Does anyone else pay DME extra to get APAP?

At the end of last month I took the prescriptions for CPAP for my wife and I to the BIG DME SUPPLY COMPANY that supplies her oxygen. We were quite satisfied with their Oxygen Department. After 18 bottles and two missed deliveries the first week, it wasn't all that difficult to talk them into a snazzy home fill system with 2 large bottles and 3 small bottles with built-in regtulators. But truth is, after the initial set-up we haven't needed much contact with them.

It was a rude awakening when we went to see their CPAP department. In spite of the fact that our prescriptions called for C-flex, they gave us proprietary RemStar System One CPAP machines that do not have C-flex or data capabilities (other than compliance data). They started us both with Swift LE masks. My wife has a very small nose, but they did not have an XS size nose piece that would fit her. When we called to complain about that, they ordered the Swift FX masks our prescriptions called for. But again, they did not give her the XS size she needs.

She tries sleeping with the machine every few nights, but only lasts a few hours before ripping it off her face because it hurts her nose. I have a different problem. A deviated Septum, small nasal cavities, and severe allergies do not make breathing through my nose easy on good nights. On congested nights, it's almost impossible to breathe through my nose. I tried Benedryl a couple of nights. A neti-pot almost works. Nasonex seems to be keeping one nostril or the other clear enough to use the mask since I started it.

The first DME let me try a Respironics Full Life mask for 3 nights. My wife tells me I was snoring away in the mask, and she even observed me stop breathing repeatedly while wearing it. Since here is no data to check, I'll never actually know what was happening in that mask. Also, in spite of using moleskin, my nose continued to be sore for several nights after I stopped using it.

So I decided there had to be better customer service out there. I did some calling around and found a place that that I thought would work with me. Then I went to see my regular MD, to try to talk him into writing a script for this new company.

But he pushed HIS favorite DME provider on me instead. At this point, I don't really care who we get it from, as long as we get either Resmed S9, or a PR System One APAP (and I was leaning toward Resmed).

I got a call from the doc's favorite DME Supplier today. They got my new prescription from the doc and have a Resmed S9 machine waiting for me. My insurance will rent a basic machine and humidifier for the first 3 months, then buy it outright. (At that point it becomes mine.) The catch is, I have to pay them $250 to upgrade from the basic machine to the S9. (On top of the monthly $15 insurance co-pay.) That seems like as good a deal as I am likely to find.

I say to call your Ins. Co. and ask them cuz w/o knowing who they are and their agreements w/the contracted DME's all we can make are WAG's (wild azz guesses). Taking money from you could be a violation of their agreement.

Also ask if you can buy online and get a refund.

Others may have more WAG's.

I am not aware the Swift FX has an x-small pillow but maybe it does. The Swift LT does have one available. She might have to resort to some kind of nasal cover mask to find something really small or perhaps one of the Nasal Air models has something XS in a prong.

As Gumby said, check with your insurance and see if such an upgrade is allowed. We have seen a few cases where it is (including one man who actually worked for BC/BS when he got his APAP). You are asking for a machine that isn't the basic model your insurance has a contract with the DME to obtain.

When I started on treatment, I was given a basic machine. Later, when I learned a little from this forum, I knew I wanted a data capable machine. I talked to my DME about it, and he said it would cost me an additional $150. I talked to my sleep doctor and he agreed to write a new DX and asked me to have the DME fax him exactly the machine I wanted. The DME did, and the Dr. faxed a new DX to the DME -- and I got my Apap -- and no additional charge. I then got the software for my computer and a card reader. Since, I keep tabs on my treatment, made some adjustments and have an average of 2.3 AHI for several months. Every situation seems to be a little different, so you will have to work out the best you can do in the situation you find yourself. Hope it works out well for you. This treatment has been a lifesaver for me - and I continually improve even after more than a year.

