Best argument for an autopap??

I'm on my way to the doctor's appt now. But I just spoke with the DME who sold me my Elite II and he said it basically doesn't matter what my doctor says. He says that any prescription for a CPAP can be viewed as a prescription for an APAP ... if I'm willing to pay the $300 upgrade fee. According to him, all insurance companies view APAP as a luxury so it's always on my to pay the upgrade fee. If that's true, then my trip to the doctor is irrelevant.

I would be willing to pay the $300 if that's really true, but of course I'd rather NOT pay and I'll explore it with the doctor and insurance company first. Anyway, I expect I'll be back on here asking questions after the doctor's appointment, since it doesn't sound like that will be the end of it.

Wow, it might depend on the insurance but my DME (who is unusually wonderful and accomodating) just swapped my Elite II out for an AutoSet II free of charge. They even told me the insurance is billed for CPAP and APAP with the same code so no more money would be necessary. I weas shocked. I thought for sure it would be a used machine but the used hours said 0 and they told me it was new.

Good luck today. please let us know how it goes. I had to go through another PSG bc my doc wanted to be sure of my pressure accuracy, then try that a week before getting the APAP.

2girlsmom, I had the same response from my DME .. there was no "up charge" for the switch from the basic CPAP to the Auto for me either.
AuntieNae

I think your DME, like most DME's, is a liar. I had a M Series Plus for about a month while I waited to get in to see my neurologist to request a new Rx for a new machine and mask. My insurance paid for everything the first time around, and then they paid for my new APAP and mask a month later. I returned the old machine and got the new one without any charge.

If your doctor deems your auto medically necessary and writes AUTO CPAP on the Rx, the DME has to fill it as written. Your insurance may well cover it in that case. I wouldn't pay the $300 difference until your insurance denies you.

First off, there is NO WHERE NEAR a $300 price difference between the Resmed S8 Elite w/EPR and the Resmed S8 II AutoSet!!!!

Second, it would be an unusual insurance company that pays by brand or by model, most all insurances pay by HCPCS code: all CPAPs, and all autoCPAPs are HCPCS code e0601.

Third, if your insurance is contracted w/more than this one local DME supplier you've got some bargaining/negotiating room to hit this one over the head with!

Slinky wrote:Second, it would be an unusual insurance company that pays by brand or by model, most all insurances pay by HCPCS code: all CPAPs, and all autoCPAPs are HCPCS code e0601.

But there are insurance companies that do just that.... mine, for instance. In addition to the Rx, it requires the particular model info and will only pay for an APAP if (1) the Rx is specifically for an auto or (2) if CPAP therapy "fails." My doc will only write an auto Rx IF CPAP therapy fails. Regardless of what I've said, it's his considered opinion that the CPAP is working well.

So I'd definitely wait until I knew exactly what your insurance company (1) requires and (2) will pay for. That upcharge sounds wacked to me, but then so do a lot of things.

Marsha

Soooo ... just spent 20 minutes on the phone with an absolute moron from BCBS of Illinois. The company I'm now with is based in Illinois, but I live in California, so I use BCBSIL but apparently BCBSCA sets the spending limits within Cali. The BCBSIL person on the phone was unable to tell me what my spending limit is for HCPCS code e0601 because only BCBSCA knows. She also insisted that I can't find out from BCBSCA since I'm a member with BCBSIL. She said I should go by what the DME says. The most she would tell me is that BCBSIL pays 100% up to "the approved rate." I said, that's what I'm trying to find out: what's the approved rate. She said ...

Well, I suppose I don't need to describe how circular conversations with insurance company reps go to anyone on this board. Long and short of it, many words were spoken yet no information was transmitted.

What I can gather is that the principle of what my DME supplier is saying is true. My BCBSIL coverage includes some kind of fixed ceiling on what they will spend for any XPAP. Is that fixed ceiling truly exactly $300 below the price of a ResMed Autoset II? Dunno. I do know that they already gave me essentially the same story when I got the Elite II, saying BCBS' "100%" coverage is only for a very basic generic CPAP and I did end up agreeing to pay a differential rental fee of $10/month for the next 12 months. $10/month didn't sound so bad at the time, but that plus $300, plus total lack of transparency from BCBS is starting to piss me off.

Maybe I'm better off making the Elite work until I start that new job and can start from scratch with another insurance company.

On a different but related note, Sweet Lord, do I love charging insurance companies for stuff. Those morons paid the hospital $26k when my son was born -- totally normal, no-problems birth (thank goodness). And it felt good to see that bill. Felt really good. I think I'm going to need to go to the emergency room tonight for a hangnail. Lavish overspending combined with a net failure to adequately address medical issues ... somehow, I think my life must be a kind of microcosm of all that's wrong with the health care system in America.

Forgive me, SongBird, but was that info regarding brand and model, and CPAP failure before an APAP, straight from the horse's mouth or from your sleep doctor or local DME supplier??? AND are you SURE the person providing this info understood the DIFFERENCE between an APAP and a BPAP???

