CPAP Racket

Is there a racket going on in CPAP equipment or what?
Let me introduce myself... I'm a new CPAP user, of about two months. My PCP referred me to a sleep study at a local sleep center, which was done just before the new year. A doctor affiliated with the sleep center read the results. He prescribed CPAP. The sleep center set me up - An M-series Auto was used for a month to auto-titrate, and then replaced with an M-Series Plus.

Nowhere along the line was I, as a consumer, presented with a choice of equipment or DME providers.

After finding these forums and getting more knowledgeable, I made my first return visit to the sleep doctor (after one month with the Plus). He re-wrote my orders to read "Please setup with CPAP unit that can download both compliance and events". However this DME says they carry the M-Series Plus and the Auto. They don't carry the M-series Pro. They could set me up with the Auto, but my insurance won't cover it. They tried to convince me that the Plus provided all the data I needed. (I know better).

I've escalated this up to where I'm expecting a call from the DME company owner. Is there any course of action anyone would recommend?

Unless it is a bipap, the Auto bills at the same rate (using the exact same billing code) as the Plus, the insurance company has no clue whether it is a Plus or an Auto. They see a billing code. I believe the doctor does need to prescribe an Auto, but others here will correct if I'm wrong.

Get your prescription from the doctor, it is your right. Take the prescription to another DME that has a fully data capable machine. Let the owner of the current DME know you are doing this. Bet you get a Pro fairly quickly

The billing code they will use is: E0601

Let him know that works for both the Plus and the APAP. They stand to make alot of money over you...but I'd find a new one who is more willing to work with you.

I don't see the problem. They carry one machine that provides data and one that doesn't. Your Rx was written to provide the data so they have to issue that machine. The cost code is the same and if they are contracted with your insurance company to accept that code reimbursement as payment in full they don't really have a choice.

This was resolved to my satisfaction. Rather than call me, the DME owner told them to issue me the Auto. They will bill it the same way, as you all knew and said. Thanks for your help.

My Plus went "all the way to 11." I've learned here that the tech could have set the Auto to emulate this by setting both limits to 11, but he set it to range from 9 to 11. Would I be be better off with a constant setting? It is actually prescribed at this point.

If you were titrated at 11 cms and your script was written for 11 cms then your auto can be set to straight CPAP mode at 11 cms. Since you were issued an autoPAP for the first month did you ask for and receive a printout of the COMPLETE download? If not, I would do so. Its part of your medical records and you have a legal right to that copy under HIPAA if you are in the USA.

Legally, its not a racket, but yeah, it is VERY common, almost universal, for local DME suppliers to foist a compliance data capable only CPAP on unsuspecting first time CPAP buyers.

gbuskirk wrote:This was resolved to my satisfaction. Rather than call me, the DME owner told them to issue me the Auto. They will bill it the same way, as you all knew and said. Thanks for your help.

My Plus went "all the way to 11." I've learned here that the tech could have set the Auto to emulate this by setting both limits to 11, but he set it to range from 9 to 11. Would I be be better off with a constant setting? It is actually prescribed at this point.

Glad to hear you got the better machine. Only YOU will know whether fixed pressure or a range of settings will work best for you. I always recommend at least TRYING the titrated/prescribed pressure (with a data-capable machine) and see how that setting works before experimenting. Every once in awhile, they get the pressure "right" in the sleep study.
Just because you have an APAP/Auto, doesn't mean you HAVE to run it that way or that it gives the best therapy in that mode. Many of us who have the Autos, found that we get better therapy in CPAP mode.

Good luck,

Den

I won't be experimenting....at least for a long while. 11 is my titrated pressure and was the setting on the Plus for the last month. Now the Auto will be ramping 9 to 11. The tech didn't seem real sure about how to set the Auto for CPAP.

gbuskirk wrote:I won't be experimenting....at least for a long while. 11 is my titrated pressure and was the setting on the Plus for the last month. Now the Auto will be ramping 9 to 11. The tech didn't seem real sure about how to set the Auto for CPAP.

