Dealing with Insurance, Doctors & DME

[SuperSleeper]

I have searched the forum over for the same questions I am about to ask with no luck. Of course that doesn't mean I didn't miss them. SuperSleeper wrote a very informative post about dealing with insurance carriers and DME's and my questions came about because of the post. I know you must have a prescription to buy any CPAP equipment so let's start there.

I understand I may not be able to get the "best" equipment due to an insurance decision or maybe even the severity of my OSA. This would ensure I would receive something less than what I've already drooled over on these web sites. As information my primary carrier now is Medicare and I also have a very good BCBS supplement.

First question: If I am willing and financially able, can I bypass insurance and a DME as long as I have a prescription?

Seems I could eliminate substantial rental fees for 6 months to a year (possibly) on a machine I wouldn't have purchased anyway.

I am the type person who buys the best (if I am able) to ensure myself future problems are usually not due to the equipment. I was the same way about golf clubs after buying my first cheap set. When I finally bought the best it was me that was the problem - not the equipment.

Second question: If I did bear all expense on my own at start-up, would it ensure that future mask replacements would be totally borne by
me?

I only know at this point that my sleep study indicated I would be returning for titration (sp.) and was given no details on particulars after my first sleep session. So, why am I concerned with this type thing this early in the game? I want to start my planning early in order to be organized when those days come. I appreciate any comments I might receive on this post. I have enjoyed reading here.

[SuperSleeper]

Hi jimnsc - welcome to Apnea Board!

First question: If I am willing and financially able, can I bypass insurance and a DME as long as I have a prescription?

Absolutely. Get a copy of your prescription, and you can purchase a CPAP outright, bypassing any sort of government or insurance program.

Second question: If I did bear all expense on my own at start-up, would it ensure that future mask replacements would be totally borne by me?

Now that's another story, altogether. Dealing with Medicare and not following all their rules might get you into trouble. Hopefully someone more experienced with Medicare can chime in here to help you.

In the meantime, some things to think about:

1. Does your Medicare provider require some sort of "reporting" to insure that you are remaining "compliant" with your CPAP therapy? (They sometimes have you bring in your machine (for older CPAPs) or have you bring in your memory card to prove that you're using the machine a minimum number of hours each night.)

2. If they issue you a basic no-frills CPAP, and require you to use their machine to remain compliant, and you instead choose to use your brand-new, fancy-dancy auto-CPAP with all the bells-and-whistles, this might cause ongoing coverage issues for you with Medicare.

3. But, as I've heard some say, "what they don't know won't hurt them"... so if they pay for a basic CPAP, you might want to take it, and then use your own machine... as long as they don't have some sort of mandatory "compliance monitoring" set up to insure that you're using their CPAP. That way you can continue to get supplies such as hoses & masks, and maybe filters if the two machines use the same size.

You probably read my other statements in other threads on this, but I'm pretty sure that if you convince your doctor that a new Auto-CPAP is "medically necessary", Medicare will cover it, as long as the doc writes the prescription up properly with a script for a specific make and model of CPAP.

Anyone else have thoughts on this?

[SuperSleeper]

Hi jim would like to congratulate you on doing the research for new cpap prior to your titration as knowledge is important when dealing with doctors and DME ,here in sydney our system works slightly different than yours but can add my two bob worth that you ask your doctor to write a prescription for APAP and dispense as written (becuse apap has all the bells and whistles ,data capable so that you can get in charge of your therapy early on ,and it can also used in cpap mode ) the other thing might add that medicare pays the DME the same amount ,as all cpap/apap have the same code so the DME makes more more profit if he gives you the cheaper ones (no data capabilities ,lcd screen shows ahi , leaks mask fit etc ex S9 escape )and he makes less profit if he gives you the ones with all bells and whistles ex S9 auto set ,good luck .

[SuperSleeper]

Total newbie here (just signed up), but I do know a little be about Medicare and commercial policies. I worked for Medicare (CMS) for 8 years doing med review for DME and I now work for a commercial insurance.

You can bear the costs yourself, but there's really no reason to do so. You can choose the machine you want because all CPAP/APAP machines are billed to Medicare using the same code (E0601) and that code covers the most basic machines all the way to the most hi-tech machines. Medicare does require a 3 month rental period and then proof of compliance at the 4th month (must use 4 hours/night at least 70% of the time over a 30 day period). The DME supplier handles all the paperwork for the compliance report.

I'd let Medicare pay for the rental - just choose your machine. Find a supplier and let them do the billing.

Or, you can buy the items yourself and submit the bill to your DME MAC (Medicare DME contractor for your region).

