Insurance and CPAP question

Capri

Hope you don't mind that I added a link to the faq above for your post. It is very good and something that everyone should read.

I tried to add it to collective wisdom and did forward it for review.

Hope you don't mind.

I think that there are a number of other things that have been left out of this discussion.

From my experiences.....there could have been pitfalls:

My sleep doctor's office hadn't sent a copy of the sleep study to my insurance provider. I had done all the preauthroizations with them, but things got delayed by about 10 days because of that screw-up.

I made sure that I got the ORIGINAL of my prescriptions.
On the day that the sleep doc gave me my prescription, he told me to go to a local DME to get my equipment......it was located in the local hospital.....so, I went there and looked at what they had and since I had already been investigating what machines were available and their prices (from Internet searches), I was able to ask some relatively intelligent questions.
I had also previously done some inquiries at a couple of other local DME shops, too.
NOW......had I signed the papers at the DME office that my doctor sent me to......AND had my insurance provider NOT approved the sleep study, I could have been on the hook for about 3 times what my equipment actually cost me from CPAP.COM.
As it turned out, after seeing what that DME had and what they were going to charge my insurance (and ME), I went back home and did some further studying. Between the calls to my insurance provider and CPAP.COM was where I found out about them needing a copy of the sleep study. They also approved my purchase from CPAP.COM and were going to reimburse me for 80% of my purchase.
At that time, there were two Respironics PRO machines.....one was the previous "Pro" and then there was the (new) "Pro 2". The older Pro didn't record nightly details.....only compliance. The new Pro 2 DID. Respironics had already declared the older Pro as obsolete. SO, guess which one the DMEs were trying to sell me?

My points of this story is to NOT get herded into a DME office and get handed what they want to make the most profit from.
Be sure that all of the "I's" have been dotted and the "T's" have been crossed.
Get the physical piece of paper with your prescription on it.
DO THE MATH.
In many cases, by the time deductibles and co-pays are figured into the costs of buying from a local DME at their highly inflated prices, you can buy a better machine (the one you WANT) from an Internet seller.

DO YOUR HOMEWORK!

Den

Where do you get your supplies from?

KarenAZ wrote:Does anyone know if you have a choice of machines with insurance? I specifically switched to BC/BS HMO to have the benifit of autodelivery of supplies every 3 weeks that I don't pay for plus they paid 100% for my machine. I don't know if the sleep study place recommends the machine or if it's the only one the insurance company will pay for. I'm single and on a limited income so I don't have the $$ to purchase my own outright.

Does anyone know how that works? I looked in the light bulb and couldn't find an answer. Thank you for your time.

Karen

Before you get 30 days on that xPAP you have, call BC/BS and ask what local DME CPAP suppliers they are contracted with. Hopefully you have the option of more than one. If this current DME supplier isn't working with and for you, you want to be sure to shop around and switch during that first 30 days if at all possible. Its a lot harder to do that the next 30 days and after that - fergeddit, you're stuck w/them until the purchase/rental is completed, often as much as 13 months.

The choice of xPAPs provided is pretty much left up to the local DME supplier to make. It shouldn't be that way, but that's pretty much the way it works unless the patient has been able to educate themselves first or the sleep doctor is an unusually caring and considerate one.

Most all insurances do NOT pay for xPAPs by brand or model but rather by HCPCS code. And all straight CPAPs and autoPAPs are classified under that one HCPCS code: E0601. However, obviously some autoPAPs cost more than some straight CPAPs meaning the local DME suppliers are going to have their profit margin in mind when left to their own devices in deciding which xPAP to provide because they've contracted at one set price for ALL E0601s.

Most won't give you any grief if you insist on a fully data capable straight CPAP (meaning a Resmed or a Respironics). Altho some will. And some of the better ones routinely offer the fully data capable straight CPAPs such as the Resmed S8 Elite w/EPR or the Respironics M Series Pro w/C-Flex.

Generally the sleep doctor just writes a pretty generic script only specifying pressure setting, maybe Ramp and heated humidifier andmaybe expiration pressure relief. Some don't even bother to specify a "heated" humidifier.

Keep in mind that YOU ARE paying for this equipment (thru your insurance) so be DIPLOMATIC but be FIRM about what you want in an xPAP. Once you accept and sign for receipt of one you could be stuck w/it or at least in for a big battle to get what you do want. The local DME supplier is getting paid to provide education, service and support so don't be bashful about asking them for help when you need it. Until you get to know them tho take what they have to say w/a good grain of salt.

There are some really good local DME suppliers out there, there are some good ones too - and then there are the sheisters. Don't go in expecting the worst, but be prepared for it. Just keep in mind: YOU ARE paying for this equipment and service so be DIPLOMATIC, but be FIRM.

Good luck! May you be blessed w/a good local DME supplier at your first encounter.