Let's clear up some misinformation

Are this clown and Therapist related? Hmmmm...

NateS wrote:

Guest wrote: Let me give you an education on how insurance payers apply this statement on a day to day basis, and let's use autoset as the example. There are no studies that show that patients without autoset are going to die or have negative MEDICAL outcomes over a static pressure setting. In fact the vast majority of studies show that autoset improves quality of life, and that's it's main advantage. That, in fact, it does not impact survival at all. Autoset IS seen as a convenience for you and/or your doctor. That's not to say you can't have that feature, just that most insurance payers don't consider them medically necessary, and won't pay for them.…

Why don't you take a rest for a moment from telling us what we already know about the unscrupulous practices of private health insurance companies, and instead give us a reference to the medical studies you claim you know of which have concluded that it is not medically necessary for physicians to monitor xPAP patients' sd card data as part of their reasonable standards of care of apnea patients.

I would like to see and read these studies, in reputable professional medical journals, which you claim knowledge of.

And since companies like ResMed state that their ResScan software has been developed and is distributed for use by physicians and related health care professionals, how do you reconcile that with your assertion that the medical profession has concluded that they don't need this information as part of their reasonable standard of care of apnea patients?

I can't post links here, but I would suggest you go to google and search on "autoset cpap studies" The data collected by the vast majority of studies do not show it as a make or break issue to treatment, which is what the insurance payers want to see to cover those additional features.

And I reconcile my "assertion" (which is actually a fact, not an assertion) by the fact that ResMed and sleep physicians do not get to decide CMS or other insurance payer regulations. When the feature first came available the manufacturer's lobbied the insurance payers very hard to create a separate HCPCS code and they got some physicians to lobby with them. But the insurance payers declined. Millions upon millions of patients had been adequately treated before autoset was invented and they saw no reason to pay extra for this feature.

I don't say it's right, but if you understand the way insurance payers work it makes perfect sense. There are very objective coverage critiera that must be met for payment of every medical device, procedure, etc. For instance, the patient must have an AHI of 15/hr over a mimumum of a two hour period of time to qualify for PAP usage. Or they have to have an AHI between 5 and 14 with additional symptoms to qualify, etc.

So what would be the objective criteria used to indicate that this patient needed autoset? What would be different between patient A and B to indicate that patient A had a medical need for the additional feature?

Keep in mind that there are some physicians who don't feel the autosets are sensitive enough, and don't want varying pressures based on what the machine is sensing. Their concern is that the patient will experience pressure that don't adequately treat the apnea, or that they will be delivered pressures in excess of what they require, decreasing compliance. That's a legitmate medical opinion as well.

LinkC wrote:Are this clown and Therapist related? Hmmmm...

Not that I know of. But I can't say for sure because grandfather's reputation was that he sowed seed deep and wide.

Who are you related to fat cheeks? Is there anyone who would admit to it?

ltts: I think you've made your point about 50 times. The approach you used could be improved if you wish to persuade. If you are the "boss", I'm not sure why you are spending your time this way. I'm a "boss" of a small multinational corporation and I've been working all day, at the moment taking a break because my brain is momentarily numb. I like my Autoset by the way. It works great and saved my ins. co. money with less Dr. visits since I don't have to run to him whenever I want to make a small change.

Have a great weekend. I've got to get back to work, and I suggest you do too.

Thanks.

LinkC wrote:Are this clown and Therapist related? Hmmmm...

LOL -- is there someone else here also trying to clear up some of the misinformation that is so consistently posted here? Apparently anyone who tries to provide actual facts from a professional perspective is unwanted here. That's quite odd. Most forums love having a person with actual knowledge of the questions they have show up on an internet forum and provide education.

In any case, as I have said over and over again, please don't take my word for it. My purpose here is to provide enough information to make folks understand what they may not be aware of, and can then verify with their individual insurance provider. You can't verify if you don't know what you don't know.

