Need help With SoCal Kaiser/Apria BS

Hi and thanks for all the help. The reading I have done here has been of tremendous value. Apria wants to give me Resperonics Remstar Plus. I understand it is not data capable and they were not offering me a humidifier with it. I live in the desert so I knew this was not acceptable. Spoke to the Dr. and got him to approve a humidifier but he says he can not specify data capable. Fine I am willing to pay extra for this feature. But Apria claims to only supply the Remstar Plus at a price of $750 of which I am to pay 20%. $750 for this compliance only antiquated model with no humidifier seems unacceptable to me when this same model may be purchased online for $400. How can I get Kaiser to reimburse a Non-Apria unit or get Apria to provide a better model?

I'm not sure if it will work, but in talking to a customer service guy at my insurer about masks, their prices "they" want us to pay and how much we can save THEM by buying off the web, he suggested I talk to their Care Coordinator about "gap extension". It's what they will consider if you're more than 30 miles from a service provider.

I haven't tried it, as I'm trying my damnedest to work with one that has actually set up shop in my little town. We're 90 miles from many
DME's and 55 miles from a town that has 2-3. There's every bit of 10 different vehicles that try to service people, and I hope the newbie makes it. The business is here!! But, since it took them 32 days to get me my first mask since trying them, I doubt any success.

I've ranted and thank all for listening!!! The truth of it is, the last time I knew what the insurance was paying, 2 years ago, they paid $125 for a Respironics Profile light, that I could get off the web for $65. Let's see, "if" they'd even pay for it, I'd pay about the same for my co-pay since in-network is 10% and out of network is 20%. Trouble is, they the insurance company would save over $80!! Seems worth the hassle of processing odd paperwork!!!

Not sure how to suggest proceeding, but ask about service distances, if you live in the wilderness, like I do!

Good luck
Kelvin

Have 1 suggestion on working with Kaiser. 1) Go to the member services department and discuss this with them. They can work with your primary physician in getting you another equipment. Kaiser has to directly intervene because I believe that Kaiser also has at least 2 DAME that they deal with. I know that in Northern California they do.

Also there could be a contract that Apria has signed with Kaiser on what CPAP machines they will allow payment for.
I have worked in the health care field in Northern CAlifornia where Kaiser reigns and they do have a contract with ARPIA on their oxygen equipment whereby they have "standard equipment" and will not give upgrades to Kaiser patients. This is the downside of working wth HMOS. But Kaiser has written exceptions when it was deemed an absolute necessity for the patient to have certain piece of equipment.

I have healthnet ppo and Apria is a preferred provider with them as well and they would only allow me to get the Respironics SEries m autoflex and when I wanted another brand they would not even consider it. I now have filed a grievance with my insurance company against APRIA.

Newbie wrote

Spoke to the Dr. and got him to approve a humidifier but he says he can not specify data capable.

You need to clarify with the Dr. whether he is saying "he can not" or "he won't" regarding a data capable unit. I suspect that he is really saying that "he won't".

I have a Medicare HMO with Kaiser Northern CA. I had to stand my ground with the Sleep Dr. in order to obtain a data capable machine (w/o humidifier) that would be covered by my HMO (my 20% copay was $236). I bought (during the same week) an equivalent machine online as a backup for $526 including free S&H. I received my backup machine in 2 days from 880 miles away - it took more than a week for me to receive my insurance covered machine from the DME located 20 miles away (both places had it in stock).

IMHO, if you accept a compliance only machine, you have a < 50% chance of succeeding. You will significantly improve your chance for success if you buy (online) a data capable machine IF you can not get your Dr. / Insurance to provide you with a data capable machine. Don't waste your $150 copay on something that provides no feedback. You wouldn't buy a car without headlights (and drive blind at night) so don't buy a compliance only CPAP (and try to figure out without any useful data what is happening during the night when you are hooked up to a machine that is supposed to help you get a restful sleep).

Will Kaiser reimburse for "out of network" purchase? Health Net paid 50% of what I paid online. Not as cheap as letting Health Net/Apria supply the machine, but I did get what I wanted.