Insurance Strikes Back

Just had to tell y'all what a recent EOB (Explanation of Benefits) from our insurance said in reply to a bill from the Sleep Study people.
"Does not pay for things deemed medically unnecesary. No proof given of medical necessity, so therefore since they are contracted with the network, we owe $0 of the $1500!

On another EOB, from all my medical equipment purchase (hose, mask, humidifier, they had only about 50% as the allowable versus what the DME was charging them. And on my APAP, which they paid $181 to rent for two months they only paid $540 to buy it off instead of the $1400 the DME charged them.

Go Blue Cross!

Janelle wrote:Just had to tell y'all what a recent EOB (Explanation of Benefits) from our insurance said in reply to a bill from the Sleep Study people.
"Does not pay for things deemed medically unnecesary. No proof given of medical necessity, so therefore since they are contracted with the network, we owe $0 of the $1500!

On another EOB, from all my medical equipment purchase (hose, mask, humidifier, they had only about 50% as the allowable versus what the DME was charging them. And on my APAP, which they paid $181 to rent for two months they only paid $540 to buy it off instead of the $1400 the DME charged them.

Go Blue Cross!

I fully understand the need for every business to make a profit. I've worked in the business world all my life. But, the charges submitted to insurance companies is outrageous! Since I pay the first $2,000 of my health care each year, you better believe I scrutinize those EOB's. My DME submitted charges to my carrier as follows: 147.05 for the Breeze nasal pillow interface (which I promptly returned), 49.68 for the headgear for it and 41.00 for the tube that attaches to it. That's $237.73 for an item that can be purchased for $92.99 from cpap.com. Then, they charged 376.52 for the heated humidifier (mind you, it's integrated in to my ResMed VPAP III - couldn't use the unit if you removed the humidifier chamber) and 320.75 for a month's rental of the unit itself. You better believe I'm not paying that kind of $$ without some old fashioned negotiation! Insurance companies need to start fighting back. It's in everyone's best interest. The problem is, when they do, they're crucified on the evening news as cold, heartless, greedy SOB's.

I'm trying to understand all of this.
When I saw the Pulmonologist yesterday, I mentioned what I could get my equipment for at cpap.com. I asked if their prices were comparable. He told me the DME was seperate from what he did, but explained it this way.
He said, quote: The reason the DME charges so much more than what you can get the same equipment for online is the support. If things do not work out right, or you need help, adjustment, trade masks, etc., this care is built into the price of your equipment. He then said this:
"I have a doctor friend who initially bought his first equipment from the DME here in this building. After he became used to it and was on it a few years, he became so familiar with everything that now he orders everything he needs off the Internet. But he said the hands-on care from the DME was vital in the beginning."
His explanation made me pretty much decide to pay the piper initially, then later on, order anything new I get online.
What do you all think?

Problem is that "care" is practically negligible with most DMEs. Very few deliver the equipment and tell you how to use it, set it up for you anymore. No cost effective. They give you one mask, and once you open it it's yours. You can't trade it, return it or anything. you want a different mask you have to buy it from them or elsewhere. They might trade out machines during the initial two month rental but after that forget it. I thought my Breeze had broken, and called them about it. Did they offer me a replacement? No. They offered to fix it. The mask was under warranty, what was the big deal. I called when I had pressure problems and got a "we'll look into itl" Never heard a word in 3 weeks. Found the answers on this forum. So much for all the care you get.

Photgal,

What your Doc says sounds legitimate to an uninformed individual which makes me wonder about your Doc. The support from the online supplier I used (cpap.com) is phenomenal! You can call them till 10pm, six days a week. The dozen or so local DMEs I dealt with before I decided to buy online would take three days to return my call. The only reason you would need to use a local DME is if you don't even know how to plug the machine in. They are REALLY easy to assemble and operate. The one I have (REMstar Auto w/C-flex) turns itself on when you breathe into the mask. How much easier could it be?
If you would like, PM me and I'll give you my phone number. You can have your Doc call me and I'll let him know what kind of "support" people will get if they buy online because he obviously does not know the true story and is assuming incorrectly.

photogal wrote:I'm trying to understand all of this.
When I saw the Pulmonologist yesterday, I mentioned what I could get my equipment for at cpap.com. I asked if their prices were comparable. He told me the DME was seperate from what he did, but explained it this way.
He said, quote: The reason the DME charges so much more than what you can get the same equipment for online is the support. If things do not work out right, or you need help, adjustment, trade masks, etc., this care is built into the price of your equipment. He then said this:
"I have a doctor friend who initially bought his first equipment from the DME here in this building. After he became used to it and was on it a few years, he became so familiar with everything that now he orders everything he needs off the Internet. But he said the hands-on care from the DME was vital in the beginning."
His explanation made me pretty much decide to pay the piper initially, then later on, order anything new I get online.
What do you all think?

