Anyone else had their insurance company tell them this?

It's just a bit scary when you first start and only have 1

Whatever you have to do, get backups for everything as soon as possible. As you said, you want to have them in case something happens.

I even wanted a backup machine. It took a year, but I finally got one for no cost to me. Contrary to what it might seem, there is a lot of wriggle room between doctors, physician assistants, DMEs and insurance companies. You have to work them to your advantage.

CowFish wrote:

It's just a bit scary when you first start and only have 1

Whatever you have to do, get backups for everything as soon as possible. As you said, you want to have them in case something happens.

I even wanted a backup machine. It took a year, but I finally got one for no cost to me. Contrary to what it might seem, there is a lot of wriggle room between doctors, physician assistants, DMEs and insurance companies. You have to work them to your advantage.

Thank you! Yes I do want a backup machine eventually too but it just isn't in the budget right now.

And I'm in the process of working things to my advantage as we speak. I'll let you all know if it works.

Whenever you speak to insurance, DME, or doctor, only tell them what you need them to believe
in order to get you what you NEED. Never think of it as dishonesty as long as you plan to use the supplies yourself.
Remember, "Murphy" has no office hours, and never takes a weekend off.

chunkyfrog wrote:Whenever you speak to insurance, DME, or doctor, only tell them what you need them to believe
in order to get you what you NEED. Never think of it as dishonesty as long as you plan to use the supplies yourself.
Remember, "Murphy" has no office hours, and never takes a weekend off.

Well I knew that lenient policy the guy from the insurance company told me about was too good to be true. He said there was no replacement schedule for SUPPLIES and that if I needed something just go get it. So then the DME told me that yes the insurance does have a schedule. A couple more phone calls to the insurance company and DME and this is what I finally learned. Remember, this if for MY insurance company and may or may not be true in your case. My insurance company does not have a replacement schedule because they know that the DME uses a replacement schedule and as long as the DME adheres to its own replacement schedule then my insurance company is happy.

The lady at my DME is being very helpful though. I am having a small issue with my mask and she is going to pretend that I am within my 30 day exchange period and let me get another mask to try. And she lets me keep my other one too. Which is good because it works for me MOST of the time.

Sharrykb wrote:I'm a little hesitant to post how lenient their actual supply replacement policy is though. It seems too good to be true...

It will be fine... my DME is lenient as well. I expect it now and won't be happy if it goes the other way.


Edit: Hi Sharry... we posted at the same time. I still don't think you'll have problems.

ems wrote:

Sharrykb wrote:I'm a little hesitant to post how lenient their actual supply replacement policy is though. It seems too good to be true...

It will be fine... my DME is lenient as well. I expect it now and won't be happy if it goes the other way.

Oh don't get me wrong!!! I am VERY appreciative of how nice and helpful she is. I just have a very curious nature so I can't help but wonder how it works. I guess I should just shut up and be happy.

Sharrykb wrote:

ems wrote:

Sharrykb wrote:I'm a little hesitant to post how lenient their actual supply replacement policy is though. It seems too good to be true...

It will be fine... my DME is lenient as well. I expect it now and won't be happy if it goes the other way.

Oh don't get me wrong!!! I am VERY appreciative of how nice and helpful she is. I just have a very curious nature so I can't help but wonder how it works. I guess I should just shut up and be happy.

Hey... ya don't look a gift horse in the mouth! Do you know that old saying? You might be too young.

ems wrote:

Sharrykb wrote:

ems wrote:

Sharrykb wrote:I'm a little hesitant to post how lenient their actual supply replacement policy is though. It seems too good to be true...

It will be fine... my DME is lenient as well. I expect it now and won't be happy if it goes the other way.

Oh don't get me wrong!!! I am VERY appreciative of how nice and helpful she is. I just have a very curious nature so I can't help but wonder how it works. I guess I should just shut up and be happy.

Hey... ya don't look a gift horse in the mouth! Do you know that old saying? You might be too young.

Nope not too young!

What I am understanding is that there are now TWO hurdles to new stuff:

1. There is still a schedule. So if your mask breaks after two months, the insurance will still not pay for a new one until 3 months have passed.
2. They are not allowed to just automatically replace according to the schedule. No more automatic supply shipments. There has to be some demonstration of necessity. So, you call your DME and say "this cushion is no longer sealing properly" and your DME has something to write down to justify the new cushion.

It may be that your particular insurer requires the DME to call for prior auth for each item. So what that means is your DME is going to be reluctant to order new supplies which have a low profit margin to begin with, since there's more hoops to jump through. And it's going to be a little harder to stockpile supplies than it used to be.

The positive side of this is less waste. Some DME's used to automatically ship supplies according to the Medicare schedule, and we all know that at some point that's ridiculous--having one spare is OK , but 10 is not. The down side is that we are going to have to really push the DME's when we really do need something. The less assertive among us are going to go without.

--and some of those less assertive may simply give up and quit therapy.
--which may well be the motive for such regulations.
Reason enough to fight for your own health!

I also had a tough time figuring out my insurance's rules on CPAP supply replacement. The insurance told me it was as medically necessary, and they had no schedule. The DME tech said I should follow the typical schedule and they would approve it, without needing a new prescription each time. The DME biller again said it was as medically necessary, and the insurance would approve what I needed as long as it was reasonable. They suggested supply replacement on the typical schedule (I ordered a three month supply of 3 mash cushions).

The DME definitely takes advantage of the insurance's liberal policy as they billed a second mask immediately after my initial mask, since they could, instead of doing a free swap (they said if insurance denied it, it would have been a free swap). Sucks for me. At least I do have good coverage...their negotiated amounts have been in line with CPAP.com, and in some cases even less, then I only pay 20%. So as I understand it, for me, I should order what I need, using the typical schedule as a guide, and as long as it doesn't get to be a crazy amount, it should get approved just fine. I wouldn't want items automatically shipped, and actually don't like the robo reminder calls either, since I just use my own calendar.

I hope everyone else has success getting what they need from their insurance. Best wishes.

Anyone remember the days when you bought insurance and they actually sent you a copy of the policy ? Boy do I miss that ! What's online is abbreviated and what's on the phone is uninformed.

the oldie wrote:Anyone remember the days when you bought insurance and they actually sent you a copy of the policy ? Boy do I miss that ! What's online is abbreviated and what's on the phone is uninformed.

Yes, I remember those days. You had no worries about them paying for CPAP machines and supplies.

It was prior to 1981. CPAP had not been invented. You just suffered and died.

The good old days.

Whatever the insurance company tells you about this crises, I bet the rules would have changed by the time you have another similar crises. Insurance companies are constantly tinkering with the rules in the belief it will save them money.

Maybe the issue is that it is too easy for the insurance agencies to change rules.