Noob with Humana/Aprea Experience

[FrankNichols]

I have been annoying people here with silly posts while waiting for my machine from Aprea. I am posting this as a personal experience dealing with Humana/Aprea so that other noobs can hopefully benefit from my experience on what to expect.

First, I am retired and living in the country in North Central Florida in what can only be called Small Town USA. Our entire county population is only 14,000 and has no sleep centers or DME Suppliers. So, I drive 30 miles to a "BIG" town (16,000 in that town alone - wow!) in the next county.

I have Humana/Medicare PPO and they have an exclusive contract with Apria as their sole in network CPAP supplier. That means if you want to stay "In network" and get the best coverage/price you have to deal with Apria. (Apria had about 1000 complaints filed with the BBB in the last 3 years alone, evenly split on charges/billing and customer service issues)

If you want to go out of network, say by from a supplier online, then you have to get pre-authorization from Humana before buying in order to be reimbursed. If you go out of network instead of paying 20% and Human paying 80%, you will pay 30% and Humana pays 70%. In order to get pre-authorization you must have your sleep doctor request the preauthorization then you can buy from anyone and get reimbursed. (That may not be true, but after numerous email exchanges and conversations with Humana, that was the only option I could uncover. I was able to find NOTHING pertaining to how to get pre-authorizations on their website.)

I had my two sleep studies last month, first to diagnose me having OSA and second the titration study to determine what type of machine and what settings I needed. My titration study was done on the 7th of March and my follow up with the doctor on the 10th. My prescription was for a CPAP and a pressure of 10.

I took my documentation from the doctors office and drove to Apria a couple miles away to expedite the process (silly naive me.) In speaking with the Apria representative I was informed that the only CPAP machine they sold was the Airsense 10 CPAP (I don't believe this to be true, but is what I was told) unless the doctor specified a model on the prescription. I was told they would get pre-authorization and notify me in 3 to 5 days of a date to come back and go through training and pick up my machine.

I then checked in here and found the CPAP was NOT the machine I wanted since it did not record very much clinical data. I called my doctors office and ask them to modify the prescription and make it for a ResMed Airsense 10 Elite, which would record the data I would want. That was Friday, 11th and on Monday 14th I called back to verify the Doctor had changed the prescription for me. I was informed the doctor processed requests like that on Wednesdays, and it would be done that Wednesday.

I called back to the doctor's office on Friday 18th, and confirmed the doctor had updated my prescription and faxed it to Apria. I called Apria and confirmed they had received the prescription. I was told they were updating the order and would get back to me in 3 to 5 days once they had pre-authorization on the updated machine/order.

I did not heard from Apria again within the 3 to 5 days and on Friday the 25th I called them to check on status. They informed me that the order had been placed with Corporate on Tuesday the 22nd and they then placed a call into their expediter department and I would be notified via call back on the date to pick up my machine within 24 to 48 hours.

This morning April 4th I had still not received the call back from Apria and so I called again to check the status. I was informed the order was complete and ready for scheduling a meeting for me to come in and be trained and pick up the machine. I was transferred from corporate (btw, the local number at Apria is always answered by the corporate office after winding your way through they rob answering machine.) to the local office/store and spoke with a representative there to setup the appointment for tomorrow morning, Aril 5th.

Summary, 3 to 5 days turned into 3 to 5 weeks at least partial my own fault for changing the order midstream, but it could be worse, so hopefully that phase is over - and tomorrow I will have my machine.

Next, I discussed the costs with the local office and she said they can't give exact pricing until I am fitted for the mask, etc. But, the initial cost will be about $75 which will cover mask, etc and "setup" fees. And then I will rent the machine for 13 months at about $11/month after which I will own it. There will also be recurring consumable supplies that will be shipped directly to me, or I can go pick the up (30 mile drive). The recurring supplies she could not quote until after the meeting tomorrow, but they should be around $20 every 3 months - maybe.

Okay, that is big news, if true. I have heard prices ranging from about that much up to as much as $45/mth. At $45/mth they would be charging close to 300% interest over retail pricing (combined with Humana's portion that would make the machine cost close to $2500) - which I was not happy about, since my Medicare would be paying that inflated price, and my wife and I had decided to just buy outright online and not pay that high of an interest rate. So that is good, if true...

