Saw the sleep Dr. for the first time today...

Ok here is the usual way that it works.

The DME can code an auto cpap using the cpap code (as it is a cpap) E0601. They can also choose to use some misc. code (I don't recall it) if they want to make a fuss.

They get reimbursed one rate for E0601 no matter what brand and what level of bells and whistles. The reimbursement is based on contract between the insurance and the DME. They all vary. I think it hovers around $1500 plus or minus (machine and heated humidifier) of which you pay some copay and possibly a deductable.

Obviously the more expensive the cpap, the less profit for the DME.

An insurance company may cover anything the doc orders, but also may have clauses restricting coverage to basic machines, data collecting cpaps or whatever else their heart desires.

If the Insurance won't cover what you want, you may be able to get the DME to give it to you and code E0601 and chances are insurance won' t reject it on the title of the machine if the code is right.

If the Insurance won't cover what you want and the DME is being stubborn you are toast.

You can always appeal the insurance company decision. I went 3 levels and lost all appeals (finally got the DME to code E0602 for Apap and it went through). My insurance said APAP is deluxe and not covered, not even to the extent a cpap would be (in other words I could not even kick in additional money and upgrade, I would get nothing for APAP). Some people have policies that allow this but you have to be careful of the final out of pocket cost. My insurance has their own doctors who review the appeal (you never meet them) and they decide all on their own what you need and that is that.

SO the bottom line is to determine how much your insurance coverage is really picking up. Total out of pocket copay and deductable if any. Compare that to cash online price. See if it is worth the fight. Probably is for a 20% copay and your deductable already met, but 50% copay even with deductable met is probably a wash or even more expensive to you to use your "benefits".

Each contract is different. You have to research the best you can (given no one wants to give you any decent information) and run the numbers.

Some people have been successful at getting online cash machines and billing their insurance co. Even with out of plan rates this can be a decent way to go if you can get the insurance co to pay you back.

Many times it is difficult to get the machine swapped if you leave the DME with one and sign on the dotted line. My advice is get what you want the first time. Sometimes people can get upgraded by having "Issues" with the straight CPAP machine and can get it swapped. But you never know that this will work when you walk out with that machine that you really dont want.
I think it is best to get it right the first time if at all possible.

Never trust DME interpretation of YOUR insurance benefits. Call them yourself. And call a couple DMEs on your insurance companies in plan network, they are not all the same.

Heated humidifer and mask you will own when you walk out the DME door. Machine most likely is a 3 or 6 month rental pending compliance (use for 3 months 4 hrs per night min almost all nights). So even if you end up with a machine you don't want, you own the mask and tube and humidifier, so it will be cheaper to buy cash online if you decide to give the DME rental back and buy cash. Integrated humidifiers are somewhat compatable between models within a brand, there are some stand alone humidifiers that you can hook up to anything. So if you "rent" and decide to return, the brand you buy is actually important as you have an accessory that can be used with another machine.

Good luck.

More questions, just ask Great to see people doing research BEFORE walking out with a machine.

As stated, you can call another DME to ask if they would balk at getting an Auto for you. And/or, you can tell your original DME that if they can't/won't help you, that you will go find one that will.

Also, if your prescribed pressure is very low, you probably would be fine with straight Cpap anyway. Just make sure you get one that has software capabilities -- like an M Series Pro.

Thank you! I'm going to call them at 9p...I'll report back!

I found that it paid to do my homework before I called the DME, so I woudn't call them until I had a better picture of the factors.

Call the insurance company and ask about coverage and limitations first.

Call some other DMEs and ask about what they will cover. Don't forget to contact online places, like cpap.com and billmyinsurance.com since they are also an option. BillMyInsurance.com gave me the whole story and I would have gone with them had I known I could go to a local hospital sleep lab for my mask fittings, because that's the only reason I went with my local DME. But the mask fittings were important and I didn't know there was another option for them. Not all places have this service, though.

I was able to get an auto machine. However, if your insurance won't pay for an auto machine, getting a FULLY data capable machine (not just compliance data) is likely to be fine, too.