Yeah the support from most DME's makes a big difference.


That is why we are all here!!!


Unfortunately the kind caring DME is the EXCEPTION, not the rule. If you happen to be one of the lucky ones that has such a DME, then your doc is right, having someone to "hold your hand" so to speak is a great thing.

Reality is tho, you are more than likely not going to find that. AND, they are going to charge a high premium for that.

I'm new to all of this too Photogal and I was completely uninformed and uneducated on the whole subject of treatment. I understood OSA pretty well before I ever had my sleep studies but I knew nothing about the treatment and equipment. And, I learned practically nothing from my DME. This forum has been absolutely invaluable to me and I can't thank the participants and cpap.com enough for it. I have already experienced most of the problems with DME's that others have mentioned in this thread. Seems to me that the primary concern of most DME's is to get as much $$ as possible from the insurance carriers. The well being, education and comfort of the patient seems to be considerably further down their list of priorities. As mentioned by someone else, your doctors comments make perfect sense - in theory. But, the real world is far different. Best of luck to you. You'll find all the hand holding and help you need from the great folks here on this forum.

Okay, I think you've convinced me. But I'll need to call my insurance company and find out if they'll reimburse me for part of the cost of the equipment if I order from cpap.com.
My RX is for a BiPap. I had done all my homework here on this forum and had decided on the Remstar auto with C flex and heated humidifier, and the Resmed Ultra Mirage FF mask.
The pulmonologist said the BiPap was what I needed because you can set the exhale lower than you can with the autopap. He's said he will fax that RX to anywhere I want.
I have COPD, which doesn't bother me 75% of the time. My oxygen level was 98% two days ago. It's just that any cold or anything goes to my chest and I get severe asthma, and breathing is very difficult for me for a month until I get better. The exhale, especially.
So the autopap is out, Bipap in. Which Bipap is the best? Still recommend Remstar brand?
Betty
ever grateful to all of you.

Hmmmmmm..............too bad he won't drop the "BiPap" from your script. For me, it took a special trip back to the pulmonologist (Who, I'm convinced, knows very little about all of this and has seen me twice so far for a total of about 15 minutes) to beg for an auto pap script so that I could order the RemStar Auto w/C-flex from our good friends here at cpap.com. I used the machine for the first time last night. I started off with a ResMed VPAP III (a very good machine by the way) which is a bi-level. From what I can tell, when the RemStar is in c-flex mode, it behaves nearly identical to a bi-level except it is easier to exhale and much quieter than my ResMed machine. I invite the more knowledgeable here to jump in and correct that statement if it is incorrect. Mine is set to my prescribed pressure with C-Flex enabled and set to "3" and a ramp time of 20 minutes - same as my ResMed machine. Now, my ResMed Ultra Mirage FF mask.............that's a whole 'nother story!

This is what I just looked up on cpap.com.
BiPap Pro 2 (Remstar) with heated humidifier, bag & hose & manuals $1569
Ultra Mirage FF mask $150
Filters (washable) $14.00

Does this look right? Is there anything else I would need to order? Does the Bipap come with C flex or is C flex only for autos?
Betty

OK...Jerry, what you are saying is the auto with c flex is as easy or easier to exhale with as the BiPap?
Oh, I am so confused...I don't think there is any way I can get back in to discuss this with the Pulmonologist as it took me 3 weeks to get in the other day.
And am I crazy or what, but is the Remstar Auto with C flex only $829 compared to the BiPap being $1569, and if that is so, why is the auto cheaper if it is better?
The pulmonologist did act like he knew what he was talking about when he was discussing the equipment, but does he? He said that the autopap senses the pressure you need...let's say for this discussion, a pressure of 9.
While the inflow is a 9, the pressure you exhale against is a 9 also. Of course, the pressure varies during the night according to your needs. But he claims the pressure on the exhales is equal to the pressure on the inhale.
Is this not correct?
And if a person needs a Cpap, period, and an RX is written for it, then why do we need another RX to choose an auto or bi? For insurance purposes only?
Questions I need answers for before calling my insurance company.
~Betty~

photogal wrote:While the inflow is a 9, the pressure you exhale against is a 9 also. Of course, the pressure varies during the night according to your needs. But he claims the pressure on the exhales is equal to the pressure on the inhale.
Is this not correct?
And if a person needs a Cpap, period, and an RX is written for it, then why do we need another RX to choose an auto or bi? For insurance purposes only?
Questions I need answers for before calling my insurance company.
~Betty~

