Can I buy my own CPAP machine? (USA)

Thanks for the input, I was worried about that as well. I'm thinking that it may just beBest to rent it for the 13 months and see how treatment goes before considering buying one. My psychiatrIst and sleep doctor said this may not be thecause of my lethargy/depression but since the sleep study showed mild apnea we're going through with the treatment to at least rule it out if I don't feel better after a year on it.

sarajane82 wrote:Thanks for the input, I was worried about that as well. I'm thinking that it may just beBest to rent it for the 13 months and see how treatment goes before considering buying one. My psychiatrIst and sleep doctor said this may not be thecause of my lethargy/depression but since the sleep study showed mild apnea we're going through with the treatment to at least rule it out if I don't feel better after a year on it.

At the end of the year you will own the machine .

Sara, I think you've got some pretty good advice so far. One thing, as others have aluded to, is that you really have to understand how your insurance company reimbursement program works. Most now, I think, have a rental program as you are describing and after a certain period like 13 months - you own the machine. You can have as many machines as you like (if you want to pay out of pocket) but you must have a Rx to buy one. I agree that you should get an autopap that is data capable. If you pay out of pocket, you would pay more, but if your insurance is paying, the supplier likely gets the same amount regardless of the machine, so most suppliers (DME) push the least expensive one to increase their profit margin. I would be a little leary of a Doctor acting as a DME as yours sounds like. Generally, you can ask your doctor to provide a Rx which specifies auto-data capable and that gets around the DME wanting to give you a lesser machine. But, you must understand your insurance company reimbursement rules.
As others have said, get the most machine you can. You can use a smart one like a brick, but you can't use a brick like a smart one.

Good luck,
Jay

sarajane82 wrote:I'm playing phone tag with the doctor's office now about the billing for the CPAP machine. They never seem to call me back, but I am going to call everyday until I get an answer because if I can get one cheaper out of my own pocket, I will be doing that ASAP.

Which is exactly why they haven't and prob won't call you back. They know you can get it cheaper elsewhere. You are trapped in what is known as a "money mill". This doc has no interest in your health - ONLY your money. Find another doc - one who won't care who you buy your supplies from. Don't get charmed by the office staff neither. You will find they will lie right to your face, it's just a matter of time now.

Time for you to just pop in for a face to face with your hand out. Don't leave unless you get it in your hand and don't fall for "we'll mail it to you". Ask your insurance what you need for them to cover future supplies but my guess is just as long as you have had a PSG and Dx they will.

Let your insurance know you are trying to save them money. Do yourself a favor and start a notebook now. Write down questions leaving room for answers and who you talked to when. I always confirm their names up front, I think it let's them know, you know who they are

Good Luck

Sara, just to clarify one thing, most insurance companies use the HCPCS of an item to determine reimbursement. I forget now what it stands for, but you know, its the numbers you see alongside a treatment on your EOB. Most insurance companies don't care the features and benefits, the MSRP, or the invoice cost. They pay by the HCPCS only. For example, the S9 Autoset (smart machine) HCPCS is E0601, the S9 Escape (brick) HCPCS is E0601. Consequently, medicare and most other insurance companies will pay the same amount for either machine. To the insurance company, there's no difference.
You may also want to check with your insurance company regarding the AHI level at which reimbursement is authorized. I don't remember for sure, but I think medicare requires something like 14 in a particular position - could be wrong on this, didn't look it up.
Hope you find this helpful,
Jay

Jay Aitchsee wrote:Sara, just to clarify one thing, most insurance companies use the HCPCS of an item to determine reimbursement. I forget now what it stands for, but you know, its the numbers you see alongside a treatment on your EOB. Most insurance companies don't care the features and benefits, the MSRP, or the invoice cost. They pay by the HCPCS only. For example, the S9 Autoset (smart machine) HCPCS is E0601, the S9 Escape (brick) HCPCS is E0601. Consequently, medicare and most other insurance companies will pay the same amount for either machine. To the insurance company, there's no difference.
You may also want to check with your insurance company regarding the AHI level at which reimbursement is authorized. I don't remember for sure, but I think medicare requires something like 14 in a particular position - could be wrong on this, didn't look it up.
Hope you find this helpful,
Jay

Thanks, Jay. Yeah, I found some of the codes that my doctor was going to be using to bill the insurance, and noticed that there is just one general code for the CPAP machine itself (although I think there may have been another code for a BiPAP machine). Anyway, I don't see any reason why they shouldn't give me a better machine (other than them wanting to keep their profit margin large) but I feel that if I insist on getting a better one and they refuse, I will just demand a prescription and get one of my own.

