will ensure the CPAP therapy is still effective.

As far as insurance, your MRI example shows you have experience maneuvering through the insurance morass. I recommend you do it. Self-pay should be a last resort. On the other hand, the funds seem to be no problem for you. If there are delays in getting insurance to act, you could buy self-pay. If you are like most of us, you are going to want a backup machine. You can never know when a machine, even a new machine, will fail just as you get in bed.

Before you take delivery of any machine, run it through this thread for comments. Currently, the only machines I would recommend are the ResMed AirSense 10 or 11 AutoSets.
OK, so mouth breathing is NOT a good thing to pursue, so I really need to find out why my nose is constantly partially blocked at night (as I mentioned earlier, I don't currently have a cold, nor any allergies, and yet at night, one nostril or the other is typically 90% blocked. Also, FWIW, when I get up in the morning, and spend my first hour or so peacefully drinking coffee (decaf ... ), I'm blowing my nose constantly and after an hour, my nose feels pretty clear (this has been going on for years; it's just that the CPAP machine is making it more noticeable). The sleep specialist suggested I pursue this with my PCP. I'll see if I can get a referral to an ENT.

I just mentioned in another post, I got the humidifier attachment and get to keep the device for 30 days, so plenty of additional time to explore. Sounds like you prefer the AirSense devices, and that's what I currently have (10).

Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Tue Aug 01, 2023 11:41 pm

Pugsy wrote:
Tue Aug 01, 2023 5:59 am
...
I guess it all depends on what is most important to someone.
I have been on cpap since 2009 and on Medicare that whole time...yet I have never used my insurance to buy me a machine.
I have always just bought my own machine and usually private purchase. For me the first machine was a wash in cost anyway. Meaning my out of pocket cost for my first machine was about what my 20% copay would have added up to over that 13 month capped rental. BTW I have bought several machines over the years this way and now that my Medicare Advantage plan has gone to perpetual rental I will continue doing what I have been doing for years and just not expect my insurance to provide a machine. I usually buy privately and slightly used machines at a discounted price. I accept the fact that I probably won't have any warranty if I run into problems and will be on my own if the machine breaks but I have never had that happen....yet.

For myself...buying privately eliminated the "hassle factor" meant I got what I wanted when I wanted it and without big brother being involved in any of it. That "hassle factor" has been fairly important to me but it may not be so important to someone else.

Since you aren't on Medicare as of yet and have private insurance with a high deductible you have to do the math and figure out how important the "hassle factor" is going to be to yourself.
I suggest that you first wait to see what is offered by your insurance in terms of equipment and costs to you so that you can make the best decision for yourself. They will be prescribing something based on the data that this week long trial shows them.

Is your Kaiser plan an HMO plan or PPO plan or something else? If Kaiser is the equipment supplier they may offer a very good machine at a very good price point. Check out your options so you can best figure out what you are most comfortable with doing.
All good info, thanks! As I just mentioned in another post, I got the device for another 30 days plus the humidifier attachment, so I get to play for another month. By the time that's over, and taking into account a few vacation plans, I'll be on Medicare by the time I'm ready to buy anyway. My Kaiser plan is a crappy HMO through the 'exchanges' and currently has no provision whatsoever for DME (with a $1,200/mo premium and something like $8k max out of pocket! - pretty unbelievable, really! (I do get a subsidy on those rates, thankfully)). I'm going to be saving so much by getting on Medicare I won't mind forking out a few grand on a machine, if needed.

Regarding "I usually buy privately and slightly used machines at a discounted price." ... are you comfortable elaborating, or is your source unique to you?

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Re: New CPAP user, a few questions

Post by Steerpike58 » Wed Aug 02, 2023 12:45 am

SleepGeek wrote:
Mon Jul 31, 2023 8:26 pm
...
Medicare, like any insurance or MA plan, has negotiated prices they will pay regardless what kind of price the biller sends. They pay by billing codes and not make or model. So they pay 80% of the negotiated price. Check your previous insurance bills or partners MA plan.
I've led a somewhat charmed life so far, hardly using my medical insurance and never needing anything considered Durable Medical Equipment.