You should note that all of MY costs in this are the 20% that I pay after Humana pays their 80%. And that I have NO deductibles on any of this because Humana/Medicare does not have deductibles on in network purchases of CPAP equipment.

Summary then is, I take partial responsibility for changing the order a week or so after it was originally submitted, which would then require recoding and reprocessing. Based on that they took 2 weeks to get the order done instead of 1 week, not too bad. Based on the pricing, if true (I keep saying if true because 1/2 of all of Apria's BBB complaints were billing or charge related.) But, if the pricing is true, then it is a "fair" price for rental and I am happy about that.

Lastly, I received a second call from them today and was informed that they do not sell the ResMed Airsense 10 Elite per the prescription but would be substituting the ResMed Airsense 10 Autoset and wanted to confirm that I would be okay with that substitution as long as it was set in CPAP mode per the prescription. I told them that would be fine (grinning broadly) since I in fact preferred the autoset over the elite. The price would not change she said.

So, that is my experience so far as a noob getting started with Humana/Apria/Medciare PPO experience in N. Florida. The reason I wrote this is that in searching I found it difficult to find specifics on how the process works and so I had a lot of questions. I understand that everyones situations will vary, and this only applies to my specific case, but hopefully it will give some information to noobs. If you are a noob and have any questions please ask, I will try to answer based on my experience and I am sure the more experienced people here will correct any mistakes I may make.

(OH, a foot note, it may be that the "reasonable" price I got was a result of some recent CMS regulation changes. The CPAP market is booming and expected to be over $10B the year. As a result CMS has cracked down on excessive pricing models used by some DMEs (like Apria?) in order to hold down medicare costs. This is probably also related to the rumors of diagnostic criteria being raised from 5 to 10 AHI for OSA).

[Mosquitobait]

Yay for you getting things going PRETTY smoothly. 2-3 weeks is a common wait time. I'm very envious for those who get a machine within days after going through Medicare. You might consider asking for their written policy if anything goes wrong with the machine during the 13 month rental. If your machine needs repair, do they provide a loaner (they should, if they service Medicare)? What about masks? Is there a return policy if, after a week, the mask isn't working for you and you want another? My local Lincare does not provide such a service and I'm quite disappointed.

You should be aware that each supplier seems to read something different in the rules. Chances are, they will want to contact you monthly for your supplies. They aren't permitted to have an automatic order and Lincare tells me that they don't ship 3 months of supplies (although, I am puzzled about that since they did so for my family member). So find out. I have told them now not to call me and I will call them regularly on a particular date each month. We'll see how that goes. Most importantly, save everything you get from Humana and Lincare. One common complaint I've seen with Apria is double billing that occurs months and months later. If you have all the paperwork, you can jump on it.

[FrankNichols]

Yay for you getting things going PRETTY smoothly. 2-3 weeks is a common wait time. I'm very envious for those who get a machine within days after going through Medicare. You might consider asking for their written policy if anything goes wrong with the machine during the 13 month rental. If your machine needs repair, do they provide a loaner (they should, if they service Medicare)? What about masks? Is there a return policy if, after a week, the mask isn't working for you and you want another? My local Lincare does not provide such a service and I'm quite disappointed.

You should be aware that each supplier seems to read something different in the rules. Chances are, they will want to contact you monthly for your supplies. They aren't permitted to have an automatic order and Lincare tells me that they don't ship 3 months of supplies (although, I am puzzled about that since they did so for my family member). So find out. I have told them now not to call me and I will call them regularly on a particular date each month. We'll see how that goes. Most importantly, save everything you get from Humana and Lincare. One common complaint I've seen with Apria is double billing that occurs months and months later. If you have all the paperwork, you can jump on it.

Thank you very much, I am certain that I would still be waiting if it had not been for all the helpful advice I received on this forum from people like you. I will make note of your suggestions and keep them in mind as I navigate the next step of the process tomorrow - lol... sad that we have to dance to get what should be ours from our insurance company.

Anyway. I will verify how the consumable orders will take place. I am still debating giving them a CC for the rental. We certainly will not under any circumstances give them a Debit card number. There is more protection under the CC contract. Not sure yet... And I know that she said I would be shipped consumables every 3 months, I don't think she said it would be automatic - I will keep that in mind and get clarification..

