My CPAP purchase and insurance experience

So in November I was diagnosed with severe OSA (AHI of 114+). Being a frugal person (some would say "cheap SOB") I spent many hours researching available machines, purchase options, insurance coverage, etc.

My Doc prescribed CPAP at 12 cm H2O and was going to provide me with a Remstar Pro machine. He was going to bill my insurance $1400 (they allow $900), write off the add'l $500 and I would pay 20% of the $900 figure ($180)

Heated humidifier was to be billed at an allowable amount of $300, my 20% would be $60.

Additionally, he was going to charge me $100 for the hose and $150 for the carry case. Insurance allows $50 and $100 respectively, and I would pay 20% of $150 ($30)


So for $270 out of pocket, and insurance paying $1080 I would have the CPAP, humidifier, hose and carry bag.

Now just a little bit of internet surfing and I found cpap.com. Their direct price for the Remstar AUTO with humidifier was $760 and it included the hose and carry case (as ALL machines seem to). The price difference between the auto and fixed machine was $215, with my 80/20 insurance coverage, that meant the difference in my cost was only $43. I figured I would rather pay that now instead of buying a fixed pressure machine, and then in a year or so have my situation change to where I need APAP and have to buy a new machine.

Being a gadget freak, I also was intersted in purchasing the card reader and Encore software (which the Doc told me I COULDN'T have, even if I paid him for it as it wasn't covered by insurance and was "restricted")

Due to frequent travels, I was going to need a DC power cord as well but since it wasn't a "requirement" I wasn't expecting insurance to cover this item.

So I bought the machine, software, and DC cord from cpap.com. They offer free shipping on orders over $100, but I opted for next day delivery at a charge of $35. My total out of pocket was somewhere around $950. I was willing to pay it out of pocket and then wait for insurance reimbursement because by my calculations it would save me over $100 vs. gettin the equipment from my doctor. Plus I would be getting an APAP instead of the CPAP.

So I got the gear, have been very happy with it and am learning alot more about OSA. I have done some amature studies and have now "self-prescribed" myself to APAP therapy with a range of 11.5-15 instead of the originally prescribed fixed pressure of 12. I sleep better and the Encore software shows I have fewer Apneas and Hypopneas with that setting. Also less snoring.

Best thing is that I got my insurance claim the other day and they covered 80% of EVERYTHING! INCLUDING the Encore Software, INCLUDING the DC power cord, even INCLUDING the $35 overnight delivery.

Total cost for me out of pocket was $190 for the order. A savings of $80 over what I woild have paid but I got a LOT more in addition to what the Doc was going to give me. An apples to apples comparison and I would have saved $154.

I look at it this way, for $75 more out of pocket I got the APAP instead of CPAP ($215 value), the DC cord ($25), and the Encore software ($99) . not a bad deal eh? THANK-YOU cpap.com.

My first mask, which I could have gotten direct for $150 ($30 after insurance) ended up costing me $60 out of pocket because the Doctor billed all the "pieces" separate. $150 for the mask, $100 for the headgear, $50 for the hose swivel. The direct price of $150 was for a complete unit with all the pieces.

Dealing with insurance can really be a hassle and I know I am one of the lucky ones, I have good insurance. You'd think insurances would make the process easier since it also saves them money (in my case over $300 by my calculations). The whole "we charge what your insurance allows" leaves a sour taste in my mouth. If I go to a restaurant or grocery store they don't "adjust " the prices based on my salary, so why does the medical profession do this? I think most of the problem with healthcare costs could be solved by simplifiying the process.

Bottom line is that it PAYS to do the reasearch, make some phone calls and if at all possible buy the equipment direct and get reimbursed from your insurance. Providers who "contract" with your insurance may be less hassle, but you will pay more.


Wayne

Why bother going to see your physician and going through testing if you feel like the treatment plan is not right. Is the benefit of saving a few bucks more important than properly treating your health? By going your route and getting the machine that give you varied settings is not necessarily the best way. During the test itself that diagnosed you those performing the test may of tried the other settings and those may not of shown to be as beneficial although you feel better now, in the long run not having the proper treatment wont do much for you!

Just my opinion, to each his own.

just passing through wrote:Why bother . . .

It's fascinating to me that being an educated and informed consumer of medical services is viewed with such disdain in the medical community.

It has been well established on this board and others that treatment of apnea generally improves when patients take responsibility and control for their own treatment, as Wayne has done so admirably. Physicians can play a part in this, but often they choose not to.

Physicians may have been "Priests of the 20th century", but no longer. Physicians are not gods and many times they possess scant knowledge about the medical conditions a person is seeing them for. The days of the aura and mystique are gone for good. Detailed information about health issues is so generally available that often the patient knows more about specific aspects of a condition than the physician he sees. And, in most cases, a person knows better about his own health than his physician does anyway.