A CPAP is a CPAP. A fully data capable CPAP is still a CPAP. A fully data capable APAP is still a CPAP. All of these CPAPs are HCPCS (insurance code) e0601. MOST insurance companies contract w/the local DME providers at set rates for the various HCPCS codes. Very, very few contract by brand and/or model. Therefore it IS worth checking w/your insurance company regarding this. While quite a few local DME providers do try to charge extra to upgrade to a fully data capable CPAP or APAP, it pays to make sure that it is "legal" according to their contract w/your insurance for them to do so. AND - are you even sure that the local DME provider your family doctor prefers is contracted w/your insurance. Are you sure that the local DME provider YOU prefer is contracted w/your insurance? AND - did you ask your doctor WHY he prefers the provider he insists on. Most likely he has good reason - but - in this day and age you never know if there is some type of "sweetheart deal" involved. MAYBE one of his patients had difficulties w/the provider you prefer. MAYBE he has patients using the provider he is pushing and they are all happy w/them.

I definately agree with those that said to get in touch with your insurance and find out exactly what they will cover. I was told by my DME that the insurance didn't care what brand and they didnt have codes for specific models it was all one code regardless. Typically DME's will try to get you to take the machine they say because that is the most profitable for them when in fact your insurance will pay for whatever machine you want. Luckily my DME didn't give me any hassle when I went in and said I had done some research and wanted the Resmed S9 they said absolutely and set me up with it no questions. From what I hear though that is the exception and not the norm for most DME's.

Did your doctor's prescription specify S9? If so, I don't see how they can give you anything other than that, and I don't see how they could charge you extra for it. The DMEs on this site should be able to answer that question, though. To me it doesn't sound so kosher, but I can't put my finger on why... It's almost as if they've contracted with the insurance company to provide CPAPs, they agreed to your insurance's "allowed amount", and now they are trying to recoup the difference from you. Doesn't sound right.

If this is your doctor's favorite DME, he probably refers a lot of patients there. So he has leverage because they won't want him to be displeased. Get him on board by verifying that he wrote the Rx for that machine specifically, and let him know what is happening.

SleepingUgly wrote:If this is your doctor's favorite DME, he probably refers a lot of patients there. So he has leverage because they won't want him to be displeased. Get him on board by verifying that he wrote the Rx for that machine specifically, and let him know what is happening.

I know it's cynical to ask, but do docs get kickbacks from DME's for referrals? Just curious...

DreamDiver wrote:

SleepingUgly wrote:If this is your doctor's favorite DME, he probably refers a lot of patients there. So he has leverage because they won't want him to be displeased. Get him on board by verifying that he wrote the Rx for that machine specifically, and let him know what is happening.

I know it's cynical to ask, but do docs get kickbacks from DME's for referrals? Just curious...

If they do, it is illegal and unethical. That doesn't mean it doesn't happen, but it means they could face serious consequences if caught.

First, SleepingUgly is right. My doctor told me he refers patients to this company because he wants to be kept in the loop about his patients. He said this company does that for him. He seemed to understand about Sleep Apnea, but knows very little about CPAP machines. When I saw him last week, I asked him to write the prescription for a S9 machine. He didn't seem to know he could.

As I said before, my insurance will rent the machine for 3 months, then purchase it. If the machines we have now are not returned to the old DME supply company before the 29th., they will be able to bill another month. Our insurance is ending when my wife's medical leave of absence is over this summer. That barely leaves enough time to get the insurance to pay for our machines. So there is a sense of urgency about what I am trying to accomplish.

The insurance company has a code for CPAP, and another for Bi-PAP, but does not have a code for APAP. That's why they wanted a letter of medical necessity. The new DME supply company suggested it would be difficult to prove medical necessity to the insurance company's satisfaction without doing another titration study on a congested night. The Nasonex is starting to work, and I am not nearly as congested as I was. Truth is, I don't have time for that.

It really boils down to I want APAP simply because I think it will help me on congested nights. But also, I figure I will have the machine for many years and want the best machine I can get my hands on while I have insurance that will pay for it. So I'd rather pay the $250 and get what I want without having to wait for their permission.

In between doctor appointments today, I drove over to the new DME Supply company so they could copy my wife's sleep study and original CPAP prescription. Since they did not supply her Swift FX mask, they offered to sell me an XS nasal pillow for $22.50. That seemed fair.