I totally understand that insurance will only pay according to their negotiated 'rates'. What I DON'T understand is, what does the Vender of the DME 'get paid' (and thus what do I actually pay)?

To use an example, let's say there are three models - A, B, and C, all of which perform the same basic set of minimum functions (plus extra features not deemed essential by Medicare). Medicare has determined that the 'negotiated price' for any model of that category is $1,000, and thus, they will pay $800 towards such a model. But the vendor has set a retail or 'sticker' price for A at $1,100, and for B at $1,200, and for C at $1,300. If I prefer model C for whatever reason, do I take the $800 from Medicare and then add $500, and buy Model C? Assuming this is true, can I ask the vendor for a 'cash price', and get a lower price somehow, bypassing Medicare altogether? Hope that makes sense!

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Re: New CPAP user, a few questions

Post by Respirator99 » Wed Aug 02, 2023 2:28 am

Also, I see 'Centrals' are at 8.2, 'Obstructives' at 2.7. Shouldn't these two numbers add up to 11.1? I guess this constitutes "high levels of centrals' ...
The level of centrals is high enough that you should do something about it. Your WatchPAT report doesn't seem to discriminate between central and obstructive apnea, if I'm reading it correctly, so we don't really know what the pre-treatment breakdown was. One thing you might try is to turn EPR off - that often reduces central apnea. Or to put it another way, EPR can cause central apnea in a proportion of susceptible users.

Your AHI is your Apnea Hypopnea Index, which is given by Obstructive apnea index + Central apnea index + Unclassified apnea index + Hypopnea index. From your report, this is 8.2 + 2.7 + ?? + 0.8. The total is 11.9, which means the unclassified apneas (the ?? in the equation) must be 0.2. Unclassified apneas occur when the machine can't determine if it's obstructive or central. This usually occurs if there is a large leak, but your leak numbers look OK. So don't worry about it.
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Re: New CPAP user, a few questions

Post by ozij » Wed Aug 02, 2023 4:29 am

Respirator99 wrote:
Wed Aug 02, 2023 2:28 am
Also, I see 'Centrals' are at 8.2, 'Obstructives' at 2.7. Shouldn't these two numbers add up to 11.1? I guess this constitutes "high levels of centrals' ...
The level of centrals is high enough that you should do something about it.
Well.... if those CA's happen when you're falling asleep, or waking up, the don't mean much.
When the events happen can be seen on OSCAR charts.

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Pugsy
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Re: New CPAP user, a few questions

Post by Pugsy » Wed Aug 02, 2023 6:10 am

Steerpike58 wrote:
Tue Aug 01, 2023 11:41 pm
Regarding "I usually buy privately and slightly used machines at a discounted price." ... are you comfortable elaborating, or is your source unique to you?
Most of the time I have used forum member LSAT who dabbles in reselling of these machines.
I have used other members as well. My last machine was an AirCurve 10 VAuto that I got from someone here (not LSAT this time) and I paid 350 for it with less than 100 hours on it.
Steerpike58 wrote:
Wed Aug 02, 2023 12:45 am
I totally understand that insurance will only pay according to their negotiated 'rates'. What I DON'T understand is, what does the Vender of the DME 'get paid' (and thus what do I actually pay)?

To use an example, let's say there are three models - A, B, and C, all of which perform the same basic set of minimum functions (plus extra features not deemed essential by Medicare). Medicare has determined that the 'negotiated price' for any model of that category is $1,000, and thus, they will pay $800 towards such a model. But the vendor has set a retail or 'sticker' price for A at $1,100, and for B at $1,200, and for C at $1,300. If I prefer model C for whatever reason, do I take the $800 from Medicare and then add $500, and buy Model C? Assuming this is true, can I ask the vendor for a 'cash price', and get a lower price somehow, bypassing Medicare altogether? Hope that makes sense!
Great idea but it doesn't work that way when it comes to Medicare. Medicare will want you to use the machine that they paid for and that's where the compliance usage report comes into play and the report is tied to a specific serial number on the machine.

