I want to scream!

@ LSAT you are right! I am trying to be calm and professional in my dealings with EMP...... I just called and ascertained that my Rx's were received today. I am now awaiting a return call from the person handling my paperwork. I was told she would call within 20 mins. So..... we will see. I just might be pleasantly surprised....who knows!

Emilia, my insurance can be hard to deal with too. Before I left the sleep clinic the clinician told me to ask my DME if i could rent a machine until my s9 arrived. My insurance said the 2 weeks I rented a cpap from my DME would count toward the rent to own on my s9.

So talk to your insurance company about renting one until yours arrives.

Update:
I actually found the EMP folks to be very nice and professional. I was told that if my Rx was for a cpap only, it would have been expedited quickly; however, since the doc specified the ResMed S9 Auto Cpap, they have to first get the ok from BCBS/FL before proceeding to designate a DME to supply my equipment. The gal handling my file said she recommended that I stay on top of BCBS to be sure they are working on my doc's request and not let it sit. So...I will need to dog them about this. She said it could take a week or two for them to approve.....or not.

Ugh.... I am thinking of getting a nice little travel cpap to have as a backup and for this waiting period. Any recommendations?

Emilia wrote:Update:
I actually found the EMP folks to be very nice and professional. I was told that if my Rx was for a cpap only, it would have been expedited quickly; however, since the doc specified the ResMed S9 Auto Cpap, they have to first get the ok from BCBS/FL before proceeding to designate a DME to supply my equipment. The gal handling my file said she recommended that I stay on top of BCBS to be sure they are working on my doc's request and not let it sit. So...I will need to dog them about this. She said it could take a week or two for them to approve.....or not.

Ugh.... I am thinking of getting a nice little travel cpap to have as a backup and for this waiting period. Any recommendations?

Sounds like double-talk to me.
The insurance billing code is EXACTLY the same for APAP as it is for CPAP....."E0601"
Whoever bills your insurance will use "E0601".
Plus, they will bill EXACTLY the same amount for an APAP as they would for a bottom of the line CPAP.


Den

@Den .... yes, I know the codes are the same. The issue is that EMP is not empowered to OK an AUTO CPAP without getting BCBS to sign off on it first. They probably are very reluctant to approve the more expensive machines....but the doc's Rx was specific and states 'medically necessary' so I think it is a formality.

It'll get done....just not as quickly as I wanted.

Emilia wrote:@Den .... yes, I know the codes are the same. The issue is that EMP is not empowered to OK an AUTO CPAP without getting BCBS to sign off on it first. They probably are very reluctant to approve the more expensive machines....but the doc's Rx was specific and states 'medically necessary' so I think it is a formality.

It'll get done....just not as quickly as I wanted.

If the HMO is the hold-up ask them about getting a loaner for you.

snoresliketrain wrote:So talk to your insurance company about renting one until yours arrives.

Emilia wrote:@Den .... yes, I know the codes are the same. The issue is that EMP is not empowered to OK an AUTO CPAP without getting BCBS to sign off on it first. They probably are very reluctant to approve the more expensive machines....but the doc's Rx was specific and states 'medically necessary' so I think it is a formality.

It'll get done....just not as quickly as I wanted.

Seems like a moot point when the billing amount would be the same. And REALLY moot when the doctor has specifically prescribed it.


Den

it's a HMO - they don't give a flying leap about what is and isn't proper - what the doc rxed - what the codes are

I would think the prescription would empower the EMP to get you what is ordered.

rosiefrosie wrote:I would think the prescription would empower the EMP to get you what is ordered.

not necessarily at an HMO - it can happen but it doesn't have to

The issue is that EMP is not empowered to OK an AUTO CPAP without getting BCBS to sign off on it first. They probably are very reluctant to approve the more expensive machines....but the doc's Rx was specific and states 'medically necessary' so I think it is a formality.

I don't buy it. The only one who cares that it is a more expensive machine is the DME. The insurance is going to pay the same amount no matter what machine you get, so they couldn't care less.

Emilia wrote: The Rx is specific for the S9 Auto CPAP machine and states it is to be dispensed as written.

Did you get a copy of this script?

@GumbyCT -- I will have the Rx in hand in a couple of days. I worked with my doc's office staff who handled faxing all the paperwork to EMP today. I asked for copies of the titration study (I have the initial sleep study copy already) and Rx's, and she indicated I could pick them up in a couple of days. This is not a problem. I would have had everything on Monday, but the computer system was down and they couldn't access my report to process my requests. Today, I called to find out if they had accessed the titration report from the lab's computer (my doc is affiliated with this lab), and they had. I went over the Rx's with them before they faxed it to EMP. I also verified with EMP today that the script did, indeed, say what my doc's office said it was written for so I know it was exactly as I stated. So, once I have the Rx's in hand, I plan to upload a copy to cpap.com so I can be ready to buy if it comes to that!

I guess what I don't understand is how might an HMO have override power over a legal document such as a Rx. I am naive on that front, I guess..... I agree that if the code is the same and the reimbursement is the same, what is the difference to the insurance company? The local DME who will be assigned to me by EMP (the middleman) is the one who will be billing the insurance company and writing off the difference from their inflated price. And I really don't get this middle man thingy.....just another level of bureaucracy getting a cut, if you ask me!

the HMO pays for treatment w/o any bells and whistles - minimal required based on the diagnosis

if a vacuum cleaner works, they will pay for a vacuum even if your doc writes you need a CPAP

the DME is to provide whatever minimal machine the HMO issues - if the rx is approved for a higher end model, the HMO pays extra not the DME - this is not how other insurance works just how HMO's work in my understanding so the code is meaningless

just cause the doc wrote APAP doesn't mean the HMO will let an APAP fly through without a few extra letters being written back and forth between the doc and the paper pusher at the HMO -- this all takes time, energy and well..... I hope you are starting to see the picture and sometimes the doc loses and the patient gets the vacuum cleaner

in joining an HMO you accepted what they said would treat you - some are better than others - some listen to the docs better than others

just an HMO is a whole different game

Emilia, stand your ground and get what you know you need. This MIGHT, of course, mean leaving your HMO/DME entourage in the dust and purchasing your equipment out-of-pocket.
And Jules, thanks so much for your explanation of how the HMOs rig this game. I'm not in an HMO right now, but that's one of the options available at my workplace, so it's good to know what their rules are before getting involved in their game.