~off to read more about OSA since I just got my sleep study report today~

[SuperSleeper]

I knew there were smart folks in this forum and I appreciate the comments. I got to thinking about my post and was concerned that you all might get the feeling I was trying to beat the system but I'm really not. I'm just concerned that I get good equipment and wanted to know what my options were. Thanks again - now off to research APAP. I almost hate to admit I haven't been there yet. 'Two bob worth' is a first for me - thanks Zonk. I may use that one to impress my friends, Thanks again, folks!

[SuperSleeper]

I was about to start a new topic about how to deal with DME ,Doctors and Insurance as suggested but i did remember that been discussed before and searched for it and that would serve better purpose ,as it had good input by "Super Sleeper" and "crayongrl " .
Also suggested that the input from members of their opinions and ideas to be combined into a blog or something similar as that would help anyone seeking that information .
Your help and contributions is greatly appreciated and very much needed .
Thanks

[SuperSleeper]

I don't see why a DME would not bill Medicare for the mask and associated equipment if you provided them (DME) with a prescription.

[SuperSleeper]

I'm almost 100% sure I cut all ties with my DME today by what I did with my S9 AutoSet. I down loaded "ALL" my information and have it stored on "MY" computer.

How does that cut the ties with my DME.

The SD card they gave me has been "FORMATED" and I use my own SD card. I erased "ALL" data in my machine and I start from scratch. My DME requires me to bring my card in for down loading in about 3 weeks. Are they in for a suprise, a blank SD card.

It's SPRING!!!

As for compliance, my Dr. has all the information and I can send it to them (insurer) if they need it. She was surprised that I was able to print out the reports she needs and was pleased that I had taken a very active role in my treatment.

I've attached, in PDF form, the final e-mail. My original in black. Our representatives comments in blue, to include the insurance companies rebuttal in black. My final rebuttal in red; that was sent on to the insurance company. ...and still waiting for that call!!! (To bad you don't have an emoticon for holing your breath)



I do not condone everyone / anyone who has to deal with or rely on a DME to do what I have done. I'm sure there are one or two good ones out there - maybe. I'm in somewhat of a fight over this issue. I have plans to try and get State Representatives and / or Media support involved. I have to wait because of all the termoil going on in Madison at this time.

Can You Fight City Hall? I'll give it one hell of a try!!!

I've briefly posted about this in the past. Several wise members have informed me that I will run into a lot of non-caring entities and shouldn't bother. I'm afraid those individuals will have the opportunity to say - I TOLD YOU SO!!! Regardless; I still have to try.

[SuperSleeper]

jeffy1958,

You bring to light one of the things that annoys me the most about medical care today- everyone is charged a different price based one the relationships they have (or don't have) with insurance companies. Imagine going to get a burger, and I pay $2, your pay $8, and the guy behind us pays $24 for the same meal. That is modern medicine, and it's what happens when you let profit enter the medical decision tree.

A DME who has a CPAP with a "street value" of $1,000 might be reimbursed $400 for that machine from Company A, $600 from company B, and they might charge $1,500 (or anything they want) to the guy who walks in off the street. If you cannot figure out what a CPAP (or heart transplant, office visit, lab work, XRAY....) is really worth, how can you make any intelligent decisions at all regarding medical pricing?

And I thought used car salesmen were slick...

[SuperSleeper]

Get the fancy one .
If you have no insurance than you better sprint don,t walk or run to on-line cpap supplier ,in case you do have insurance than it is a bit more complicated here are few points which picked up along the way :
Talk to your insurance before meeting with DME ,find out about your entitlement ,how the system works ,your contributions ,if you have to rent the machine before you can own it ,and if your insurance pay by the billing code E601 than all CPAP/APAP comes under that code as the insurance pay a set amount regardless what machine you chooses and you should not sign anything before you understand what the insurance cover and your out of pocket expenses .
The fanciest top of the line APAP data capable machine with efficacy data should not cost you any more than the cheapest basic machines with no efficacy data which can save you from making a repeated doctor visits or having additional sleep studies .
By having auto titrating machines is like having two machines in one and most of them record overnight data on its LCD sceen and breakdown of AHI .the dumb basic machine which only record compliance only "hours used "is to show that you are using the machine and satisfy insurance requirements ,these machines should not be sold but the DME like to flog them on you as they make more profit than the better ones .once you find out what machine you want ,to be on the safe side talk to your doctor to specify the machine you want on the prescription and write dispense as written .
Let the DME knows that you are aware that masks from Resmed ,Respironics and fisher paykel have a 30 days mask return policy which you can return the mask if tried and been unsuccessful .

Research Research Research
If you are looking for a new machine, the manufactures provide a lots of information on their web sites and are very good place to start machine search .it is very important to know the options you have and find out about the machines that are available before you go to DME to get your machine .
Regardless what model you choose it should have full data capability ,you need to see what,s going on with your therapy as do your doctor ,if your apnea is not under control there is no way for you to know if your machine does not collect data .