Difference between revisions of "Dealing with a DME"

Revision as of 02:07, 22 January 2018

This article is a stub. You can help expand it by becoming an Apnea Board Wiki Editor.

The acronym DME stands for "Durable Medical Equipment". "DME" is also loosely used to refer to a company that sells medical equipment or to the individual representative of an equipment supplier; it is in this context that we use the term "DME" in this article.

Advice for brand-new patients

Read this. New to CPAP - The Process

Documentation is important.

• Get a copy of your Sleep Study/Studies.
• Get a copy of your Prescription

Most users do not need a BiPAP/BiLevel or an ASV machine. Thus most users need a CPAP machine (BiPAP/BiLevel or an ASV machines treat more advanced apneas) Within these basic CPAP machines are many models with different capabilities. The machine of choice is an Auto CPAP. The most recommended Auto CPAP recommended on the Apnea Forums is the ResMed AirSense 10 AutoSet (best choice) (E0601) with heated hose (Fixed CPAP, Auto CPAP) (or the for her version) Another good machine is Philips Respironics DreamStation Auto CPAP Machine (DSX500x11) (Not all DreamStation Models, Check SN on bottom, bricks look the same) (Fixed CPAP, Auto CPAP) (best choice)

Why you want Auto CPAP.

• It is a very versatile machine
• It can be used in either Fixed CPAP or Auto CPAP modes
• It provides Compliance Data
• It may be used for home-titration
• It provides full efficacy data (detailed data down to breath by breath info if necessary) that can be read and evaluated by doctors office to modify treatment or yourself for “info. This data can either eliminate the need for an additional sleep study or highlight the need for an additional study.
• You will be using this machine every night for about 5 years, It is likely that your treatment will change over this time. The autoset function will adjust pressure as required to meet changing circumstances (even mundane things like sleeping on your back or side)
• The "For Her" includes an extra algorithm which provides gentler pressure changes and is (apparently) more attuned to the patterns of apneas experienced by women
• The Resmed machines typically respond much faster to precursors, killing many apneas before they get a chance to develop
• These machines are supported by SleepyHead software to allow you to monitor and optimise your own treatment.

Read this APAP Prescription

On-Line Purchase

If you do not have insurance, Medicare, have a high deductible, etc. to help you pay for your machine or supplies, this is the way to go. Options include various on-line DME suppliers, Amazon, craigslist, other private purchases. Try to use known suppliers.

CPAP Supplier List is a list of on-line DME suppliers generated by Forum Advisory Members. Read the cautions in this link. Craigslist is a private sale, use all due cautions.

The used (craigslist) market is available without a prescription, but the choices and prices are all over the place.

It is highly recommended to post to the Apnea Board Forum for current information on on-line sales.

In the US a prescription for CPAP has been a requirement since the beginning of CPAP use. (CPAP machines are an FDA regulated class II medical device in the U.S., which requires a prescription). In recent years, FDA regulations have also included CPAP masks as an "integral" part of a CPAP and therefore also classified as part of a class II medical device as well (prescription required for those as well). That said it is possible to purchase without a prescription.

Handling the DME

The DME gets paid the same for a (ResMed AirSense 10 AutoSet) state of the art Auto CPAP as it does for a much cheaper, potentially older model, fixed CPAP that has no data capability (affectionately called a brick). The “Brick” will be more profitable for them, and much less useful for you. YOU are the customer. YOU have the right to choose your DME. Do not be afraid to go elsewhere to get what you want, and let your DME know that. Know what model machine you want, not just the brand. For example below are two current ResMed models. If your Rx is for a "CPAP" with Humidifier, in the ResMed line you could get either of these.

AirStart™ 10 Auto CPAP with HumidAir™ Heated Humidifier (you do NOT want this machine) $400 retail May 2017

• Compliance Data to SD Card
• NO detailed efficacy data, which is used to identify alterations and tweaking of your treatment.
• Operation Modes
• Fixed CPAP only

AirSense™ 10 AutoSet CPAP Machine with HumidAir™ Heated Humidifier $883 retail May 2017

• Compliance Data to SD Card
• Advanced Data
• Operation Modes
• Fixed CPAP
• APAP
• Detailed breath by breath data indicating how you are responding to all breathing events thru the night

The DME gets paid, from your insurance, the same for both of these devices, which do they make more profit from?

How to make it easier

Your leverage: You have a choice of which DME you use, you can always use another DME, if you do so the original DME makes nothing. They frequently try to make you think you have no choice.

Think of the DME as a grocery store. If the grocery store doesn't want to sell you what you want to buy, what do you do? If the employees of the grocery store are rude or obnoxious, what do you do? I go to a different grocery store.

If your prescription states a specific model and states dispense as written (DAW), the DME has no choice. Work with your Doctor to do this. Know the reasons that you want an Auto CPAP. Most doctors wand to prescribe a fixed pressure. Point out that an Auto CPAP will operate in Fixed CPAP mode BUT has the flexibility to switch to Auto CPAP if needed.

