Pugsy wrote: ↑
Wed Aug 02, 2023 12:37 pm
apap is common term but it just means a single pressure that can auto adjust as needed while in use
single fixed pressure machines...won't/can't auto adjust at all while in use
The above lists are all going to qualify as E0601 machines for the HCPCS billing code.
E0601 is simply a single pressure (fixed or auto adjusting) machine that provides cpap therapy
Big difference in retail pricing because of features on each machine...some worth it and some just "fluff".
Some provide efficacy data and some don't.
Doesn't matter to Medicare though....they are going to pay the same amount (allowed) for any of those machines.
Same with other insurance companies that pay by the HCPCS billing code.
DME equipment suppliers like to dispense the cheapest model (in terms of wholesale cost to them) that they can that meets the RX requirements. That way they increase their profit margins. DMEs can legally substitute these "cheaper" machines if they have a mind to and the doctor hasn't specified exactly what he/she wants dispensed.
I had this happen with my very first DME and they wanted to provide a non data producing fixed pressure machine that at the time was the cheapest on the market.....I refused it and their services and bought my own machine privately (paid about my 20% co pay for that first machine and it had zero hours on it and it was an apap and full data).
Then I went to another DME and told them I already had a machine and just wanted masks from them and they were happy to do that. So I fired my first DME without ever getting a damn thing from them except the run around.
If a DME has a contract with Medicare or any other insurance company they will have to write off any difference between their pie in the sky billed amount and what gets actually approved/allowed.
Some DMEs will provide what you want simply by your asking for it....but some won't do it.
That seems utterly bizarre to me, but - it's the government and I guess I shouldn't try to make sense of it. So - to take a couple of examples from the list you gave, selling at cpap.com:
Resmed Airsense 10 Autoset ... $639 'our price' (cpap.com), $1,199 'list price' (or whatever they want to call it).
Resmed Airsense 11 Autoset ... $989 'our price' (cpap.com), $2,253 'list price'.
That's a huge difference in price between the two models!
They both fulfill the same basic 'function' and are both E0601 'class' machines, and ... Medicare will only pay one number for either machine - 80% of ... some unknown number. A quick google search suggests that the 'unknown number' is around $1,100 - taking this as a source that I could quickly find - https://www.superiorhealthplan.com/news ... rsion.html
(it's from 2019, it's specific to Texas, etc etc but - for a ballpark number
, is that about right - Medicare considers the '100%' number for E0601 to be around $1,100? So very roughly, if I go through Medicare, some DME vendor somewhere will get 80% of that number from Medicare ($880) and 20% of that number ($220) from me. And that will hold whether I get the Airsense 10 or the Airsense 11. So of course, as you suggest, they will make a lot more profit by selling me the cheaper model. I can imagine that a DME vendor would simply not bother to carry / offer the Airsense 11, because they make so little money from selling it, so the patient loses out due to lack of choice. However - if the numbers above are roughly accurate, even the Airsense 11 is 'only' around $989 from cpap.com, and that includes cpap.com's markup, so even the Airsense 11 still yields a profit if the DME vendor is getting $1,100! So DME vendors seem to be making a killing if they are getting $1,100 for something that cpap.com is selling for $639.
Further - if I decide to go outside my insurance, I could simply go to cpap.com and buy the models at the prices shown on their site.
I guess the ideal outcome would be - I get my Dr to specifically require an Airsense 11, from the DME vendor, and all I have to pay is $220 for something I'd otherwise have to pay around $989 for.
Is all the above roughly correct, in concept?
Pugsy wrote: ↑
Wed Aug 02, 2023 12:37 pm
It will write to the SD card....the supplier cannot do anything at all to prevent that from happening as long as the SD card is in the slot.
AND...I already provided information on how to get into the clinical menu setup area where you can indeed make any changes you want to change despite them saying you can't. They can't stop you at all and there is no cpap police going around checking. Worse thing to happen...you get your hands slapped and told "don't do that".
OMG - just went online and found the 'big secret' (two buttons ...
). I guess I had in mind something more dramatic like the 'rooting' of an iPhone (which can go wrong, and can be irreversible!), or whatever! And once you exit the 'settings' menu, you are back to the same 'basic' mode, so no residual effect. So - piece of cake. I would still want to be 'respectful' of the settings made by the sleep specialist though, as he offered to make adjustments for me. If I show up back at his clinic after a month, and the results are all over the place (and I never called for changes), I would at least want to explain to him what I changed, so the results are in that context. Anyway - SD card inserted and now I actually have something to look forward to tomorrow, to offset the torture of 'the mask'