With a RemStar with C-flex, this is not correct. C-flex drops the pressure during the exhalation. There are three C-flex "levels" available with 3 being the least exhalation resistance. Your pulmonologist does sound rather saavy regarding the machines but he may not be familiar with RemStar and c-flex.
Regarding the script: cpap.com would not sell me an auto because my script called for a bi-level. Even when I obtained the new script from my doctor, he wrote "bi-level auto pap" and cpap.com would not honor it. I had to contact the doctor's office yet again to have them remove the "bi-level" language as well as the pressure settings from the script and fax that to cpap.com. I can't fault cpap.com for it - they're following Federal law. It took some doing, but I got what I wanted. Does this make a bit more sense?

The autopap w/ c-flex is fairly new, so the doctor may very well not be aware of it. Years ago, there was just cpap or bipap. Now that there is autopap w/c-flex I don't know why a bipap would be used? It seems the apap w/ c-flex does everything the bipap does plus more, for less money...
but I am not an expert.
Perhaps cpap.com can give you the comparable specs?

I'm not an expert either, coffee, and I do agree almost completely with your statement:

"It seems the apap w/ c-flex does everything the bipap does plus more, for less money..."

Experimentally I've tried my REMstar autopap with C-Flex up at a pressure of 20. C-Flex doesn't make a dent in a very high pressure...or at least, didn't for me.

Based on that very brief, subjective test I think people who have to have very high pressure (perhaps 15 or more) most of the night would not get much relief at all with C-flex.

A bi-level device like BiPap would let the exhalation relief be set exactly, unlike the vague "some drop during exhalation" that C-Flex gives.

The degree of C-Flex's drop seems to depend on each person's individual exhalation force. Going only by the sound of the machine revving down as I exhale, I hear much more "drop" when I breathe out hard, than I do when I breathe out more lightly, using C-Flex at "3" (3 being the greatest drop C-flex will give.)

That said, I'd still want to have a trial on Autopap with C-Flex first, before being prescribed a bi-level machine like a BiPap. Particularly if the reason the doctor wanted to put me on BiPap was that the sleep study had recommended a high pressure, and I had difficulty breathing out against that pressure.

I'd always want to at least try an autopap first. It might be that a person really doesn't need the sleep study's recommended high pressure most of the night while sleeping at home.

If the trial on the REMstar autopap with C-Flex gave good results using lower pressures throughout the night, C-Flex certainly can give plenty of exhalation relief for most people. I'm with you, coffee!!

Rested Gal wrote:

I'd always want to at least try an autopap first. It might be that a person really doesn't need the sleep study's recommended high pressure most of the night while sleeping at home.

My Dr. and RT have both told me that pressure needs do vary during the night for many reasons. Sleeping on your back is likely to need higher pressure to keep the airway patent than is sleeping on your belly. Sleeping on your side is likely to require less pressure than on your back, but more than on your belly.

Further, relative to the stage of sleep that you are in, your muscle tone will change -->the pressure that you might need to keep your airway patent when you are in REM is likely to be more than what is needed in the other stages of sleep.

Having said all this, I believe that Rested Gal is giving you a really good suggestion... trailing out one or more autopap machines, including a machine with C-Flex, is a good idea no matter what. I'd suggest trialing more than one autopap so that you can find the machine that suits you best. They all do the same thing, but not all in the same way. Also, the Respironics machines with C-Flex are a good alternative if breathing out against the pressure is difficult.

Bear in mind that C-Flex is not good for everyone (I hated it!) but it is great for many users. Personally, I'm really pleased with the PB 420E. My prescribed pressure is 15, but with autopap, I'm sleeping the entire night through (8 hours) and feel great during the day. With the single-pressure CPAP machine that I started with (RemStar with C-Flex) I was sleeping terribly and was about ready to open a wrist.

Good luck!