You want to get a New machine. You will be using it for about 5 years and usage hours (not therapy hours) should be very low. (DME’s have been known to provide “used” machines as new.) So learn how to get to and read the usage hours for your machine.

Call the DME before you show up and let them know what you expect to get, specifically an AirSense™ 10 AutoSet CPAP Machine with HumidAir™ Heated Humidifier and Heated Hose. Let them know that you are an INFORMED customer. When you jump into the clinician menu to check the total hours they will be surprised.

Masks are extremely important. So much so that they are at times called “Interfaces” because they interface between the machine and your face. Masks are typically the hardest to get right. That is because your face is unique. Visits to the DME are opportunities to try masks. Take advantage of these visits. Oh and read the Mask Primer.

User DME interactions

One users Path to machine

Here's my thumbnail sketch of how I got my latest CPAP/ASV blower:

1. I called my health insurance Customer Service, we discussed which DME's were in-net nearby, I noted names/addresses/phone #
2. I called above noted DME's to decide which I wanted to deal with, determined mostly by geographic location and products carried, AND by reputation
3. After the ASV version of PSG, I called the pulmonary docs office to tell them which DME to use for the ASV script
4. Called DME, doc, and insurance MULTIPLE times until my script was filled with newly prescribed ASV
5. Waited 24 hours and repeat step 4 then step 5 over for a few weeks

BTW step 5 has NO sarcastic intent; this is really what happened. I didn't sit very long while waiting on these 3 amigos to do anything. At least one of the 3 heard from me every day until I knew the machine was to placed in my hands on a certain date and time.

Another User

I would call your doctor's office and let them know that the DME they've referred you to is interfering with your ability to get treatment for your affliction. Make it a medical complaint rather than a service complaint because the staff is trained to deal with medical complaints in a much more structured manner. That is, you are more likely to get results that way. One call from the doctor's office to that DME may be enough to get them in gear.

For example, when I told my doctor that I needed my machine because a lack of sleep was having a serious effect on the quality of my life he had his nurse issue a "stat" order. The DME called me a couple hours later and delivered a machine to my home that afternoon.

Medicare and DME (for CPAP)

Go to this site (official Medicare Site). Medicare Supplier Directory Enter your Zip Code then select "Continuous Positive Airway Pressure (CPAP) Devices" The results will be a list of DMEs that you must use for Medicare coverage. Note: This is not applicable to those who have Medicare Addvantage plans, who must check with the insurance company who provides your Addvantage plan.

Medicare CPAP Qualifications CPAP Qualifications (E0601) Patient must meet all the following criteria to qualify for an E0601 device (CPAP)

Patient has had a face-to-face clinical evaluation by treating physician prior to sleep test.

Patient has had a sleep test which meets Medicare Requirements that meets either of the following criteria:

• AHI/RDI3 is ≥ 15 events per hour with minimum of 30 events; or,
• AHI/RDI is ≥ 5 and ≤ 14 events per hour with minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke.

Resulting in

• Diagnosed with OSA (ICD-9 code of 327.23)
• Patient and/or caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.

Medicare usually pays rent to the DME for 13 months, and after that time, you own the machine.

And then there is compliance, min of 4 hrs use for 21 of 30 days, easy since you are going to use this every day for a number of years.

Medicare Addvantage plans

You need to check with the insurance company who provides your coverage. For example, if you check the Medicare site, your only choice may be Apria. My Addvantage plan provides coverage from four different DMEs. Lincare was chosen, which could not be used with conventional Medicare.

Medicaid

Details to come later

Obtaining disposable supplies

For apnea patients, disposable supplies include but may not be limited to; masks, mask interfaces (cushions), headgear, chin straps, filters, hoses and humidifier chambers. For patients obtaining disposable supplies through insurance (personal, employer provided, Medicare, Medicare Supplement, Medicare Advantage etc.) guidelines for replacement intervals vary. For patients that self pay, practically any provider will be happy to sell whatever is needed. Some will ask for a prescription, some will not.

For the patient obtaining disposable supplies through insurance some DMEs will remind you when you become eligible for supplies and others will make no effort to remind their patients making it necessary for the patient to initiate the process. Recent changes appear to make it necessary for the DME to obtain a new prescription for each new supply order. This situation emphasizes the necessity of teamwork all around. More than ever the patient must be actively informed and at times involved in the process. If the doctor and the nurse are not on the same page as the DME the patient may need to add some diplomacy to the mix. It's not unusual for the doctor's nurse to be the key player.

Medicare prohibits auto fulfillment of replacement supplies. You MUST initiate the ordering of all replacement supplies with Medicare. How often can you replace disposable supplies? Look at the Medicare Replacement Schedule.

Note: Many non-Medicare Insurance plans follow the Medicare schedule, but call and ask to be sure.

Obtaining a replacement machine

(insert content here)

Donate to Apnea Board