It's D-day (or DME-Day)

Well the day is finally here I'm going in to place my order at the DME, I'm actually looking forward to it! I've already been in and talked to them but my prescription wasn't in yet and they seemed very nice and extremely helpful. Now my question is this I've already picked out the Remstar Auto with Cflex as my machine of choice but if for some reason my insurance won't cover it what is a good 2nd choice. I'd really like one that can track my progress and I'm pretty sure I need something with Cflex or something similar, no bipaps tried that in the sleep study and had a hard time with that. I am also going to go with the swift mask, don't think I'll have any problem there cause the guy at the sleep study center said if I couldn't get one through the DME he'd give me one as it only costs them like 8 or 9 dollars, what a markup.
Thanks
Roger

Two BIG problems here Rog.

1.) Request to your DME you want an Auto. Get the Rx from your Doc. Insurance pays for CPAP biling code E0601. It does not matter what machine it is the insurance will pay the same amount.

2.) The sleep tech must have left out a 0 after the 8 or 9. If he is getting a Swift for 8 or 9 bucks I would love to buy them from him all day long.

Hope this helps.

What do you mean that you had a hard time with the BiPAP?

FWIW, I couldn't use the one they had in my first sleep study because they had it set way wrong for me. They had it set like a straight CPAP at somewhere around 8/8 or 10/10. No way could I use that. The second time they were told by my Dr. (Sweetie that he is - NOT the ENT) to set it at 10/2. Much easier to use - until they started fiddling with it <LOL>

But I guess it's their job to see just how uncomfortable they can make us, right?

- JB

PS... or maybe the DME said that he would sell them to you at 8 or 9 dollars over his cost?
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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, CPAP

ahujudybear wrote: set it to 10/2

I was under the impression that 4 instead of 2 was the lowest setting???

DME is right!

Are you sure it was your insurance that said it won't cover an auto machine or did the DME tell you that. Your insurance will get billed the same if you get a cpap or an apap.

Regarding the $8 or $9 Swifts, I'll get in line and buy a bunch too.

Hi Roger,

You asked:

Now my question is this I've already picked out the Remstar Auto with Cflex as my machine of choice but if for some reason my insurance won't cover it what is a good 2nd choice. I'd really like one that can track my progress and I'm pretty sure I need something with Cflex or something similar

The poster nicknamed "DME" is telling you right. Autopaps are regarded the same as a straight cpap for billing purposes at your local DME. Of course they'd rather give you a cheaper straight cpap than a more expensive autopap, since they're going to be reimbursed one price (the price for straight cpap) from the insurance company.

If your DME gets stubborn about it, perhaps you can get your doctor to prescribe a specific type of machine: "Autopap with C-flex".

If you absolutely cannot have an autopap, the "second choice" I'd ask for is the Respironics Pro II with C-flex. That's a straight cpap machine (single pressure) but is also capable of giving you the data you want, to track your progress. In that case, watch that they don't try to give you just an older "Pro" still sitting on the shelf instead of a "Pro II". The older Pro (Respironics is phasing those out) records only compliance data - hours of use. The Pro II can give you AHI data.

Since you mentioned wanting a machine that has C-Flex, be sure to look at the top of the machine. There will be a blue sticker on top that says C-Flex, if the machine has that feature.

I guess you know that to "track your progress" via data downloads to your computer from the "smart card" with either Respironics machine (Auto or Pro II) you'd need the Encore Pro software and card reader. You don't need a prescription to buy the software and card reader from an online store.

Good luck. You're doing your homework well!!

Well just got back from the DME and they did exactly what some of you said they would they basically lowballed me, but I haven't given up yet. The main reason I quit the Cpap before is because I didn't see any immediate progress and of course I looked stupid with the get up on. So now I've decided if I'm gonna do this I'm gonna do it right. I can't believe the markup the DME's have over the CPAP store, the Remstar Plus cost me 500.00 more then the Remstar auto that's on Cpap.com in fact I think I can get everything including software for the price of the machine!!!!! The humidifier was 3 or 4 hundred more as well, couldn't believe it. As far as what I said about the Swift mask and my tech he told me there cost at the hospital was about 8 or 9 dollars so who knows. Thanks for the advice, I've got to get off here now and go fight with the DME.
Later
Roger

Which brings to mind. I've had several friends who started CPAP say that their insurance would only pay for the straight CPAP and if they wanted anything else they had to pay for it.

