Dealing with Insurance, Doctors & DME

[SuperSleeper]

Get your doctor to give you a written prescription, NOT to phone it, in to his favorite DME.

Take the prescription and go talk to the DME. DO NOT give him the prescription until you talk with him, find out whether he's a jerk, and discuss exactly which machine he's going to dispense to you.

Dollars talk louder than words.

[SuperSleeper]

Get your doctor to give you a written prescription

Amen to that. I had trouble with my DME way over charging, I found an on-line supplier that is seriously cheaper. Here is one example:

My DME charges $173.00 for my mask and that does not include head gear. That's and extra $85.00. This company charges $79.00 for the same mask and that includes head gear!!! Same DME charges $97.00 to read and print out a report for you to hand caryy to your Dr. 15 minutes of work and a few mouse clicks - REALLY!!!

You will need to send them a copy of your perscription for certian items. I've been dealing with them for several month's and have had no trouble. The only draw back is you need to pay outright and then send paperwork to your insurance for reimbursemnt. Takes a few weeks. But to me it is well worth it.

[SuperSleeper]

Hmmmm. My experience w/Medicare primary and BC/BS secondary (thru UAW/GM Retirees) starts back in late 2006 thru current.

Medicare requires a 13 month rent-to-own purchase of a CPAP.
The accessories are paid for outright (humidifier, mask, etc.)
Rusty memory is at least 4 hours use per night and at least 5 nights per week use is required for compliance and payment.
Medicare pays by HCPCS (insurance) code NOT by brand and model.
APAPs are coded the same as CPAPs: e0601
Fully data capable CPAPs and APAPs are coded the same as entry-level, compliance data only capable CPAPs: e0601

As far as insurances, most fashion their requirements on Medicare's requirements.
It is in your best interest to call your insurance (or secondary insurance if Medicare is your primary) and ask what local DME CPAP providers they are contracted with. Hopefully you have the option of more than just one.
Be sure to "shop" each of your options to find one whose staff you are comfortable with, that has a lenient mask exchange policy and that will willingly provide a fully data capable CPAP.

Ask your sleep lab/sleep doctor for a copy of:

1] the doctor's dictated results from each of your sleep studies
2] the full scored data summary report w/condensed graphs from each of your sleep studies
3] your equipment order (prescription)
Always keep these original copies in your files and provide only copies of these copies to the DME providers.
4] you might also want to ask for a CD/DVD of the full sleep study (the raw data). Your lab may or may not be able to provide one (but they aren't always truthful about whether than can or can't). This last request especially is not a usual patient request and may catch your sleep lab by surprise.

You have a LEGAL RIGHT to these copies under HIPAA (assuming you are in the USA).

If your scripting doctor will include "patient access to Leak, AHI and AI" that would preclude the provision of a less that fully data capable PAP. (The new Resmed S9 Escape Auto is NOT fully data capable).

Two pressure settings for a pressure "range" would preclude provision of a straight CPAP. Usually this would be 1-2 cms below your titrated pressure and at least 3 cms above your titrated pressure for the pressure range which would be better than the usual 4 cms to 20 cms pressure range often scripted.
The addition of "full face, nasal cushion, nasal pillows or oro-nasal mask of patient's choice" will preclude providers from limiting you to one model of mask, i.e. only nasal cushion, only full face, etc.

If your family doctor is willing you can ask him to re-write a non-cooperating sleep doctor's script w/the above additions or w/a specific brand and model and DAW (dispense as written) to ensure you get what you want (w/in reason, of course. You aren't going to get a bi-level w/a CPAP script).

I'm sure there's more I wanted to comment on but I don't remember all the issues brought up in previous posts. (I can't walk down the street and chew gum at the same time anymore).

[SuperSleeper]

... I know you must have a prescription to buy any CPAP equipment so let's start there. ...

Correct

... 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. ...

Incorrect. See my previous post.

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

You can bypass the local DME providers and go w/an online DME provider.

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

You are misunderstanding the "rental". Medicare and many if not most insurances purchase PAPs on a "rent to own" basis. In other words, payments are extended over several months (usually 3 to 13 months depending on the insurance) w/ownership of the PAP converting to the patient at the end of the "rent to own" period. And not all local DME providers insist on providing entry level, bottom of the line PAPs to new patients. (See my previous post)

... 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? ...

No. Medicare doesn't care what you buy out of pocket, it doesn't affect your Medicare eligibility items, nor your secondary insurance's.

... I want to start my planning early in order to be organized when those days come. ...

GOOD ON YOU! You are going about it the RIGHT way.

