New Member - Looking for the TRUTH!

Hello all. I am on what seems to be a never ending quest for the truth and I am hoping someone can shed light on a few things. I was first diagnosed with sleep apnea when my wife could no longer stand my snoring and I had a sleep test in October 2007. At that time I was set up with a Resmed S8 Elite with the H3i humidifier. In 2009 I was laid off and moved from Charlotte, NC where I had my initial sleep test and follow up care with my sleep doc. I moved to north central WV and no longer saw the sleep doc for follow ups. In May 2011 I started having episodes of erratic heart beat and was put on a halter monitor. It ended up I was having periods of atrial fibrillation and ended up in the hospital. If you have read this much, please stick with me I'm getting to the point. While I was in the hospital my sister in law brought my cpap to me. She didn't know to empty the water chamber on the humidifier and I didn't think to tell her. The S8 Elite was ruined. The hospital worked with my insurance (which by this time had changed due to a new job) and they got my Rx info from my 2007 study and I was able to get a new cpap from a local DME which is the S8 Escape II with EPR and the H4i humidifier. Now with having this heart issue which they say can be a result of sleep apnea I really started reading a lot about apnea over the last few weeks. Here is what I am tired of getting the run around on. From what I've read the S8 Escape II only records compliance data. When I had the Elite I would take the card in to the doctor, he would download the information, print it out, and we would discuss the data. So now that I have this Escape II and if I am reading correctly this unit records hours used, days used, etc. From what I've read it does not record the apnea related data. I asked the technician from the DME about this today and he said this information wasn't important. Now I'm far from being a genious but wouldn't you want a machine that records the apnea info? When I was in Charlotte the doctor would use this information to monitor how things were going and assess if my settings needed adjusted. When I told the DME this the guy said that wasn't what the data was for, blah blah and that you really needed another sleep study to assess if you needed an adjustment. Now I find this hard to believe and while I know that an additional sleep study is the best way to get info that insurance companies aren't going to pay for it. That is why I believe being able to get this information is important. Am I crazy?
At this point the Escape II is working (or so I think...I guess if I had the data I would know ) but I honestly feel like I am going to be paying for a machine that isn't going to provide important data relative to have success. Can someone please give me some input on this? My wife is sick of me stewing about this.

If you made it this far thank you. I know this was a LONG post.

TODD

This DME wants to treat you like a mushroom: keep you in the dark and feed you sh*t. I've seen others use the analogy of a diabetic being told they didn't need to monitor their blood sugar. Having access to your data can help you know quickly whether your therapy is working or not, and be able to be proactive about it if not. Why should you have to have another sleep study to do that? Methinks I smell a rat which, unfortunately seems not that uncommon with DME's. They'll make more money if they can foist a "dumb brick" (a machine w/o efficacy data) on you.

I feel your frustration, you're right, it is so important to have a data capable machine. Can you insist that you be given a machine comparable to the one you had (S9 Elite)? Can your Dr help you? You may have a fight on your hands but it will be worth it in the end. I hope someone will come along with some better advice. Good luck and keep us posted.

They made a bigger profit on you by selling you a brick. Since it is a replacement for a better model you should insist that is actually BE a replacement - the same level and quality of machine. You didn't get that. Keep resisting and get at least an Elite. They use the same billing code for an S9 elite as for an S8 escape.

And their logic is based purely on their Profit, not on your well being. The DME probably owns a sleep lab where they want you to spend big dollars instead of giving you control over your therapy.

The truth is that your DME wants to make the maximum amount of money off of you (no big surprise there) and one of the ways they do it is giving you the cheapest machine possible because they get paid the SAME amount if they give you that cheap brick as they do if they give you the fanciest machine made. So they have NO incentive to give you a more expensive machine.

Take a look at my blog links below and go to the latest post which is called "help, I'm stuck with a brick." That may help, but this is a unique situation since this is a replacement purchase, not a new rental. That may mean that none of the techniques I suggest will be helpful.

You could try getting a specific rx for an Elite machine (from ANY doctor) and then going back to see if they will swap it out, but I wouldn't hold your breath. The sooner you try this the better your chances of success.

Alternatively, you could buy yoru own. Stick with ResMed so you don't have to buy a new humidifier.

Ladelnutts wrote:When I was in Charlotte the doctor would use this information to monitor how things were going and assess if my settings needed adjusted.

Did the doctor ever actually adjust your settings based on looking at that data?

Cheers,

Bill

Please make sure that you get a data capable machine.
I will recommend the S9 autoset because it can be set to run in straight Cpap and Also in auto pap in case you need it in the future.

The insurance company covers any cpap because they are billed under the same code.
DME wants to make more money buy giving you a dumb brick because they get the same payment from the insurance company no matter which machine They give you but the brick cost less so they make extra $.

When I first got my machine I got the S9 Elite but after reading the posts in this forum I changed to the
S9 auto set. I just called my DME and told him what I wanted and he told me to call my doctor and have her fax the Rx for the autoset. I got it the same afternoon.