Does anyone know of ANY insurance company that will not pay this "one price for the code" type of coverage and that refuses to pay for an APAP or anything besides a straight CPAP. Sounds a bit Evil or Dumb DME-y to me. Sorry DME.

Direct from the BCBS Gods of Payment: Must start with straight CPAP until medically proven that it is not working. Must fulfill 3 month trial period in which you have been compliant. You may then move up a level to an Auto machine, with or without CFLEX was not an issue. If that does not work after the allotted trial period, you can move up to a BiPap and then, glory of glories, if necessary, you can get a VPAP. If you choose to skip any of these steps, the insurance will only pay for a straight CPAP and you must pay the difference. There are, of course, exceptions to the above rules - such as, only 1 nostril, half a lung, carbon monoxide poisoning from not being able to breathe, etc. Sort of kidding! If you have any mitigating physical conditions, proven by medical reports, you may heretofore (always wanted to use that word!) bypass the above steps and get full insurance reimbursement. So now you know why doctor's usually start with straight CPAP - even if they know that it is not the solution.......... It is all a medical and insurance game with your life as the ante...........

Maybe I can be of some assistance, as an employee of an EVIL DME!

Your insurance, like most, is not going to pay of an auto pap. They can be billed as a regular cpap, because they are just that, a cpap, with extra features.

When you want the extra features, like a navigation system on that new car your looking at, it costs more. Although it should be free, or included, its not. Doesnt everyone agree that in a vehicle designed to take you from point A to point B a navigational system should be standard? My dealer didnt think so....I regress

What BLOWS MY MIND, is people here actually expect a DME company, to provide you with the top of the line whamma jamma cpap, that they pay more for, at the same exact price they would get paid from insurance...

Lets see, on cpap.com they sell the goodknight 420 for 298.00, scroll over to the remstar pro with Cflex and its... $594?!?!?!?!?!?! What the F*&*?

Johnny? ? HOW DARE YOU CHARGE MORE FOR SOMETHING THAT HAS EXTRA FEATURES? !?!?

All joking aside, if its ok in your books for even cpap.com to reflect the upgrade in his pricing, why wouldnt you expect a DME company to be unable to sell you the top of the line cpap for the same price as a standard.

Heres how to get what you want and everyone wins. Ask your friendly helpful, willing to swap out your machine when it breaks down because they are paid a rental to do so DME company, how much they would charge you for the upgrade.

My evil establishment charges $25 a month GASP (yes for $15 months) to get you your top of the line wamma jamma cpap.

This is completely permissable with your insurance because APAP is not considered medically necessary and has no specific HCPC code.

Notice, $25 a month upgrade (interest free of course) for 15 months = $375. cpap.com difference in price between the two machines = $296. Yes I realise the DME company is making a WHOLE $79 dollars more. But considering the 15 months it takes, ability to swap out your machine within that 15 months and all other expenses tied to that transaction, doesnt it make sense? Are the prejudices starting to waiver? A little? ?

I, too, have BCBS. I was prescribed and APAP and got an APAP, right from the first day. Rented for 3 months to show compliance and then it was bought outright for the difference. There was never any, "you have to use a CPAP first". They have to give you what the doctor prescribes, right? And in this case they did. I know other similar cases. I think renting for 15 months is a bit ridiculous, even from the insurance companies' point of view. They lose money big time.

Okay, "Guest" since you won't identify yourself, explain this: WHY do DMEs charge separately for the hose when it comes as a package with the xPAP, and the filter, too? WHY do DME's charge separately for the headgear when it too comes as a package with the mask? Just curious. Or is this the way the insurance wants it.