I would suggest that you inform your sleep tech AND write on the paperwork you fill out for the sleep lab that night that you will want the prescription given to you so that you can "shop" your local DME provider options. I'd also give the sleep tech a signed, written request for the copies of your medical records I listed in my previous post if you haven't provided the sleep lab/sleep doctor w/those requests before your titration study. The sooner you request them the sooner you will get them.

[SuperSleeper]

CrayonGrl, how long ago did you work for CMS?? I'm NOT challenging you, I'm asking because I know Medicare recently enacted some changes that I'm not totally "up" on.

... I worked for Medicare (CMS) for 8 years doing med review for DME and I now work for a commercial insurance. ...

YOU are going to be a VALUABLE asset to this forum w/that kind of experience!!!

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

Are you SURE about this? THAT would be a WONDERFUL benefit and make things so much easier if a person is "stuck" w/a difficult secondary insurance or secondary that is only contracted w/one difficult local DME provider!

And, somewhat off-topic, but - I have COPD. I receive 02 concentrator and tanks, etc. from my local DME provider. WILL Medicare pay for a portable concentrator? I have a script for one but haven't presented it to my local DME provider because I want the new SeQual Eclipse 3 and have priced one out of pocket w/a reputable online provider at $3000 when most online suppliers have them priced from $5000 to $7000. I just do NOT do well on pulse and the SeQual can "do" continuous and last longer plus be plugged in to standard electrical outlet or car cigarette lighter and recharge whilst in use. The script is specifically for the SeQual Eclipse 3.

[SuperSleeper]

... 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. ...

jeffy1958, WHY on this good green earth did you erase all your data on your Resmed S9 AutoSet?? For spite? Accidentally? WHY?

Assuming you have ResScan 3.7 or higher (or is it 3.3 or higher) you can keep two files for each night. One a continuous running file of multiple nights from the start of your therapy w/the S9 AutoSet and one for each individual night's data if that is what you want. It requires two downloads, of course, but so what?

If you want insurance to pay for your S9 AutoSet and accessories instead of having to pay for them out of pocket you HAVE to provide them w/compliance data that meets your insurance's requirement. No insurance company is going to risk paying for a CPAP that might be collecting dust in some closet.

[SuperSleeper]

Local DME providers have to shell out a LOT of money UP FRONT to have inventory on hand to provide to new clients in a timely manner.

But they receive their payments for that inventory piecemeal. The bulk of their sales are thru Medicare which means they receive their reimbursement spread over 13 months, 3 months at a time, not monthly; plus the client's 20% copay monthly.

Local DME providers have to deal w/MULTIPLE insurances plus Medicare meaning they HAVE to have experienced, knowledgeable staff to code items properly and to properly submit their billing to the various insurance companies and Medicare.

Rightly or wrongly they are REQUIRED to have at least one Registered Respiratory Therapist on staff and available to supervise staff to fit masks and setup PAP machines according to script or do the fittings and setups themselves. But the DME provider can NOT bill separately for these services. They have to build that into their PAP pricing as well.

Many new clients use the provided PAP and then return it refusing to use it and now the DME provider is stuck w/a USED PAP that had been a NEW PAP when it was provided to the unsuccessful or non-compliant client - and no payment for that new, now used, PAP.

The insurances "rule the roost". Medicare does not pay the billed amount which is pretty much just a pipe dream on the DME provider's part. Medicare sets an "allowed" amount and dribbles out 80% of that "allowed" amount over 13 months, the patient is then responsible for the 20% of the "allowed" amount as their copay monthly. Medicare does NOT allow the local DME providers to sell PAPs to clients out of pocket for less than the "allowed" amount (and I think I am wrong here and that it is the "billed" amount but will go w/"allowed" amount just in case).

Insurances negotiate w/the local DME providers for a set price on PAPs. If the DME provider doesn't want to accept what that insurance offers the insurance just goes elsewhere to find those that will. Most insurances include a clause preventing an "upcharge" if a patient insists on an APAP instead of a CPAP for instance. The providers can ONLY accept what they have contracted w/the insurance company for.

The local DME providers can NOT by contract w/insurances or Medicare charge a client less than the contracted amount w/o penalty of losing their contract.

I'm no bleeding heart for local DME providers - but - I can see where insurances are our biggest problem. And I can understand the reluctance of many to provide any more sophisticated equipment than necessary. I just won't do business w/those that won't provide what I want (w/in reason, of course). But to the majority of newbies to PAP therapy .... what do they know?