Even after I had all this info, and had talked to them, they tried to get my doctor to switch the script by calling the doctor directly and telling the office person to scratch the word "auto" from the script.

I spoke to the nice person who was very agreeable on the phone, but the person calling the shots was a different story. Kind of a "good cop, bad cop" routine, if you ask me.

This DME is reported to be the best in the area. That means the others are even worse .

Another note: I found this very upsetting at the time. I was tired, tired, tired, and not thinking clearly. Plus, I think that there is an expectation that a person's health comes first and that people won't lie and give substandard equipment. Now, I know in my brain this isn't true, but emotionally it feels bad and I felt vulnerable. But with what I'd read hear and the support of some of the fine folks here, it helped.

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CPAPopedia Keywords Contained In This Post (Click For Definition): DME, auto

Please keep us updated on how it is going. Good for all of us to know and other newbie's too.

RosemaryB...you hit the nail on the head...all of your thoughts, being frustrated and OH SO TIRED, feeling like people should be concerned about my healthy first (yeah right!)...totally how I'm feeling right now!!

So...called DME #1, the person I need wasn't in, wouldn't be in until 11am. No one else can help me. So I called the insurance co...no one but me has called them about an approval for an APAP...so I KNOW they didn't spend all day yesterday 'working' on it. So I called DME #2, also recommended to me. And they work regularly with my sleep lab. They say they don't have it in stock but are happy to get it for me, blah, blah. Won't have an answer from them until Monday as the resp person won't be in the office this afternoon. I do know that they DID call the sleep lab to get my Rx and results since the lab called to verify that it was ok to send them. And the lab was quick about faxing before so I hope they will be again. Then DME #1 guy called while I was on lunch, just reached him a few minutes ago. He said that he can get me a machine, but not one with all the 'bells and whistles that I want'...I was TICKED at that point so I asked him if he's ever had to sleep with a damned mask on blowing air into his face. He said no. So I told him that until he is in my shoes I will damn well decide what is necessary for me and what is a 'bell and whistle'. At that point he did at least give me a little more info. He claims my insurance allowable amount for CPAP is $817. That his cost for the Respironics APAP ('tank' not M series) is $900. And that he would retail it for $1400. He also said he'd give me a $100 break and get it for me if I paid him $400 on top of what he'll get from insurance. HAHAHA. He also said he could give me a Puritan Bennett APAP with C-flex if I wanted that. Does Puritan Bennett make an APAP with C-flex??? I only see Bilevel machines on their website...although they do have an auto one. And also, how does CPAP.com sell the Resp M series APAP with the HH for less than $700 if their cost is $900? Something isn't right here. I told him to put a hold on everything until Monday...I want to wait and see what the other DME says. They have awakened the 'non sleeping' bear in me...so to speak...and I swear I'm getting the damn Respironics APAP that I want!!!!!

OK, rant over. Just wanted to fill you all in...so definitely no machine for me this weekend...which really bites and reduced me to tears for the better part of my lunch break. My husband is leaving Wednesday for a motorcycle trip...I'll be alone with the baby and was praying I'd get some relief before then. Now I'm not sure that will happen. So I'm hedging my bets and getting family/friends to come over every night and give me a hand. After work hours, especially Fridays, are my hardest time.

Will keep you all posted!

Well, hang in there. I know it's frustrating. But aren't you glad you have all this info prior to getting a crappy machine?

Sounds like your DME #1 should be a cattle rancher -- and deal in BS all day. I think you need to "steer" clear of him (pun intended).

And it's always nice to have family and friends as a support group. They not only can help you, but help themselves as well. A win-win situation.

Good Luck.

What is your deductible? You should compare what your out of pocket would be to the prices online. From what I have read here it can end up being cheaper to buy online. Also, if you purchase online you can buy it (APAP) with just a prescription for a CPAP. Check also the billmyinsurance aspect of our hosts site. They may be able to run it through your insurance. Good luck.