They already had my prescription for the S9 and an order for the old DME company to pick-up the machine I have now. I have an appointment with their Respiratory Therapist to pick-up the S9 on Tuesday. The only reason it's Tuesday (instead of today) is I need a few more days to get the $250.

I expected to have to pay another $250 for my wife's machine. The customer service lady suggested because my wife has COPD, she would probably benefit more from BiPap. A BiPap machine won't cost me anything out of pocket. She had already checked with the insurance and a titration study will not require prior authorization.

This afternoon we had an appointment for my Son with the same doctor my wife goes to. We blind sided him with a request for the titration study prescription. I didn't want to give the doctor's office the opportunity to loose it in their system, so I drove to a Staples store and faxed it to the DME supply company.

The Sleep Study place called at 5 pm and made an appointment for my wife for tomorrow (Saturday) night. The report will be typed up on Monday, so my wife will probably be able to pick-up her new machine (BiPAP I hope) on Tuesday when I get mine. On top of that, the sleep study place offered an extra room for me for free, so I won't have to drive back and forth. (Whew...)

The customer service lady showed me the notes she took when she called to confirm coverage. What the insurance will pay for the machine would not cover the retail price of an S9 online. My wife will probably get a different brand of machine that will require different software, but I sure as heck can't complain about the $250 or anything else that happened today.

On a side note, I ran into my MD in the hall of the doctor's office today. He told me the DME Supply faxed what they wanted him to write on the prescription. He also said the DME Supply commented that I must be an engineer (I'm not) because I knew way too much about the machine I want. He also brought-up that he had no problem if I had the software. (That must have been quite a conversation he had with the DME rep...)

I want to thank all of you for helping me. I would not have been able to pull any of this off without the help I got on cpaptalk.com.

Anybody want to make a suggestion about what to ask for if my wife qualifies for BiPAP?

frh wrote:The insurance company has a code for CPAP, and another for Bi-PAP, but does not have a code for APAP. That's why they wanted a letter of medical necessity. The new DME supply company suggested it would be difficult to prove medical necessity to the insurance company's satisfaction without doing another titration study on a congested night.

I wonder if your new DME is just stalling. The code for APAP is the same as the code for CPAP: E601. Call your insurance company directly and let them know. The code is most definitely E601.

frh wrote:First, SleepingUgly is right. My doctor told me he refers patients to this company because he wants to be kept in the loop about his patients. He said this company does that for him.

That is a weak excuse and not a reason at all but you seem happy with it. Any doc can request your records from ANY Dme, as you also can. I smell troubles ahead.

frh wrote:The insurance company has a code for CPAP, and another for Bi-PAP, but does not have a code for APAP. That's why they wanted a letter of medical necessity. The new DME supply company suggested it would be difficult to prove medical necessity to the insurance company's satisfaction without doing another titration study on a congested night. The Nasonex is starting to work, and I am not nearly as congested as I was. Truth is, I don't have time for that.

Fact is, the APAP can be set to CPAP mode. I don't believe any Ins. Co gives a hoot whether you get an APAP or NOT, they pay the same rate based on the E601 code. Think about who does care. You seem happy with it but Something smells here.

frh wrote:In between doctor appointments today, I drove over to the new DME Supply company so they could copy my wife's sleep study and original CPAP prescription. Since they did not supply her Swift FX mask, they offered to sell me an XS nasal pillow for $22.50. That seemed fair.

Maybe you should have called the other DME out on not giving you what you paid for? Or what was prescribed?

frh wrote:My wife will probably get a different brand of machine that will require different software, but I sure as heck can't complain about the $250 or anything else that happened today.

fwiw - 2 different machines will require 2 different software packages which will require someone learn to use 2 different packages (and operating instructions) and likely cost you more than $250. You are sleep deprived, my friend, AND very easy to please. Get both machines from the same mfg., period. You will thank yourself later.

Ever worked on a Chevy, then a Ford?

frh wrote:Anybody want to make a suggestion about what to ask for if my wife qualifies for BiPAP?