[SuperSleeper]

jeffy1958, WHY on this good green earth did you erase all your data on your Resmed S9 AutoSet?? For spite? Accidentally? WHY?

Spite was part of the reason. The other was the date and time were way off. Thanks to the "rocket scientist" at my DME. The day was off by two and the time was off by 12 hrs. The only way I could get it correct was to erase all the data and reset. Not to fear, I've been dealing with and building computers for a very long time. Don't think that for one minute there isn't a "full" backup in this house. I also printed out the entire report and have it tucked neatly in a 3 ring binder.

If you want insurance to pay for your S9 AutoSet and accessories instead of having to pay for them out of pocket you HAVE to provide them w/compliance data that meets your insurance's requirement. No insurance company is going to risk paying for a CPAP that might be collecting dust in some closet.

I can prove compliance - that is no problem. I did send them their card back and recieved a very intersting phone call regarding that card, wanting to charge me $40.00, for what I'm not sure. If it is a new card just like that one, I can get them a-dime-a-dozen!!!

I am currently in a "fight" with that DME about their way over charging for services and equipment. Just to give you and example: They charged $97.00 to download and print out a one page report for me to hand carry to my Dr's visit . 15 minutes and a few mouse clicks. WOW-REALLY!!! $179.00 for a nasal mask that did not include the head gear, that was another $85.00. I found the identical mask WITH head gear for $69.00. Someone is getting bent over the table!!! I doesn't end ther. I have written to every state and federal representitive of mine as well as contacting the 4 major TV stations in the area. Problem is I live in Wisconsin and if you have been followeing the news, well... there's a little fight going on in Madison at the moment.

Local DME providers have to shell out a LOT of money UP FRONT to have inventory on hand to provide to new clients in a timely manner.

Like I told my insurance company and the DME when I recieved their answers why they pay/charge so much:
I was born on a 60+ head dairy farm. I shoveld tons of it and that is what the above "quote" is. First of all it took about a week for my selected DME to get the equipment my Dr ordered. I had a choice of using 2 other DME's and their time was up to 14 days. Second of all - don't ya think the company I can get everything from for about one quarter (1/4) the cost has an inventory as well. Daaaaaaaaaaaa!!!

orry-1: if I may sound a bit put off by your post regarding this topic.

ALL I have to say 'bout that is:

Thank you for allowing me to add that much needed skylight we've been meaning to put in this house, which will be located over this computer!!!

Thank God we live in a country that allows us to do this; voice our opinions and thoughts.

I may not agree with what you say, but I will defend with my life your right to say it!!!

[SuperSleeper]

If you want insurance to pay for your S9 AutoSet and accessories instead of having to pay for them out of pocket you HAVE to provide them w/compliance data that meets your insurance's requirement. No insurance company is going to risk paying for a CPAP that might be collecting dust in some closet.

I realize that I may be the exception, but my BC/BS PPO through a fairly large group has NEVER required any type of proof of compliance for the CPAP I currently have that I purchased 7+ years ago.

And the predecessor to BC/BS (I don't remember who the insurer was before BC/BS) also NEVER required any type of proof of compliance when I purchased my first CPAP 12+ years ago.

Further, neither purchase required that rent to own provision.

I will admit that what you state probably is true in most cases, but it is NOT true in all cases.
Everyone should read their policy book or speak to the insurance company before they even go to the DME to know exactly what they are entitled to.

[SuperSleeper]

Local DME providers have to shell out a LOT of money UP FRONT to have inventory on hand to provide to new clients in a timely manner.

Like I told my insurance company and the DME when I recieved their answers why they pay/charge so much:
I was born on a 60+ head dairy farm. I shoveld tons of it and that is what the above "quote" is. First of all it took about a week for my selected DME to get the equipment my Dr ordered. I had a choice of using 2 other DME's and their time was up to 14 days. Second of all - don't ya think the company I can get everything from for about one quarter (1/4) the cost has an inventory as well. Daaaaaaaaaaaa!!!

My DME & the other 2 major ones in town have only 1 or 2 of the brands & models they sell the most (usually only 1 brand).

They order everything & get it the very next morning.

When I purchased my current Respironics 7+ years ago, I wanted to see a ResMed that the DME did not keep on hand because they and the Hospital Sleep Lab and all 3 of the Sleep Lab Doctors prefer Respironics.

They ordered a ResMed at approx 2:00 P.M. in the afternoon & it was already there when I went back the following morning at about 10:00 A.M. I didn't buy it, but the DME said no problem, we can return it without paying for it.

And, I have to hasten to add that I do NOT think that my DME is that great!