In that case, you really should go through and verify all of the settings in the machine before using it.


Den

Congratulations on getting your auto!!! Boy, that couldn't have done much for your confidence in this local DME's staff member if s/he wasn't even sure how to set the auto into straight CPAP mode! Sounds like you will know more than him/her about your APAP w/in the next 24 hours!!! I have the sneaky suspicion you are going to NEED someone to e-mail you the Clinicians Manual in pdf forum. It really sounds like you are going to NEED it!!

gbuskirk wrote:Is there a racket going on in CPAP equipment or what?

Ah, yes its a racket but no different than MRI's, angiograms or endoscopys, all of which are massively overprescribed and generate huge amounts of income for doctors, hospitals and DME's. Think of yourself as a customer, not a patient. Its in medical community's best interest to keep you as a paying customer. That way you'll have less delusions they care about your health instead of their pocketbooks. Sorry this is so blunt, but its the truth.

gbuskirk wrote:This was resolved to my satisfaction. Rather than call me, the DME owner told them to issue me the Auto. They will bill it the same way, as you all knew and said. Thanks for your help.

Is your out-of-pocket more with an auto? I had straight CPAP at first and my out of pocket was about $85 plus monthly rental of $13. Now I'm getting an auto and I'm told it's an additional $250 plus the same monthly rental of $13. Does that sound reasonable to others? I feel like someone is always sticking their hands in my pockets whenever I deal with anyone in this industry.

We were arguing about this in another forum. A couple of guys were diagnosed with OSA but didn't believe it because they said EVERYONE who does a sleep test gets diagnosed with OSA and it is therefore a racket. My argument was that you don't do a sleep study because you are feeling great and don't have a problem in the world. You do it because something is wrong. You snore or you are excessively tired, etc. Therefore, it is more likely that you will be diagnosed with a sleep problem than not.

My doctor had no relationship to the sleep doctor or the sleep center or the DME in any way, shape or form. The DME had no relationship to the sleep center or the sleep doctor. But people start to feel like they are being shafted when there is a relationship between some of these people. I can see their point but that doesn't mean they don't have OSA.

BeanMeScot wrote:We were arguing about this in another forum. A couple of guys were diagnosed with OSA but didn't believe it because they said EVERYONE who does a sleep test gets diagnosed with OSA and it is therefore a racket. My argument was that you don't do a sleep study because you are feeling great and don't have a problem in the world. You do it because something is wrong. You snore or you are excessively tired, etc. Therefore, it is more likely that you will be diagnosed with a sleep problem than not.

My doctor had no relationship to the sleep doctor or the sleep center or the DME in any way, shape or form. The DME had no relationship to the sleep center or the sleep doctor. But people start to feel like they are being shafted when there is a relationship between some of these people. I can see their point but that doesn't mean they don't have OSA.

My doctor said that he has had only two people that were NOT diagnosed with OSA when sent to have a sleep study. I guess most people are pretty much aware that they have a problem when they are sent so that skews the results. I don't know how many he has sent, but I'm sure it's over 100...

ericthomas wrote:

gbuskirk wrote:This was resolved to my satisfaction. Rather than call me, the DME owner told them to issue me the Auto. They will bill it the same way, as you all knew and said. Thanks for your help.

Is your out-of-pocket more with an auto? I had straight CPAP at first and my out of pocket was about $85 plus monthly rental of $13. Now I'm getting an auto and I'm told it's an additional $250 plus the same monthly rental of $13. Does that sound reasonable to others? I feel like someone is always sticking their hands in my pockets whenever I deal with anyone in this industry.

There should be NO "additional" charges for a higher-end model of CPAP. They bill the insurance providers with the very same code E0601.
If several months had gone by since starting (and then switching machines), that might be a slightly different story, but if you're "starting" therapy and tell your DME that you want a better machine, they should not be charging you more.

Den