Thank you

[Dawei]

Frank, my DME is not Apria, but I want to share my experience. I believe it's every other month (not positive on the timeframe) that I receive repeated, automated phone calls from my DME asking if I need any supplies. Only if I respond by calling them back and placing an order for filters or whatever will they ship anything to me. Since I often need nothing, these calls are somewhat annoying and I just let them go to the answering machine. I have heard (probably here on the forum) that DMEs get $ from Medicare just for contacting pts regularly about supplies. So, when those auto calls come in, it reminds me that the DME doesn't care a hoot about pts., they just want the $ from Uncle.

David

[FrankNichols]

Frank, my DME is not Apria, but I want to share my experience. I believe it's every other month (not positive on the timeframe) that I receive repeated, automated phone calls from my DME asking if I need any supplies. Only if I respond by calling them back and placing an order for filters or whatever will they ship anything to me. Since I often need nothing, these calls are somewhat annoying and I just let them go to the answering machine. I have heard (probably here on the forum) that DMEs get $ from Medicare just for contacting pts regularly about supplies. So, when those auto calls come in, it reminds me that the DME doesn't care a hoot about pts., they just want the $ from Uncle.

David

I understand, and in your am my cases we certainly don't need the reminders. Sadly a lot of patients are very bad at compliance and in replacing consumable parts as needed. One of CMS's goals is to improve efficacy as well as cost reductions.

Human has a lot os automated calls builtin at first. Reminders to get vaccinations, annual doctors visits etc. It seemed almost every week I got another call from Humana. At first it was annoying, then I realized that a lot of elderly suffer from lack of medical care because they don't follow up or even do some of the basics. With Humana at least you are given the option to opt out of the reminders, which I did, but I thought it was better for them to do it automatically and then let me opt out rather than the other way. In fact other than a few details I am very satisfied with Humana/Medicare at this point. I am going through a LOT of specialists since it has been 16 years since I had any form of healthcare - I made too much for medicaid and too little to afford insurance. So, now my new Primary is putting me through the ringer to make sure nothin his missed.

Echocardiogram/Stress test are next this week, and Skin cancer examination is next week. Sleep studies already (obviously) and prior to that was every imaginable blood work (some not covered). So far about $10K in tests, and I am about $200 out of pocket.

[trish6hundred]

Hi FrankNichols,
Good luck to you with the new machine and also with dealing with the DME and the insurance company.

[FrankNichols]

Went and picked up my machine today. My experience with Apria was much better than expected. The person I dealt with was professional and knowledgable and answered all my questions directly and without hedging. Considering all the negatives I have heard here, I am very relieved - so far.

The machine I got was the Airsense 10 Autoset, and had zero hours on it (I checked). The rep threw in a couple extra F10 masks for me, and some extra filters. My deal turned out to be $77 up front to cover first month rent and the various parts an pieces not covered by the rent (mask, humidifier, hose, filters, etc.) My monthly payment will be $11.45 and I opted to get 6 months supplies shipped to me every six months (6 masks, 30 filters or so - 1 per week, and hoses) - price for the 6 month package is $70 so little over $10/mth for supplies.

I have the machine at home, I have set it up using the clinicians manual I got here (Thank you) and tested it for 30 minutes. I really like the F10 mask. I then took the card and uploaded the data to Sleepyhead and that is working fine Erased that data from the card and I am ready to start my first night of therapy tonight - YEAH!.

I have my ResMed S+ setup with it, and tomorrow I will receive my CMS-50D+ so I can track BP and Oxygen Sat along with the rest in SH.

I am really excited to get started. I certainly hope that Apria does't screw up, but I am watching closely. I kind of laughed, the "receipt" that they printed me was 8x11 sheets 7 feet long - lol... I read the entire thing!

[OpalRose]

FrankNichols,

[Rcgop]

I too have the same Humana PPO/Aprea setup and had absolutely nothing but good things to say about both. Not knowing anything about anything, I just let them run me through the process. All worked out for the best and I got what I think was a good machine and service. OK, the robocalls are a bit much but I can deal with that. I have also ordered a CPAP pillow and chin strap with good turn around time.

[FrankNichols]

I think it is a very large organization and has purchased small offices everywhere. Some of those are good and some are not. We both are lucky ones.