As far as I know, the only machines that actually have c-flex are those made by respironics (the owner of the name and likely the patent for the technology). Resmed has EPR (I think). You should ask the DME to prove to you that a PB machine has c-flex or something like it. Have him show you the literature that says it does.

TM

There is no copay, no deductible for me. My insurance pays 100% of the allowed amount as long as I use a DME on their list. (And it's a long list, lots of choices.)

My knowledge of the machines isn't great but I didn't think anyone else had c-flex either. Resmed's is called EPR (or something like that) but it doesn't work in Auto mode, only in CPAP mode. Respironics C-flex DOES work in Auto mode. Or at least that's how I understand it. I have no idea about PB. I'm not even going to bother researching it, hopefully DME #2 will come through!

I have to use Apria for my DME. They said they do not give out apaps, no way no how. I fought and fought and guess what? I got the apap. So keep up the good work! Just let them know you will give your business to the DME that gives you what you want! You're doing great! You've got your facts ready and aren't afraid to stick up for yourself! Keep up the good work, it will be worth it in the end!

Brenda

BrensTiredMom wrote:My knowledge of the machines isn't great but I didn't think anyone else had c-flex either. Resmed's is called EPR (or something like that) but it doesn't work in Auto mode, only in CPAP mode. Respironics C-flex DOES work in Auto mode. Or at least that's how I understand it. I have no idea about PB.

You've got it right.

Respironics' C-Flex is exhalation pressure relief that can be used in both modes: cpap and apap.

resmed's EPR is exhalation pressure relief that can be used only in cpap mode. Can't be used in apap mode.

PB has no exhalation relief feature.

The extra $400 is a joke. Not much more for you to buy the APAP cash online.

Keep hanging in there and give it your best.

The fact that your insurance will pay 100% is a plus.

If you really strike out (and you are not done yet so I am not suggesting your have struck out), get the insurance to buy the best machine you can manage and you will have an emergency backup machine even if your APAP is out of your own pocket.

If you do go out of pocket. Try submitting the bill to the insurance for them to pay you directly, some have made it work. If this fails, take the insurance's benefits let them buy you a back up (they won't know it is a backup, they owe you a machine). Of course you may have to use it to show compliance for a couple months, then store it for travel or backup....

Thanks ladies...was having a meltdown earlier today but I've decided I'm just not going to let it bother me over the weekend. Monday hopefully DME #2 will come through and if they don't I'll keep trying! Thanks for the encouragement!

It sounds like you are doing all the right things, and the way the system is (usually) designed, that's just going to be frustrating.

If your insurer takes so many local DME's there's a good chance that they also take BillMyinsurance.com. When I spoke to them they were very helpful and upfront. It was helpful to find at least one provider that would be able to provide me with the apap I wanted and my doctor had written a specific script for, no questions asked and only my copay which was under $150. They were transparent when no one else in the system was. I don't have any connection with them, but wanted to say how important that was.

These other places rely on ignorance and just try to wear us down. Now that I'm better rested, I feel like I won a battle and am proud that I hung in there. But it was a group effort, based on the collective wisdom and some specific support of the people on this site.

We are on your side! We want you to win this one.

[quote="BrensTiredMom"]Welllll...maybe I spoke too soon! The DME did get the Rx yesterday afternoon with all the specific info on it that I'd asked the Dr. to write. So far so good. Early this afternoon I called and they said the 'CPAP person' was 'working with the insurance company' to get it approved. She said that Auto CPAPs are 'rare' and that 'most insurances won't pay for them but they're working hard to get it appoved'. Hmmmm...didn't I read here that there is only ONE code for ALL CPAPs? Or did I get that wrong? So then at 6p tonight while we were out the DME called, different person, and said that there was a problem and to please call them. They were closed when I got home. I think the wonderful, helpful person I first spoke to didn't know anything about CPAP v APAP and the profit margin or lack thereof and now they're changing their tune.

So I need some advice from the insurance gurus...I was thinking I need to ask them what code they're using to get approved. And then I need to call my insurance co myself. I suspect that they didn't call them at all to be honest. Help!! I need this machine, I'm dying here. Could only work a half day today I was so exhausted.