DME ?

Hello,
I posted last week about my DME trying to give me a standard CPAP because the Insurance company wont pay for an APAP...I went down there and argued and the following day they gave me a Remstar Auto M with C-Flex...My Doctor prescribed me a machine with A-flex....Question is....Is the DME obligated to provide the A-flex machine because it is written that way on the Rx....I took the C-Flex only because I have been without CPAP for a few weeks and desperately need it.....I am just ticked in the fact that they provided me a machine that is not prescribed...I called them and started to get the runaround ...again... tehy said that they did order me the A-flex but it was denied....They are blowing smoke.....Anyone with similiar experience and suggestion...I asked to talk to the manager who denied it but she did not want to give me their phone number..she said "We dont want to do that just yet, lets see...I'll try and re-submit it"....
UNREAL !!!!

Ah, yes, the familiar DME runaround. *sigh* Good luck. I would imagine since they didn't want you to talk to the manager that they will probably come thru for you w/the A-Flex model since that is what your doctor specifically ordered. Frustrating as ole billy heck, I know. But, hey, if you get what you want in the end you can count it as a victory. And this DME will know you mean business in the future when you ask about something.

I'd let your doctor know the DME is ignoring his orders. They really like it when someone ignores their orders:)

What ever you end up with make sure it's new and has a HH. I'd reather have the old 'Classic" w/C-Flex that a "M" W/ Aflex. A-Flex wouldn't make up for the difference in quality to me. But for sure make sure it's new and not just had the odometer turned back. Jim

Just one comment on the original question.

About whether or not the DME is required to give you what the doc ordered....

The DME is, if someone is signed up to pay for it. No business is obligated to give something that they can't get payment for.

Now, can they get the insurance to pay for A-flex? My guess is yes, since cpap has the same billing code. Do they want to? That is a different story since the A Flex is more expensive than your run of the mill CPAP.

A little strategic pressure is always worth a shot, and I agree that they may cough up the A flex due to the fact that they didn't want you talking to the manager.

There just isn't a inalienable right for a patient to be given a machine or any medical equipment or medicine etc if SOMEONE isn't signed up to pay.

The DME will get the same dollar amount from the insurance company regardless of what machine they provide to you... straight cpap or fully loaded apap w/ a-flex. Since the loaded machines cost the DME more, they make less profit on them, hence their unwillingness to provide them... that's almost certainly why they tried to foist off the basic cpap on you originally.

It really makes no difference to the insurance company what machine you get (unless it is a bi-pap), because they pay the exact same amount to the DME for any cpap/apap. There is only one reimbursement code for cpaps or apaps. There IS a different code for bi-paps, but that isn't an issue here.

Stick to your guns. Insist on the machine you were prescribed. If your insurance company provides a benefit for medical equipment and will pay for a cpap, they will pay for the apap w/ a-flex, because they are paying the exact same amount to the DME for either machine. They pay on the basis of the billing code, not on the brand name or model of machine.

Look at it this way... if an insurance company provides a benefit for prescriptions medications, and your doctor prescribes a medication that is on the insurance company's formulary, the pharmacist cannot just decide that they are going to change what the doctor prescribed and provide you with a different medication simply because that med provides a greater profit to them. (Yes, Rx drugs are reimbursed on a cost basis, not a flat fee like cpaps, but the concept is the same -- the DME can no more change what the doctor prescribes for you than the pharmacist can.) The issue is NOT that the DME will get paid for a basic cpap but won't for an apap with a-flex, but only that the DME won't make as much money.

The DME may correctly say that the insurance company won't pay for "comfort" items such as a heated humidifier; but such items are coded separately from the cpap or apap machine and are billed and reimbursed as separate items.

Good luck!