You never said if YOU talked with your Ins. Co.? Yes or No?

Knowing what I know now, I suggest you spend all of this weekend here reading and learning and asking questions.

EDIT: and making notes in your notebook. You do have a notebook, right?

Good Luck with whatever you decide to settle for.

DreamDiver and GumbyCT, I started this by calling the insurance company. They told me there is no separate code for APAP. I also called a lot of DME Supply companies that are "in network" with my insurance. None were willing to provide an APAP machine just because I think I need it.

It's unlikely that I would have been able to talk the original sleep study doc into re-writing the prescription for APAP. He got upset with me for asking about keeping track of my own therapy. I couldn't even get him to check the box on the prescription that would have forced the original DME to provide a machine with C-flex.

My regular GP is co-operative, but does not know a lot about CPAP. The DME had to tell him how to write the prescription. All things considered, I don't think I could have done any better.

The first DME gave my wife a Swift LT with nasal pillows that were too big for her nose. (A Swift LT for Her would have solved the problem.) Then they replaced it with a Swift FX, again with nasal pillows that were too big for her nose. They didn't look at how either mask fit her. At this point I simply want to dump them. I do not want to go back and argue with them about anything.

The new DME supply co had nothing to do with those first masks. And they and won't be able to bill the insurance for another mask for another 2 months. I really don't think it was unfair of the new company to ask for $22.50 for the XS nasal pillow. I was just glad they had one in stock. By the way, they offered to sell me any mask I want for what my insurance would actually pay (which is not as much as online prices).

I already had a discussion with the new DME about not settling for an older S8 or M Series machine. My best guess is they will offer my wife a PR System One BiPap if the titration study supports it. Otherwise she will get a System One, or a S9 like I am getting.

I thought about asking for a System One APAP for me so it would be the same software as hers? But I don't dare go near her computer because if it crashed it would become my fault. I think I'd be better off if I just stayed away from her machine and let her work with the DME Supply company (unless she asks for my help).

Another thing. I did not mean to imply that I know much about CPAP. I don't. I just learned enough from this forum in a short period of time to get the machine changed-out before the insurance ends. I could not have done that without the help I got here.

Anyway, I have to get out the door to do some work to pay for this. Thanks for your help.

Keep in mind there are several different PR SystemOne devices as well as several different Resmed S9 devices. You could say the SystemOne and the S9 are the series or line of PAPs and then you need to add the actual model name so we know which ones you are talking about.

For instance: Resmed S9 Elite, Resmed S9 Auto (or is it AutoSet? - I've forgotten) or PR S1 Plus (you don't want it, its not fully data capable), PR S1 Pro, PR S1 Auto, PR S1 BPAP, etc., etc. Resmed will have an S9 VPAP and S9 VPAP Auto out before the end of the year but that isn't going to do your wife much good right now.

frh wrote:DreamDiver and GumbyCT, I started this by calling the insurance company. They told me there is no separate code for APAP. I also called a lot of DME Supply companies that are "in network" with my insurance. None were willing to provide an APAP machine just because I think I need it.

It's unlikely that I would have been able to talk the original sleep study doc into re-writing the prescription for APAP. He got upset with me for asking about keeping track of my own therapy. I couldn't even get him to check the box on the prescription that would have forced the original DME to provide a machine with C-flex.

I'd thought all US insurance companies go by the medicare insurance codes. E601 is the correct code. If your doctor writes the prescription for APAP, they must supply you with APAP. Period. Who is your insurance company? I suspect if your insurance says otherwise, they're pulling a fast one. Call the insurance commissioner for your state and ask him or her to resolve the situation for you.

frh wrote:My regular GP is co-operative, but does not know a lot about CPAP. The DME had to tell him how to write the prescription. All things considered, I don't think I could have done any better.

The first DME gave my wife a Swift LT with nasal pillows that were too big for her nose. (A Swift LT for Her would have solved the problem.) Then they replaced it with a Swift FX, again with nasal pillows that were too big for her nose. They didn't look at how either mask fit her. At this point I simply want to dump them. I do not want to go back and argue with them about anything.