If physicians were healthier and lived longer than the rest of us, then I'd pay homage, but the facts I've seen suggest otherwise.

Physicians provide a useful service assisting us with specific health problems but I can tell you from personal experience, having gone 27 years with undiagnosed apnea despite two sleep lab experiences, that it wasn't until I took personal control and decided to do my own testing at home that it became obvious to both me and my sleep doc that in fact I have significant apnea.

Pardon me for not bowing down, but to me the health care industry is just that. It has been well established that it is a very bloated and ineffecient industry badly in need of major reforms. I, for one, choose to deal with physicians and others that industry as I would deal with business partners, no better, no worse.

So there's my two cents, too.

[/rant OFF]

Regards,
Bill (I feel better now.)

WilsonVilleUSA wrote: I sleep better and the Encore software shows I have fewer Apneas and Hypopneas with that setting. Also less snoring.

Way to go Wayne. It's great that you've been able to improve your own therapy. And why shouldn't you be able to? (Perhaps the drive-by poster will provide an answer.)

WilsonVilleUSA wrote:Best thing is that I got my insurance claim the other day and they covered 80% of EVERYTHING! INCLUDING the Encore Software, INCLUDING the DC power cord, even INCLUDING the $35 overnight delivery.

Thanks for detailing the absurdities of the existing price structures. I don't expect to be quite so lucky with my own insurance company, where my claim is still in limbo. (But, I have absolutely no regrets about buying direct.)

Regards,
Bill

just passing through wrote:Why bother going to see your physician and going through testing if you feel like the treatment plan is not right. Is the benefit of saving a few bucks more important than properly treating your health?

I have no problem spending money where necessary, I just want to get the most value for what I spend. I also spent a lot of time here and using other resources learning about the condition and what others have gone through. I am certain that my condition IS being "properly" treated.

I have plenty of faith in my sleep doc and was very satisfied. My adjustments amount to only a slight variation over the initial setting. I also did a 10 day trial with each setting, then compared the data. It doesn't take a genious to realize an AHI of 0.7 is better than an AHI of 2.3. It only takes first grade math skills to see that 65 snores is less than 182.

My initial sleep study showed an AHI of 114.4, the follow up with titration showed a AHI of 3. That was a whopping improvment. At home it got a little better, and then after a little tweak, it is now under 1. These are objective results.

I don't worship my physician and believe is he the end all be all. He is essentially my employee. We work together, but I am in charge. He is the expert and a consultant, and is needed to sign the magical forms that allow me to access what I need for my treatment, but I make the final decisions.

just passing through wrote: By going your route and getting the machine that give you varied settings is not necessarily the best way. During the test itself that diagnosed you those performing the test may of tried the other settings and those may not of shown to be as beneficial although you feel better now, in the long run not having the proper treatment wont do much for you!

Just my opinion, to each his own.

My machine can do auto or fixed pressures. It is it's ability to sense and record the data that allows anyone (with the neccessary software) to see what is happening when I sleep. More importantly, this data is "real world" and therefore much more accurate.

My sleep study consisted of a single 6 hour sleep period in unfamiliar surroundings, at a different time of day than I normally sleep, with multiple interruptions. While it is a good starting point, it is far from an accurate picture of my "normal" sleep.

I am a shift worker, working graveyard. Of course, the rest of the "world" assumes everyone follows their schedule and sleeps nights. The sleep lab doesn't run sleep studies from 9:00 am to 4:00 pm when I am normally sleeping.

They used a very small, single "sampling" of my sleep to determine the setting. This was a starting point. Additional data was collected and using the larger, more routine sample the results were analyzed and adjusted. Then another sample was taken and comparisons were made.

It's not just that I "feel" better, the data from the machine supports the changes. EVERY measurment shows improvement. "Feeling" better just backs up and proves that what the data shows is correct.

It's not like I bought a machine off Ebay and then just picked a number between 4 and 20.

I suppose I could have done several more office visits, I expect the outcome would be the same or only minor differences. Since it took me nearly three weeks to get my initial appointment, two weeks for each test and a week to 10 days for the follow ups to the test, I would still be waiting for results.

Instead I am reaping the benfits of improved sleep and the Doctor's valuable time can be spent helping others instead of molly-coddling me through simple tweaking of the adjustments.

WW

Way to go Wayne!!! Congratulations!

Well Done!!!!!!!!!!!!!!!!!!!!!

Very well Done

Well analyzed, well done...and well written, Wayne! A pleasure to read. Adding my "WTG" to the others!