ZiggyTosh, maybe you oughtta make a quick trip to ILto get your equipment??? Sheesh! Sometimes you gotta talk to 3-4 people in the office and then compare notes!!! Duh!

Between the DME and another round of calls to BCBS, I think I have some clarity. BCBS pays $94.50/month on a lease agreement for code e0601, under which I own the machine outright after 12 months. As it happens, $94.50 is exactly the amount my DME charges for a basic CPAP (at least to their BCBS customers -- it's not like there's a fixed price list, of course).

After pointing out that the base prices of the various APAPs are all different, they did acknowledge that it was unfair to charge an even $300 upgrade fee regardless of which APAP I choose. I noted, for example, that an Autoset Vantage costs LESS than my Elite II online. They said the Vantage is no longer in production and hard to find, but that they would get back to me with some less expensive APAP options. We'll see.

The other option, since this is a lease agreement, would be to cancel and take my business elsewhere. So I'll be looking for a DME in California who takes BCBS and is willing to give me an APAP for $94.50/month.

E0601 covers both CPAP & APAP. If your doc prescribes specifically a Respironics Auto M with AFLEX and integrated heated humidifier, they have no choice but to hand you that exact unit at the same exact price as other E0601 machines.

Their problem is that it costs the DME more to hand over an auto but don't fret as they still make money on it.

Well, as others have said, my DME may well be a liar, but he's claiming it doesn't matter what the doctor prescribes as far as brand or whatever. Anything other than a basic CPAP -- something like the ResMed Escape -- costs extra. I am in the process of calling around to other DMEs in my area to at least get some bargaining power. So far, the cheapest I've found is one that would give me the Autoset II for $235 on top of the $1134 my insurance would pay (in 12 monthly lease payments). If I can get that down to about $150, I'll probably pull the trigger.

Sorry, they just flunked the lie/ignorant test. They must fill the script as written or not at all.

In CA check into SleepQuest. See below for info.

Our corporate headquarters are located in San Carlos, California.
985 Industrial Road
Suite 200
San Carlos, CA 94070
Phone: 800-813-8358
Fax: 650-412-0124 (Corporate Office)
General Email: contact@sleepquest.com

Central Valley Field Office
5475 North Fresno Street
Suite 112
Fresno, CA 93710
Phone: 559-436-8800
Fax: 559-436-8818
fresno@sleepquest.com

Peninsula Field Office
985 Industrial Road
Suite 200
San Carlos, CA 94070
Phone: 650-412-0123
Fax: 650-412-0130
peninsula@sleepquest.com

Salinas Field Office
680 East Romie Lane
Suite D
Salinas, CA 93901
Phone: 831-772-0555
Fax: 831-772-0557
salinas@sleepquest.com

San Francisco Field Office
1489 Webster Street
Suite 203
San Francisco, CA 94115
Phone: 415-775-3379
Fax: 415-775-3380
sanfrancisco@sleepquest.com

OldLincoln wrote:Sorry, they just flunked the lie/ignorant test. They must fill the script as written or not at all.

In CA check into SleepQuest. See below for info.

Thanks a lot! I'm calling them now.

Slinky wrote:Forgive me, SongBird, but was that info regarding brand and model, and CPAP failure before an APAP, straight from the horse's mouth or from your sleep doctor or local DME supplier??? AND are you SURE the person providing this info understood the DIFFERENCE between an APAP and a BPAP???

Oh, yes -- straight from SEVERAL horse's body parts at my insurance company, though I'm not sure it was their mouths. Back then, I was on a calling spree to the point that people were recognizing my name. (You could almost hear, "It's HER again." I've been told that when I get on a quest, I can be like a very quiet, very patient, highly irritating Chinese water torture. ) Same answer every single time. And they absolutely understood the differences between ALL of the paps. They wouldn't budge, and neither will my doc. The truly amazing part is that my (wonderful) DME is also mystified. He'd gladly give me an APAP if only I could give him an Rx for it. And yes, I even tried doing an end run around my sleep doc and talked to my GP, who is usually very easy to work with, but no go there either, since he'd referred me to the sleep doc. I can't think of any other avenues, but if you think of any, I'm certainly open to suggestion. When I can, I'll get my own auto, but that'll be a good piece down the road.

Marsha

Hmmm. I just spoke with someone from Sleep Quest. They were very helpful and much more clear, but it sounds like this has to do with my specific insurance. They really do only pay up to a maximum amount that is too little for most DMEs to just hand out an autopap. Sleep Quest and the other DMEs say that BCBS doesn't recognize APAP as a prescription, just as a luxury type of CPAP. So bottom line, I'm going to pay something extra. I've talked to probably 10 different DMEs in the last hour and a half and they are pretty consistent about it, once they have my insurance information.

Still ... it does NOT make sense that every APAP out there, regardless of brand or model, should cost me exactly the same surcharge. My original DME said he'd get back to me with some more options, and one of the others I spoke with has the ResMed Autoset II for $235 out of pocket. I'll, er, sleep on it a few nights and decide how bad I want this, but at least it looks like I'll be able to get something for less than the original quote. Whatever. Freedom ain't free.