If her nose is really that small she may need to go with a child's nasal mask. I'm not sure, but it may be possible to use a regular, larger-sized nasal mask as a full face for someone who's face is small enough. I've not come across this, but some here may have.

frh wrote:The new DME supply co had nothing to do with those first masks. And they and won't be able to bill the insurance for another mask for another 2 months. I really don't think it was unfair of the new company to ask for $22.50 for the XS nasal pillow. I was just glad they had one in stock. By the way, they offered to sell me any mask I want for what my insurance would actually pay (which is not as much as online prices).

Not much to be done about that. Frankly, I wonder how DME's even stay in business. Surely they can't make any money at it. I imagine it creates a lot of corner cutting. One thing they often do is not supply you with everything that came with the mask. For instance, the Hybrid comes with all three size mouth pillows and three sizes of nasal pillows. At the DME's office, they may try to only supply you with one size and keep the extra pillows. Some won't even give you the mask travel bag. My DME, before I dumped them, would charge my insurance per part for each mask part (strap, nasal pilllow, mouth pillow, clips, bag, etc.) rather than the whole mask unit price - how they actually bought the mask. It's considerably more expensive that way, I assure you. I would never have known if the newbie DME clerk hadn't given me a copy of the health-insurance billing with their prices. When the more experienced rep saw what she had done, she whisked them out of my hands and gave me a different set of agreement forms to sign - with no numbers on it at all. Pretty dodgy, if you ask me. Tell them you want to see the price - what they're making your insurance pay and what they're making you pay out of pocket before you sign anything. If they don't agree - be polite, but walk out.

frh wrote:I already had a discussion with the new DME about not settling for an older S8 or M Series machine. My best guess is they will offer my wife a PR System One BiPap if the titration study supports it. Otherwise she will get a System One, or a S9 like I am getting.

I thought about asking for a System One APAP for me so it would be the same software as hers? But I don't dare go near her computer because if it crashed it would become my fault. I think I'd be better off if I just stayed away from her machine and let her work with the DME Supply company (unless she asks for my help).

I cannot say everyone is better off with APAP. That's not always the case. It's just that APAP gives the interested owner more options. An APAP machine can be set to use CPAP mode, for instance. Whatever machine you get, make sure it is data capable. The most modern machines today include:
PR System One BiPAP Auto with BiFlex - fully data capable BiPAP
S8 VPAP Auto 25 BiLevel - fully data capable BiPAP - don't discount the S8's they really are good machines.
ResMed S9 Autoset - fully data capable APAP
PR System One Auto - fully data capable APAP
ResMed S9 Elite - fully data capable CPAP
PR System One Pro - fully data capable CPAP
If you get an S9 and it doesn't say Elite or Autoset, it may not be datacapable. I'm not sure they make one that way, but they may.
If you get an S9, make sure you get the climateline hose.

If they offer you a PR System One Plus or DS150, it is NOT data capable. Refuse.
If they offer you a ResMed Escape, same thing. Refuse.

From what I understand, M-Series is being phased out. I don't think they're even making it anymore. Any sold now should probably be sold at a bargain. Don't discount the M-Series Pro with C-flex or the M-Series Auto with A-flex if price is a big concern. They are noisier than the newer models, but it may not bother you.

frh wrote:Another thing. I did not mean to imply that I know much about CPAP. I don't. I just learned enough from this forum in a short period of time to get the machine changed-out before the insurance ends. I could not have done that without the help I got here.

Anyway, I have to get out the door to do some work to pay for this. Thanks for your help.

If you have the energy, add up your out-of-pocket costs and compare with what you will be spending for the machine to the DME in the next year. Chances are, it will cost you less to simply buy the machine outright from CPAP.com. I hope you'll be able to resolve the question of whether your insurance can pay for Auto.

Sleep docs who don't want you to have an auto when you show an interest, in my estimation are either too ignorant to be decent sleep doctors, or they simply don't want you to take away business from their very lucrative business model. Make it plain from the beginning that you see this as a partnership, but that you will be taking the reigns of your sleep therapy in order to insure that you can track your results.