NateS wrote: instead give us a reference to the medical studies you claim you know of which have concluded that it is not medically necessary for physicians to monitor xPAP patients' sd card data as part of their reasonable standards of care of apnea patients.

I would like to see and read these studies, in reputable professional medical journals, which you claim knowledge of.

You are barking up the wrong tree NateS and weakening the argument for data. It is not studies that prove to us that having our own data is a reasonable thing to do. It is our own experience with having data to tweak our settings and our mask and improve our therapy. This experience is what proves to us that data (complete data not hours usage) is key to getting the best therapy.

Your argument is also very weak because very few (if any) doctors have the time or staff to monitor the data and make appropriate recommendations. If a doctor has, for example, 500 active patients, who do you think can do a better job of monitoring data - the doctor and 1 or 2 staff members or 500 patients? The answer should be obvious.

No, I completely disagree with you NateS. I don't want a doctor to monitor my data. It is too important to me to leave it to the doctor. I will do it myself.

MaxDarkside wrote:ltts: I think you've made your point about 50 times. The approach you used could be improved if you wish to persuade. If you are the "boss", I'm not sure why you are spending your time this way. I'm a "boss" of a small multinational corporation and I've been working all day, at the moment taking a break because my brain is momentarily numb. I like my Autoset by the way. It works great and saved my ins. co. money with less Dr. visits since I don't have to run to him whenever I want to make a small change.

Have a great weekend. I've got to get back to work, and I suggest you do too.

Thanks.

At this point I am just responding to questions directed at me - not trying to repeat points already made, unless the question is asked again. I think it's quite possible that aside from the people who are mad at finding out that they have been blaming the DME when they should have been blaming the insurance company, future searchers may find this helpful information. Particualary in understanding that if they want a free upgrade they will need to shop around a bit to find a nice DME willing to provide that.

PS. The nice thing about being the boss is that I get the weekends off. And with that said, I think I will chill on the couch and watch some Diners, Drive-ins and Dives. I love that show.

Itts your beginning to sound like a stuck record.

ltts wrote: Of course I agree that the data is important. But any machine with an SD card slot is capable of collecting data. I'm also not saying that patient's shouldn't have autoset systems or systems that monitor your AHI (for as accurate as those machines are). What I am saying is you should not expect your DME provider to buy those extra features for you simply because your insurance company doesn't deem it a necessity. Why is that so difficult to understand?

Right! that proves you no absolutely NOTHING about cpap machines. You are not qualified to offer any information. Crawl back into your little hole and pull the manhole cover over it.

Guest wrote:PS. The nice thing about being the boss is that I get the weekends off.

That tells us a lot about who you are, and who you are not. Thanks. I now can see you. Do yourself and these good folks a favor and enjoy the show.

1. If I went to my DME for the first time and they told me flat out, "Insurance pays a flat fee for all CPAP machines, so for $0 out of pocket, we provide this one. If you'd like to upgrade for a little extra out of pocket, here are your options: {list}," I'd be a little bummed, but I'd understand.

What my DME said was, "if the prescription doesn't list the machine name on it, we select the machine."

2. If when I asked my DME if I could upgrade my machine from a S9 Elite to an S9 Autoset, and they told em flat out, "Your insurance company only pays for a new machine every 5 years, unless your doctor documents it's medically necessary, or you go 100% out of pocket" I'd be a little bummed, but I'd understand.

What my DME said was, "No." When I pushed they added, "The one you've had for the last few months is the only one you get for 5 years."

3. When I asked my DME if an Autoset machine might make me more comfortable or be more effective, if they'd said, "it's possible, but you won't know for sure until you try, you should really ask your doctor" I'd have thought that was a fair answer.

What my DME said was, "your machine's fine."

---

If there's somewhere I could complain to, I would, if nothing else, to get the jerks I deal with re-trained. My point is, a lot of us found our way here because a lot of us have stories like this. We aren't the majority of xPAP patients by a long shot, but we're probably the largest community of them by a long shot.

