Need some advice on working with a DME

So I had my sleep study a month ago, I've been using a rental unit (paid for out of my own pocket) for the past month while traveling abroad, now it's time to find a DME and get my insurance to pay for a machine that I'll keep long term. I live in New York and my insurer is United Healthcare (POS plan 90% reimbursement for medical devices with a 2 year replacement interval). I phoned them and they recommended Apria as a DME. I have read very bad things about Apria on the web, and my initial interactions with them were baffling (their CPAP specialists don't pick up the phone? their voicemail is down, so I have to fax them?!?) so I probably will stay away from them unless I have no other option.

Based on what I have read here and elsewhere, the ResMed S9 Autoset plus H5i humidifier is state of the art and would be good to get. My doctor recommended a unit with EPR and data collection capabilities and this unit of course meets those criteria. The prescription he wrote me specified CPAP not APAP, did not specify a machine by name, nor a humidifier. It specified patient preference for a mask (I am currently using a Comfort Fusion Nasal mask and it works OK but I am dealing with intermittent rash issues and I think I may want a full face mask to deal with mouth breathing and the occasional head cold.) My doctor seems willing to rewrite my prescription to specify particular equipment if needed. (I'm not sure if this will trigger a round of insurance company battles, or if the DME will comply with a dispense-as-written prescription.

So... where do I find a good DME? Local or national is OK with me. What approach will put me in the best negotiating position to get the equipment I want - do I need the prescription specifying equipment by name and dispense as written? In the end am I actually going to be saving money by going through the DME, or should I just bail out and buy a machine on cpapauction.com?

Best,

Dan

Call your insurance company FIRST. Here are the questions you want to ask:

1. How is CPAP equipment reimbursed? Do you require/use a HCPC code or is there are reimbursement schedule for each particular type of machine? (Cross your fingers it's HCPC's codes--the same code is used for CPAP and auto machines, so the insurance company won't care what you get)
2. If the insurance company does NOT reimburse by HCPC code, then you need to ask for the reimbursement schedule for various models and types of machines and if you need additional documentation to get an auto.
3. Does the insurance company require you to use a particular DME provider, or are there preferred providers for whom the reimbursement rate is higher?
4. Based on standard reimbursement, are you responsible for a percentage of the insurance company's negotiated or allowable fee with the DME, or must you pay the difference between the insurer's allowable reimbursement and the retail price of the machine?

Now, if you have a choice of DME companies, start calling around. Tell them exactly what you want and ask if they can (and WILL) supply it with your prescription as written. Ask what your out of pocket costs will be.

Sometimes it is better to order online and pay out of pocket (it is the RARE insurance company that will reimburse you for an online purchase) or you may want to do it if you can afford to just to avoid the hassle. BUT, if you have good insurance, it may be worthwhile to do a little sluething and put up with some nonesense to get most of the machine paid for--after all, you paid for the insurance!

Do you live "in the city" or "upstate"?

here is an example in case you wanted to know, what a cpap prescription might look like which would be faxed to your doctor
from on online cpap supplier:

You'll definitely want to verify insurance, but it sounds like you have a great doctor!
Have you asked him for suggestions for a local DME?

I live in the city (Manhattan specifically). I called United Healthcare and the rep that answered was clueless about whether they reimburse equipment by code or whether they have a schedule based on prescription type (CPAP vs APAP etc). He did say that there are dollar limits and if you want something in excess of the dollar limit you must pay the difference. He didn't state what the limits are, however. If I have to pay the difference on DME inflated pricing for the S9 it's game over, thanks for playing and I'm going to cpapauction.com. He gave me a reference to another DME (Byram Healthcare) that based on their website does not appear to carry CPAP equipment at all. Useless.

Thanks for the prescription iamge.
I've seen the cpap.com prescription form - I have a copy filled out by my doctor btw, it's what I used to get my rental machine - not from cpap.com as it turns out, by cpapsupplyusa.com. Those guys will happily supply an apap, after all, I'm paying. When we get to DMEs and insurance reimbursement it may be another story.

Well, I hesitate to do this, so I'll give a list of disclaimers first:

I have no actual firsthand experience to know if these guys are any good or not, but the owner, Chip, sure talks a good game. I have heard him with his own mouth describe to people the importance of their getting a full-data machine and have heard him tell patients directly of the importance of understanding that any mask that doesn't work should be replaced with a different one at no cost to the customer if returned within 30 days. I met him at an A.W.A.K.E. meeting in Manhattan when his DME company sponsored it. Here is the business:

http://www.sleepsearch.com/providers/14444

Personally, I would still get a list of who is in network for me, and I would check out a place before getting locked in.