I think that you are misconstruing some of the things that are being said. I have not had a pleasant experience with my DME and live in an area without any options. So, as an adult, it is my choice to seek medical equipment elsewhere; whether it be off the back of a truck, in a dark alley or on the internet. Of course the costs immediately can be blamed on the insurance companies and it becomes a game that is not limited to the DME. It affects all areas of medical care, dentistry, physical therapy, everything. The DME raises their price so that after the insurance "adjustment", they are able to be reimbursed their cost of the item plus a profit. They know exactly what each insurance will pay. The same exact thing is done by all medical services. Doctors do the same thing - they charge a certain amount, the insurance makes an adjustment, you have a copay and voila, the miracle amount is reached. This is not a criticism of the DME, it is simply a statement of fact. This is how the system works. The insurance payment varies according to the average billing in your state. I happen to live in Tennessee, hence the billing tends to be lower. However, I retired from the State of Michigan; where everything is more expensive. My bills are cleared through BCBS of Tennessee at the going state rate. They are then reimbursed by the State of Michigan, who just loves me for moving because they can get off more cheaply. In the long run, it helps me because I rarely pay a deductible. The main issue is service. There will be EVIL people in every profession known to mankind. It is not limited to one group. In general, I think that people are venting their anger at something that is simply out of their control. Insurance rates are skyrocketing, prescription drugs are skyrocketing........ so sometimes you just need to vent. This is a forum, so people are venting. If I knew of an insurance forum, I could go and vent there but I know they do not care. I am blessed to be wellinsured and I thank God every day for that but it is still not right for outrageous prices to be charged, especially for people who really cannot afford to get their basic needs met. It is a problem with the system, all the way to the top. However, I still do not like my DME and will discontinue using them. It would not matter to me if they charged me 10 cents rental. If we cannot work together, so be it. Maybe someday, I will drive 3 hours to the big city and try again. People vent on this forum because they know that other people with similar experiences will offer suggestions. There are 2 sides to every fence - nobody ever walks on top, you might fall off! Hope this explains my viewpoint.

janelle, good questions and i will answer them for you...since ive been stood up in my office for over three hours trying to provide EVIL SERVICE...
(read about it in my OTHER thread)

A provider doesnt have to give you something they are not going to get paid for. No body would expect that. Would you work overtime at your job for free just because you were DEMANDED to? Maybe if you were desparate for your job. Maybe for one time, but not as a way of doing business.

The problem that I have, is that no one is blaming the insurance companies and their setup. Think about it, are they in the business of wasting or saving money? How do they profit, by getting ripped off from DMEs or by squeezing what they can? Do they save tens of thousands of dollars per patient paying what they pay for cpaps compared to what they would have to pay to get you out of the hospital due to serious health difficulties related to untreated sleep apnea? Do they spend more money on adjusters whose sole job is to calculate how the can get away with paying less than the did last year?

The simple answer is that tubing and filters are provided by the cpap manufacturer. Its their decision to include it. That doesnt mean we dont pay for it in our cost of the cpap. What I mean is, if I requested that the manufacturer NOT include the tubing or filter, my cost of the machine would be less.

Apparantly in their opinion, these items must be included to make use of the machine. So just like your printer didnt include a USB cable to use it, you paid $79 for the printer. If it were included somehow, you would pay $89 for the printer. Its not free, its rolled into the price.

Same example could be used for a PC. You can buy a computer without an operating system for about $100 less than you would with an operating system. Does that mean that the Dell computer you bought just threw in windows XP to make you happy? Or is it still factored into the price?

Theres no free lunch!

Well once again I have to thank you all, if not for reading all your posts I would have taken the machine they gave me and lived with it, but I stood my ground and went after what I wanted. I'm not sure if I am getting the Remstar Auto or the Pro 2 but it doesn't matter as long as I can track my progress, that was the big reason I quit before it didn't seem like the machine was helping. I'm the type if I can see it on paper I'm good to go! DME is supposed to get back with me on Mon. or Tues. with my new machine and I can't wait.
Thanks To All
Roger

Always gets an auto pap. rested gal is our professor and her help and knowledge is invaluable. FWIW, I use the PB 420E, set on apap, and the swift nasal pillow.

If you can get the swift n. p. for 9 bucks, PM me faster than fast, and I'll buy some.

I buy thru cpap.com very reliable very fast, friendly, helpful and there are LIVE people to talk to not automated voice mail garbage (that's another story). Anyway, I like the 420E, it's small compact, and of course, I hope you are getting a heated humidifier whatever machine you get.


RG is our resident expert on the machine you mentioned.

Good Luck...
[quote="dirtsurfer57"]Well the day is finally here I'm going in to place my order at the DME, I'm actually looking forward to it! I've already been in and talked to them but my prescription wasn't in yet and they seemed very nice and extremely helpful. Now my question is this I've already picked out the Remstar Auto with Cflex as my machine of choice but if for some reason my insurance won't cover it what is a good 2nd choice. I'd really like one that can track my progress and I'm pretty sure I need something with Cflex or something similar, no bipaps tried that in the sleep study and had a hard time with that. I am also going to go with the swift mask, don't think I'll have any problem there cause the guy at the sleep study center said if I couldn't get one through the DME he'd give me one as it only costs them like 8 or 9 dollars, what a markup.
Thanks
Roger