Kenwood wrote: Fri Apr 05, 2013
Wow....seriously WTF!!! I'm soooo pissed off at my DME.
I just got off the phone with the lead respiratory tech at my DME company (there is a much more detailed post a couple pages back in this thread about my convo with DME tech). I sent him my SD card on Monday as he personally wanted to look at my CPAP data for the last month. As he didn't think the insurance company would authorize the Auto BiPAP machine. Said the Insurance Co ONLY base their decision on the sleep study/titration results. And looking at those results he says Aetna will not approved the added costs of an Auto. The DME STILL claim they never received the RX fax from my sleep doctor (which has been faxed twice now). Even if they did, they wouldn't submit it to the Insurance company as it would just get denied. WTF...really not even try!!? So went into the whole thing again about why my sleep doctor thinks an Auto BiPAP would help my treatment and such, etc. But the Insurance Company won't look at my machine data from my SD card. That the added costs between a BiPAP and an Auto BiPAP is over a $1,000 dollars and the insurance company won't authorize the added costs as my sleep study/titration doesn't show I need it medically. I said the difference between a PR System One 650 and 750 was not that much money online. He said that retail insurance rates its a $1,000 deference. I said I could buy a PS 750 online for less than a $1,000. Then it gets better. I told him that I'm still dealing with Major leak issues with my mask....get this.....he says based upon the printout from my SD card he's looking at I'm not have ANY LEAK ISSUES.....AT ALL! Are you kidding me!!! (Mind you he hasn't seen this weeks improvement with the new gel cushion). I said I see nothing but Major Large Leaks every night over 33% of the night on Sleepyhead. He said it doesn't show. That I'm now not due for a mask replacement until June. I was done after that!
So needless to say, I'm gonna have a very long talk during my appt with my Sleep Doctor on Monday about this DME company. I'm written up a list of things to talk about (Pugsy - anything you wanna add?). See if they can send my RX's for an Auto BiPAP and Mirage Quattro FFM to a different DME company that will work with Aetna Insurance.
Pugsy wrote: Fri Apr 05, 2013Not that's suitable for public viewing or what a lady should be saying.Kenwood wrote:(Pugsy - anything you wanna add?)
I would have lost it with the "your leaks are fine" statement. Geez....frigging idiots. They would have thought I was most unladylike and said some things that would probably make a sailor blush.
It's not their decision to decide what machine you need...that's between your doctor and any special requirements that your insurance company might have...and I wouldn't be asking anyone but the insurance company what those requirements might be. They don't want to supply the BiPap Auto because they get paid the exact same amount of money for it as they do the BiPap Pro...simple as that. It cuts into their bottom line. Yes, it does cost a little more but their "retail" price difference of $1000 they quoted is NOT what they would pay for the machine. They pay wholesale difference and like to charge retail difference.
I would be classifying them as LSOS and based on the "your leaks are fine"....they don't know squat about what they are doing and apparently don't care about you.
I would be looking for a new DME for sure.
Call your insurance company directly to see if they would really have a problem with the Auto BiPap...I bet they pay by HCPCS billing code and the BiPap Pro (model 650/660) and BiPap Auto (model 750/760) have the exact same billing code.
Now if you were asking for the BiPap ASV model 950...that's a whole different billing code and yeah...probably some additional hoops to jump through but we aren't suggesting that machine.
Insurance/DME company update: Mon Apr 22, 2013:Kenwood wrote: Insurance/DME company update: Fri Apr 19, 2013:
Called my Sleep Doctors office yesterday. My doctor reviewed the email I sent her with all my recent SleepyHead charts showing the last 2 weeks (showing her more for my snore levels) which had a week using the Mirage Quattro FFM versus the week using the Aloha Nasal Pillow mask. She wrote and faxed my new DME an RX for the Aloha. They said they also faxed over the RX for the Auto BiPap machine. I placed a call to my CPAP rep at my DME company (US Med) asking her to give me a call regarding the status of my machine RX (as they had a call into my Sleep Doctor). But I also called and talked with my Health Insurance Company (Aetna). My Insurance basically doesn't give a crap what CPAP machine or brand I have - There is only ONE code for a CPAP machine, period. As long as the doctor writes an RX, it shouldn't be a problem (though another medical company does review em - as my original CPAP RX and Sleep Study results were reviewed by this company to see if I meet their requirements for CPAP.) I have a $2,000 per year cap on medical equipment. That cap is the money that Insurance pays, so it doesn't include what I pay out of pocket for my 50%) The bad news is that once I meet my deductible ($100 away), I will be paying 50% for my CPAP machine (rent to own) and all equipment (masks, pillows, hoses, etc). I knew I had crappy Insurance, but I thought after my deductible was met it would be 20% not 50%! Damn!
Spent time of the phone today dealing with trying to light a fire under everyone’s ass trying to get my BiPAP Auto.
Spoke with Old/New DME’s – basically I’m screwed and have to stick with my Old DME for trying to get the BiPAP Auto. I’d lose all of the $400+ rental money I’ve paid to Old DME and would have to start over with the new DME. So I bite the bullet and called the old DME “walks on water” Lead R/T guy. Once he brought up my acct, he basically remembered my situation. They STILL claim to have not received my RX for the BiPAP Auto. So I said, I will email you my RX and did. I told him, look I’m not trying to get the top of the line ResMed S9 VPAP Auto that’s $2,000 online. I’m not even trying for the PR S1 760 BiPAP Auto. I just want to swap out my PR S1 650p BiPAP for the PR S1 750 BiPAP Auto. The price difference 650/750 is only about $100 online. He said that based upon my Sleep Study, it’s not warranted. I told him I called my Health Insurance and they don’t give a crap what machine I have: CPAP, APAP, BiPAP, Auto, VPAP. They have just one code for CPAP. If my doctor writes an RX for a BiPAP Auto that’s fine with them…as long as the insurance company annual payments don’t exceed $2k – which it won’t as I have to pay 50% of everything. He said he’s call me back once he received the script. He didn’t, so I had to call him back. He said he read the script but it doesn’t make sense and he would have to call my doctor for clarification. As you all can see from the history above….yeah right. So I called my Sleep Doctor’s Office and explained everything. They totally understood the money issue of not throwing away $400 in rental money and starting over. So I told her old DME “walks on water” Lead R/T guy’s name and she would call and explain the doctor’s RX for BiLevel Auto: EPAP 4-14cm H2O and IPAP 12-23cm H20. So the Sleep Doctor’s Office person calls me back and tells me that old DME “walks on water” Lead R/T guy is an idiot. He says that the machines cannot take TWO ranges…you can only input one minimum and a maximum pressure. Does this moron not understand what auto titrating BiLevel machine does!?! She tried explaining to him the different between a BiPAP and Auto BiPAP machine but old DME “walks on water” Lead R/T guy continued to state that was impossible. HELL….I could program the damn machine myself as I can get into the clinical menu. So my Sleep Study Office will have my Sleep Doctor personally call old DME “walks on water” Lead R/T guy and educate him….cause now they are pissed off and annoyed.
To be continued until tomorrow’s phone calls….
