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what to ask my cpap provider
I have had a sleep study (a split study) that showed that I have sleep apnea and that the cpap was effective at a "nine level'". My doctor wrote out a prescription and gave it to his secretary to handle. I was told I would hear from "the provider" early this week to arrange for a cpap trial. I am covered by medicare. I have read a number of the postings that indicate I may not get the best possible equipment from some providers. I have great faith in my doctor, who is a certified sleep specialist with a fine reputation. I assume he would choose a good provider. I still wonder whether I should just follow directions or I should ask some basic questions about the equipment. If the latter, what are the important questions?
Views: 169
Replies to This Discussion
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Permalink Reply by Mike on
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great question. just to kick this off, since i'm sure everyone will have different questions to ask, here are some i think are important:
Will I get a fully data capable machine capable of giving detailed compliance and efficacy data? You'll want to make sure you get one of these fully data capable CPAP machines
Will I get heated humidification? If not, you should insist on it as a matter of comfort.
What is your policy regarding mask returns? They should return any mask, no questions asked, and swap it out with a new one within the first 30 days. A lot of people have trouble finding a mask that's comfortable for them.
How often will you read my compliance and efficacy data, if at all? They'll of course want to check your compliance data, because that's the only way they'll get paid. But any provider worth their salt will also want to check your efficacy data, meaning whether the CPAP machine is being used properly, and not just whether the CPAP machine is being used.
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Permalink Reply by Judy on
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I have OSA and Medicare is my primary insurance. You should ask for a fully data capable CPAP, either a Resmed S8 Elite w/EPR, the newest Resmed S8 Elite II w/EPR or the Respironics M Series Pro w/C-Flex.
Do you have secondary insurance that has DME (durable medical equipment) coverage? Almost all local DME suppliers accept Medicare. If you have secondary coveage as well that will pick up your 20% Medicare copay now is the time to call your secondary insurance and ask them what local DME CPAP suppliers they are contracted with. Unlike Medicare your local DME supplier choices may be quite limited. You will want to go w/a local supplier that is contracted w/your secondary to save yourself that 20% copay.
Medicare and insurances contract w/the local DME suppliers not by brand and model but by an insurance (HCPCS) code. A bare-bone, compliance data only capable CPAP is the exact same HCPCS code as a fully data capable CPAP. So don't let them foist a compliance data only CPAP on you which MANY local DME suppliers will try to get away with w/first time CPAP buyers.
Medicare purchases your accessories outright, but the CPAP itself is purchased via a 13 month capped rental. 13 monthly payments if you are compliant w/use and then the CPAP becomes yours. You will then most likely have to live w/that CPAP for a minimum of the next 5 years.
Billing and reimbursement varies thru out the country which is divided into some 4 districts or so. I can give you the figures for Michigan in 2006. Reimbursements and copays have dropped some since then. But at least it will give you some idea of what to expect.
Accessories:
Billed: $548.00 - Medicare allowed: $499.63 - Medicare paid: $399.70 - CoPay: $99.93
Broken down this was:
a7037 - tubing used with positive airway pressure device -Allowed: $48.00 - Paid: $32.82
a7034 - nasal interface (mask or cannula type) used with positive airway pressure device - Allowed: $130.00 - Paid: $94.11
a7035 - headgear used with positive airway pressure device - Allowed: $45.00 - Paid: $31.80
e0562 - humidifier, heated, used with positive airway pressure device - Allowed: $325.00 - Paid: $240.97
The 13 month capped rental monthly charges:
Billed: $135.00 - Medicare allowed: $99.95 - Medicare paid: $79.96 - CoPay: $19.99
In 2007 Medicare reimbursement dropped to:
Billed: $135.00 - Medicare allowed: $74.96 - Medicare paid: $59.97 - CoPay: $14.99
You do NOT have to use the local DME supplier your doctor sent you to. The MOST important issue w/any local DME supplier is going to be how lenient their mask exchange policy is should you have difficulty w/your mask, how helpful is their staff, how comfortable do you feel w/them.
Your reasons for insisting on one of the fully data capable CPAPs listed above if the local DME supplier gives you any static about your choice:
1] YOU want it and YOU are paying for it
2] You had a split-night study and may well need a few pressure adjustments
3] Both you and your doctor need the data these fully data CPAPs can provide to help pinpoint any problems you are likely to encounter so that adjustments don't have to be made "by guess and by gosh"
4] YOU are paying for it and you have the option of going to another local DME supplier who is willing to provide one of the CPAPs I suggested.
Good luck!
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Can I get a new cpap automatically paid for by Medicare after 5 years with no problem or does mine have to be broken ?
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Permalink Reply by Dan Lyons on
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Les,
You are entitled to a full and complete copy of your sleep study and a copy of the prescription to which the physician issued. YOU NEED TO HAVE COPIES OF THESE TWO ITEMS, no matter who you choose as a provider. Without these items, you are stuck with whom the doctor uses (can you say kick back).
With these items in hand, you can purchase a spare machine and many of the regulated materials you will need in your therapy and continued comfort in the process, from sources who are not in the business to make their monthly salary off of you alone.
Every question you have is an important one to you. Demand answers. You are paying for that service.
The DME or equipment supplier is in business to make money and they do it very well at your and my expense. They are there to take care of you as long as your checkbook is available. Stop the flow of green and they could care less about you.
Arming yourself with a knowledge base is the best medication going into this.
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Permalink Reply by Daniel on
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Do you charge any upgrade fees for particular masks or device models? Do you restrict Medicare patients to particular models. If so, which ones?
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Permalink Reply by RockRpsgt on
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Does a "nine level" mean a pressure of 9? I would also suggest a fully dat capable machine. Listen to Judy she is my resident machine guru.
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With Medicare, you can get a new CPAP after 5 years, no questions asked. it does not have to be broken.
Windi said:Can I get a new cpap automatically paid for by Medicare after 5 years with no problem or does mine have to be broken ?
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Mike, it's not quite true that you can get another CPAP from Medicare after 5 years with no questions asked. There is supposed to be some kind of need to replace the CPAP equipment, and you absolutely must get a new prescription from your doctor. The fact that your doctor has written you a new prescripition is generally considered to be the demonstrated need for the new device.
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Interesting. Thanks for clarifying this. I also think a need can be demonstrated by requiring a fully data capable machine, wouldn't you think?
Daniel said:Mike, it's not quite true that you can get another CPAP from Medicare after 5 years with no questions asked. There is supposed to be some kind of need to replace the CPAP equipment, and you absolutely must get a new prescription from your doctor. The fact that your doctor has written you a new prescripition is generally considered to be the demonstrated need for the new device.
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