If we all have stories of being treated worse than we get treated at the grocery store, whatever regulation of DME levels of care is in place isn't enough.

Now, there's 9 pages of posts, and I realize I'm not introducing anything new here, but for you, LLTS, to come on as an anon poster to troll the community is the level of professionalism a lot of us have come to expect from DME's.

Re-read your first post. You want to get out your side of the story. Fine. But walking into a room and insisting everyone is wrong the way you did is horrible communication. Maybe you're not a very good writer, or you let your emotions do the typing. Who knows.

Here's a challenge for you:

You see the complaints, and the confusion. You see our point of view laid out endlessly (we love to commiserate!). You see what we feel we need.

If you know the industry, which according to your post you do, intimately, you can be the one to suggest solutions to these problems. Maybe it's something out there, like we need a congressman with OSA to take up our cause (which I'm sure there's a few).

But shaking a finger at us and pompously lecturing only accomplishes one thing: letting us know you're one more know-it-all infallible asshole DME.

ltts wrote:
I can't post links here, but I would suggest you go to google and search on "autoset cpap studies" The data collected by the vast majority of studies do not show it as a make or break issue to treatment, which is what the insurance payers want to see to cover those additional features.



Keep in mind that there are some physicians who don't feel the autosets are sensitive enough, and don't want varying pressures based on what the machine is sensing. Their concern is that the patient will experience pressure that don't adequately treat the apnea, or that they will be delivered pressures in excess of what they require, decreasing compliance. That's a legitmate medical opinion as well.

Yes studies done and paid for by the insurance industry no doubt.

No not a legitimate medical opinion, but an opinion based on outdated information. Nothing requires doctors to keep up to date. Some of them still believe you need to be obese to have OSA

Kilgore:
Say it, brother!
Praise the LORD.
The purpose of this forum is EDUCATION.
Uneducated opinion is out of place.

BlackSpinner wrote:

ltts wrote: Of course I agree that the data is important. But any machine with an SD card slot is capable of collecting data. I'm also not saying that patient's shouldn't have autoset systems or systems that monitor your AHI (for as accurate as those machines are). What I am saying is you should not expect your DME provider to buy those extra features for you simply because your insurance company doesn't deem it a necessity. Why is that so difficult to understand?

Right! that proves you no absolutely NOTHING about cpap machines. You are not qualified to offer any information. Crawl back into your little hole and pull the manhole cover over it.

Uh huh, I have a degree as an RCP, and 27 years experience in the field, and I "no absolutely NOTHING about cpap machines" (it's know, by the way, not no). Yet the fact remains that a compliance data capable machine is a data capable machine (and your DMEs are not lying to you simply because they don't speak the special lingo you have developed here at cpaptalk).

If you want special features you should really try to learn what they are called. Have a great day!

Kilgore Trout wrote:1. If I went to my DME for the first time and they told me flat out, "Insurance pays a flat fee for all CPAP machines, so for $0 out of pocket, we provide this one. If you'd like to upgrade for a little extra out of pocket, here are your options: {list}," I'd be a little bummed, but I'd understand.

What my DME said was, "if the prescription doesn't list the machine name on it, we select the machine."

2. If when I asked my DME if I could upgrade my machine from a S9 Elite to an S9 Autoset, and they told em flat out, "Your insurance company only pays for a new machine every 5 years, unless your doctor documents it's medically necessary, or you go 100% out of pocket" I'd be a little bummed, but I'd understand.

What my DME said was, "No." When I pushed they added, "The one you've had for the last few months is the only one you get for 5 years."

3. When I asked my DME if an Autoset machine might make me more comfortable or be more effective, if they'd said, "it's possible, but you won't know for sure until you try, you should really ask your doctor" I'd have thought that was a fair answer.

What my DME said was, "your machine's fine."

What your DME told you in each instance is absolutely true. Those are rules set by the insurance payer. What you would have liked them to tell you is not reality. By all means complain to your insurance company. The DME did not make those rules. Complaining to them is pointless.