How much Medicare will pay for the machine (assuming E0601 cpap/apap model and not the higher end model) will depend on where someone lives. There's not a lot of difference in the allowed amount but there is a difference. I am betting what Medicare allows for the machine in your area is going to be more than what it allows for the machine here in southern Missouri where I live. There is a document that will tell a person how much is allowed but it isn't so easy to go digging through to get the amounts allowed. I have a link somewhere for that fee schedule but it may take some time to find it.

Also Medicare (the government) doesn't really like it when DMEs have dual fee schedules...one with the higher price for Medicare patients and a "cash" price that is less than what the government will allow.

If you want a specific brand and model.....have the doctor write for it specifically and "dispense as written" on the order.

Figure out what type of Medicare insurance you are going to be using....regular Medicare or one of the Advantage plans.
If you want to be going the Advantage route then you have to make sure what their policy is for cpap machines....13 month capped rental or perpetual rental.

With Medicare the "allowed" amount total is divided into 13 month with the first month having the biggest chunk owed because that first one includes the humidifier portion of the machine as a separate purchase. The humidifier portion of the fees is a one time purchase even if the humidifier is built in to the device like it is with the AirSense/AirCurve ResMed models. In the past humidifiers weren't considered something that could be returned if someone decided to abandon cpap therapy and return the main device to the supplier.
So after the first month's worth of copays when using Medicare....those remaining months are the machine only.
No humidifier costs or masks are included. First month is the biggest in terms of co pays....
Masks, hoses, etc....not returnable and paid in full that first month.
Humidifier...not returnable and paid in full with the first months billing.
Machine/blower itself...that is what is part of the 13 month capped rental (regular Medicare) or whatever the Advantage plan might be doing with the machine.

Advantage plans will typically be using the "allowed amounts" as a basis for their fee schedule.
Those Advantage plans don't always mirror what regular Medicare does in general though....like the perpetual rental thing.

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Miss Emerita
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Re: New CPAP user, a few questions

Post by Miss Emerita » Wed Aug 02, 2023 11:23 am

With a little luck, your CAs will diminish now that the EPR is off. Let us know about that, would you?

As others have pointed out, if the CAs persist, it'll be important to understand more about them, and the best way to do that is to use the Oscar software. If you have a laptop or desktop, you're in business. You'll need an SD card in your machine and a way for the computer to read the card. If the computer doesn't have a slot, you can buy an SD card reader for cheap and plug it into a USB port.

Some noses want more humidity, and some want less, so be ready to try out a variety of humidity settings.
Oscar software is available at https://www.sleepfiles.com/OSCAR/

Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Wed Aug 02, 2023 12:10 pm

Pugsy wrote:
Wed Aug 02, 2023 6:10 am
...
Steerpike58 wrote:
Wed Aug 02, 2023 12:45 am
I totally understand that insurance will only pay according to their negotiated 'rates'. What I DON'T understand is, what does the Vender of the DME 'get paid' (and thus what do I actually pay)?

To use an example, let's say there are three models - A, B, and C, all of which perform the same basic set of minimum functions (plus extra features not deemed essential by Medicare). Medicare has determined that the 'negotiated price' for any model of that category is $1,000, and thus, they will pay $800 towards such a model. But the vendor has set a retail or 'sticker' price for A at $1,100, and for B at $1,200, and for C at $1,300. If I prefer model C for whatever reason, do I take the $800 from Medicare and then add $500, and buy Model C? Assuming this is true, can I ask the vendor for a 'cash price', and get a lower price somehow, bypassing Medicare altogether? Hope that makes sense!
Great idea but it doesn't work that way when it comes to Medicare. Medicare will want you to use the machine that they paid for and that's where the compliance usage report comes into play and the report is tied to a specific serial number on the machine.

How much Medicare will pay for the machine (assuming E0601 cpap/apap model and not the higher end model) will depend on where someone lives. There's not a lot of difference in the allowed amount but there is a difference. I am betting what Medicare allows for the machine in your area is going to be more than what it allows for the machine here in southern Missouri where I live. There is a document that will tell a person how much is allowed but it isn't so easy to go digging through to get the amounts allowed. I have a link somewhere for that fee schedule but it may take some time to find it.