The ideal situation, of course, would be to be able to pull off what Den did, but I guess that is rare:

viewtopic/p507065/viewtopic.php?f=1&t=5 ... 29#p488629

If Den's method can't work for you and the most economical thing for you is to go brick-and-mortar DME, then Chip is the only brick-and-mortar-DME-associated human being who has ever made a lick of sense to me when talking about the subject of PAP therapy, in my limited experience. My experience with my former DME soured me from dealing with brick-and-mortar places, but I can understand why someone else would. I buy my stuff online from the sponsors of this forum (cpap.com) and plan to continue doing so.

Anyway, if you decide to call Chip at Restoration Medical Supplies, tell him that if he doesn't treat you right he will have to answer to "jnk". That should scare him. He's seen me in person with my game face on. That's usually enough to scare people. Tell him exactly what you want, what your insurance is, and ask what he would do for you, then check out his place in person. Then if you decide to go with his company and he doesn't treat you right, post here about it and I'll, uh, "confront him" at the next A.W.A.K.E. meeting. If he treats you bad enough, carbonman can fly out with his angry mob to ride the subway with me up to the A.W.A.K.E. meeting next month.

dans wrote:My doctor seems willing to rewrite my prescription to specify particular equipment if needed. (I'm not sure if this will trigger a round of insurance company battles, or if the DME will comply with a dispense-as-written prescription.

Dan, Ins. won't care they will pay one amount, period. DME's don't like it cuz they have less wiggle room but may still try to give only the lowest cheapest machine.

dans wrote:The prescription he wrote me specified CPAP not APAP, did not specify a machine by name, nor a humidifier. It specified patient preference for a mask

That will get you an APAP online or cpapauction.

Someone in your area will have to recommend a local DME. I can only say I started out with Apria. If it wasn't for this site I prob would have failed. If you order online give cpap.com a try.

jnk wrote: to ride the subway with me up to the A.W.A.K.E. meeting next month.

OH BOY....road trip.

I'll come through 'Joosey and get Dori.
Is it the 'Joosey Turnpike into "downtown"?

Rid'n the subway uptown w/JNK,
kick some DME booty,
we ain't gon'a bother to take no names...

Sounds like adventure to me.

GumbyCT wrote:Someone in your area will have to recommend a local DME.

You mean, Connecticut ain't part of the Bronx? My geography must be off!

carbonman wrote: Is it the 'Joosey Turnpike into "downtown"?

From Dori's place, I'd come in through the Holland Tunnel, because I would never take such a sweet lady through the not-so-sweet fragrances of Staten Island.

(Dans, hope you don't mind our banter, since it serves to bump up your thread in the list.)

I can just see the looks on my neighbors' faces when you two come riding up to my front door! BTW, if you want to make fun of the Garden State you'd better call it the Joisey Turnpike! And then you'll have to find out my Exit! I'll never tell!

jnk wrote:(Dans, hope you don't mind our banter,

dans, you're headed down the road many of us have already been down.
It is a Rite of Passage into the cpap world.

My experience:
The Big A that I had to deal with speaks in untruths and are ignorant.
I have UHC also. I was on the rent to own program.
My rent was only $6mth, so I did ok.
This year, they didn't raise my insc. rates....BUT....
they require a $250/deductable for DME equipment...
so there went any masks or other expendables.

The point is....I have experienced and heard too many of these
same stories and have no respect for any DME, sleep ctr. or alleged
cpap help group that I have personally witnessed.
I take care of myself and my equipment
needs through cpap.com and cpapauction.com.

We poke fun at this situation, but cpap and cpap equipment
is serious business.

It's your life.
It's my life.

Become your own best therapist.

DoriC wrote:BTW, if you want to make fun of the Garden State you'd better call it the Joisey Turnpike!

What can you expect from someone living out on the edge of the wilderness.

...........I stand corrected.

I'm wondering what the toll at the tunnel is for a bicycle built for three.

carbonman wrote:

jnk wrote: to ride the subway with me up to the A.W.A.K.E. meeting next month.

OH BOY....road trip.

I'll come through 'Joosey and get Dori.
Is it the 'Joosey Turnpike into "downtown"?

Rid'n the subway uptown w/JNK,
kick some DME booty,
we ain't gon'a bother to take no names...

Sounds like adventure to me.

Thanks carbonman. Always good to have a few people willing to commit violent acts on my behalf in the event that things don't go as planned