Even if the doctor's office or DME receives the same amount regardless of which machine it is, I would probably have to pay more for a better machine, right, since I am paying a specific percentage of the billed/allowed amount?

sarajane82 wrote:Even if the doctor's office or DME receives the same amount regardless of which machine it is, I would probably have to pay more for a better machine, right, since I am paying a specific percentage of the billed/allowed amount?

No they are not allowed to do that however they will try to pull that one over on you. That is called" Upcharge " or "Balance Billing"

Two years ago, when I was uneducated on all the information about sleep doctors, DMEs, and CPAP in general, I asked my doctor about an auto machine and he mumbled things about runaway, inaccurate titration, and that all I need is the prescribed pressure. He was linked to the sleep lab and the DME was a part of the operation. They gave me a CPAP machine and mask before my first cup of coffee at the sleep lab. It was a whirlwind experience.

Later,on a followup where I took my machine in for compliance logging, I asked for a copy of my prescription. I had been on a few sleep web sites and was becoming educated. The doctor wrote it, I folded it and put it in my pocket. Later,I looked at it and it said "CPAP supplies". That only allows you to buy a mask and filters and hoses, not a machine. I followed up and got my E601 prescription. Still, the DME can supply a machine that delivers only your fixed prescribed pressure and that's what they will try to do.

Since then, I'm finding that more people are being given an auto machine right off the bat. I had to buy mine. If you challenge the doctor and demand (nicely) that you are given an auto machine, you will save money, but you have to do that up front. It's hard to get them to trade in your machine after it is used.

E601 code on your script will get you the right to buy your own auto machine or receive an auto, provided the doctor tells the DME to provide an auto. That needs to be on the prescription if you are dealing with the DME. E601 will allow you to buy an auto mail order with no questions asked.

DaveLP wrote: Since then, I'm finding that more people are being given an auto machine right off the bat. I had to buy mine. If you challenge the doctor and demand (nicely) that you are given an auto machine, you will save money, but you have to do that up front. It's hard to get them to trade in your machine after it is used.

If they are just "renting" it to me, I don't see why they would have a problem with me trading it in...but maybe I am just being naiive!

sarajane82 wrote:

DaveLP wrote: Since then, I'm finding that more people are being given an auto machine right off the bat. I had to buy mine. If you challenge the doctor and demand (nicely) that you are given an auto machine, you will save money, but you have to do that up front. It's hard to get them to trade in your machine after it is used.

If they are just "renting" it to me, I don't see why they would have a problem with me trading it in...but maybe I am just being naiive!

You are "renting to own" or like a car where you are "leasing" it - you can't return the car until the lease is up without paying a penalty.

BlackSpinner wrote:You are "renting to own" or like a car where you are "leasing" it - you can't return the car until the lease is up without paying a penalty.

I'm not sure that's true. If the provider is "in network," the insurance company may have a contract that requires a "true" rental. The insurance company wants to be be able to stop payments if you "fail" CPAP.

Realize that the doctor's office and DME will lie to you and try to scam you in any billing matter.

Please take a look at the blogpost in my signature below called "What you need to know before you meet your DME".

Your first call should be to your insurance company to understand WHAT they cover (generally, ANY CPAP or APAP machine whith a billing code of E0601 + a heated humidifier and supplies--mask, headgear, hose, filter), HOW they cover it (outright purchase, monthly rental, capped rental--percentage they cover) and WHO they will pay (any DME, only contracted DME's, will they reimburse you for an online purchase?). You also need to know your deductibles and co-pays.

Armed with that information, you can make informed decisions about whether or not you'd save money buying online.

I have to say that having your doctor provide you with a CPAP machine and supplies is HIGHLY suspicious. In many states it is illegal, but even where it is legal, you should question the practice. Your doctor essentially has a captive audience. He can charge you way above what you'd pay elsewhere if you had the time to research and the opportunity to compare machine options and prices. The fact that his office is not transparent about the costs and billing practices for this equipment sends up even more red flags.

Archangle is speaking truth when he says

Realize that the doctor's office and DME will lie to you and try to scam you in any billing matter.

Unfortunately, you cannot rely on your doctor to act in your best interests over his own pocketbook. Beware!

Janknitz wrote:
I have to say that having your doctor provide you with a CPAP machine and supplies is HIGHLY suspicious. In many states it is illegal, but even where it is legal, you should question the practice.

Unfortunately, the scam artists are very good at getting around the laws. They'll claim you didn't actually buy it from the doctor, you bought it from an independent <cough>bulldroppings<cough> third party DME who delivers the item to you at the doctor's office.

They keep changing the laws and rules and the scam artists keep finding ways to work around them.

On the other hand, the vast majority of OSA patients use "dumb" machines, don't track their results and do just fine. Perhaps with tweaking they could do a bit better, but the difference isn't worth the effort for them. Don't feel guilty if you choose the easy way.