Also Medicare (the government) doesn't really like it when DMEs have dual fee schedules...one with the higher price for Medicare patients and a "cash" price that is less than what the government will allow.

If you want a specific brand and model.....have the doctor write for it specifically and "dispense as written" on the order.
Again, thanks everyone for the great info! It is much appreciated.

User 'SleepGeek' mentioned above "Medicare, like any insurance or MA plan, has negotiated prices they will pay regardless what kind of price the biller sends. They pay by billing codes and not make or model. So they pay 80% of the negotiated price". Based on what you are saying above, this all suggests that the vendors in this market are 'regulated' in terms of their pricing. So on the one hand, Medicare is paying according to a billing code, not a make/model. Presumably only one 'billing code' for one 'machine category' (sounds like "E0601 cpap/apap"). But going back to my 'example' above, we have make/models A, B, and C, each of which 'does the job' or 'meets the criteria' for the Medicare category/code. I presume it's normal and allowed that A, B, C have different prices - vendors presumably make product choices in terms of features, materials, R&D and charge accordingly - they don't fix their product prices at the 100% Medicare amount. So since all three - A, B, C - meet the requirements, if I get my doctor to write 'dispense as written' for make/model C (the most expensive), I presume Medicare is just going to pay for the 80% of the 'nominal 100%' amount (the amount they've established for the 'category') and I pay the difference between that and the 'approved retail amount'.

Steerpike58
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Re: New CPAP user, a few questions

Post by Steerpike58 » Wed Aug 02, 2023 12:29 pm

Miss Emerita wrote:
Wed Aug 02, 2023 11:23 am
With a little luck, your CAs will diminish now that the EPR is off. Let us know about that, would you?

As others have pointed out, if the CAs persist, it'll be important to understand more about them, and the best way to do that is to use the Oscar software. If you have a laptop or desktop, you're in business. You'll need an SD card in your machine and a way for the computer to read the card. If the computer doesn't have a slot, you can buy an SD card reader for cheap and plug it into a USB port.

Some noses want more humidity, and some want less, so be ready to try out a variety of humidity settings.
I'm a retired IT geek/nerd, so relish the idea of getting reports, etc! I've just been researching OSCAR (Open Source CPAP Analysis Reporter). I see my CPAP machine has an SD card slot and I have SD cards and readers. What I'm not sure about is if that 'feature' is enabled (writing data to the SD card). Currently, the machine is a loaner from Kaiser, and they won't give me control (I asked, and they said no). Now, it sounds like I could probably figure out how to break in (just use codes from the internet, etc) but ... I'm not sure how the sleep center folks would feel about that so for now, I'm hesitant to do that. Regardless, I will plug in an SD card today and see what I find on the card the next day. I presume there's no way to recover prior day's information, prior to insertion of the SD card (no internal storage to pull from, etc).

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ChicagoGranny
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Re: New CPAP user, a few questions

Post by ChicagoGranny » Wed Aug 02, 2023 12:31 pm

Steerpike58 wrote:
Wed Aug 02, 2023 12:10 pm
I presume Medicare is just going to pay for the 80% of the 'nominal 100%' amount (the amount they've established for the 'category') and I pay the difference between that and the 'approved retail amount'.
I'm not 100% sure what you mean.
Balance billing occurs when the doctor (or DME) sends the patient a bill for more than the normal deductible and coinsurance out-of-pocket costs, and is essentially trying to recoup the portion of the bill written off by Medicare. If your doctor is a participating provider with Original Medicare, balance billing is forbidden.
By way of example, let's say your doctor prescribes the most expensive CPAP machine in E0601. Let's say the supplier's cash price is $1000 and the Medicare allow amount is $700. The supplier bill Medicare $1000. Medicare pays the supplier 80% of $700 which is $560. You owe the supplier 20% of $700 which is $140.

The supplier cannot demand that you pay 20% of $1000 which is $200. This would be balance billing which is prohibited by Medicare.