Thank you all for the quick responses. I KNEW this guy was blowing smoke up my butt. If you all could bear with me for a few more questions. Who makes the decision as to what unit you end up getting? Is it the decision of the DME? Is it part of the Rx? Does the insurance company decide? From what I could comprehend from the DME that it is either the insurance that decides what you get or it is part of the Rx. In the beginning they did not provide me with a humidifier and they faxed the hospital and got me one. So is it ultimately the Rx that defines the make/model/etc? Is it as simple as going to my primary care doc and talking with him? From there I guess I can do another sleep study - which probably wouldn't be a bad thing. This is a replacement for another machine but this is through a totally different insurance company. Actually I've had insurance from two other companies and now through my employer since I got this cpap.
Should I call my insurance company as well?

Janknitz wrote:The truth is that your DME wants to make the maximum amount of money off of you (no big surprise there) and one of the ways they do it is giving you the cheapest machine possible because they get paid the SAME amount if they give you that cheap brick as they do if they give you the fanciest machine made. So they have NO incentive to give you a more expensive machine.

From everything I've read on this forum, that's only true regarding CPAP and APAP, which share the same billing code. AFAIK, a Bilevel or an ASV is a whole different animal, with different billing codes and different reimbursement allowances.

(That's not to say that the OP needs - or wants - anything different than the machine he had before; just noting that there's a big difference between a Porsche or Maserati and a Ford or Chevy. )

I really depends on the insurance you have. Most private insurances (PPO) are easier to get what the Doctor Rx's. HMO's are a horse of a different color....they can deny and override a doctor's order. Of course, one can always appeal, but they can drag that out for months, if they want. Medicare and VA are still systems unto themselves and others can speak to their rules. I'd advise you to check Janknitz's blog (see post above) and read all her great information on DME's and other information.

The DME must follow the doctor's Rx, unless the insurance denies the request stating it doesn't meet their definition for 'medical necessity.' For example, my charming HMO denied each and every Rx my sleep doctor wrote...finding each machine medically UNnecessary.... in other words, they only wanted to give me a brick. I wound up buying my own machine out of pocket.

I hope you have much better insurance and a doctor willing to write a specific Rx for a machine meeting your needs. It should, preferably, be as specific as possible.... down to brand, model, and features (such as flex).

Don't get into discussions about data with the DME. Set your goal to lobby hard for a fully data capable machine for your own use.... we can help you with software, advice on reading the data, etc.

Should you wind up going in the direction of buying out of pocket, get a more generic Rx so you can buy what you want from an online vendor such as our host, cpap.com. They have a good example of what a Rx should say on their website.

Good luck... keep us posted on what happens.

I'd contact your insurance and tell them that you did not get a comparable machine to the one you had. If you need a perscription for an S9 Elite tht is good, if you can get one for an S9 Autoset... even better.

You may be able to tell them that your doctor wants to see the sleep data and the machine you have now will not provide that. I'm not sure if this will help but you can tell them that you will need a new sleep study if you can't get a data machine.

I had a brick for years, got it when all machines were bricks. I talked to my insurance and they didn't want to replace it since it still worked, so I said okay, it's been more than 5 years since my sleep study, you can either pay for a new sleep study or let me get a machine that gives me data now.

Only regret was not getting an S9 Autoset. I've been inching up my pressure up and an Autoset would have gotten me to where I need to be faster and maybe better therapy on auto. If I can't figure it out, I' will get a new sleep study next year after I finish the co-pay on the machine and it is mine.

John

Janknitz wrote: Take a look at my blog links below and go to the latest post which is called "help, I'm stuck with a brick." That may help, but this is a unique situation since this is a replacement purchase, not a new rental. That may mean that none of the techniques I suggest will be helpful.

Well after reading your blog I am really pissed off and feeling pretty defeated. I'm calling my insurance on Monday to see if they will pay for anything other than a basic cpap. If that's all they pay for then I will look at purchasing my own. If they will pay for anything then I will try and get in with my doctor next week and hopefully get a Rx with more info on it. If all that aligns I'm going to call the DME and tell them I don't want this thing and I'll be returning it. I think I'll see if I can get the S8 Autoset II for on the Rx.

Thanks everyone for the help and info. I wish I would have known this last month.

billbolton wrote:Did the doctor ever actually adjust your settings based on looking at that data?

Cheers,

Bill

Actually he never did make any adjustments to them. Is that normal? Do they ever make adjustments based on that information?

Ladelnutts wrote: Actually he never did make any adjustments to them. Is that normal? Do they ever make adjustments based on that information?

Yes, they can, and do. I was titrated at one pair of levels, and after about a week, I presented the data to the RT and my doctor, and said, "I believe this, this, and this is happening." And my prescription was re-written to reflect the new settings.

Even if Ladelnutts' doctor did not see a need to make a pressure setting adjustment back during the time the doc was looking at downloads from the previous machine, the point is that the doctor was interested in monitoring how things were going, and the machine Ladelnutts had then was capable of showing data that could alert the doctor if a change might be needed. The present machine the DME chose to give Ladelnutts can't provide even a clue about that.