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Afraid I'll get stuck with a crappy machine because of my insurance
well, i go back to the sleep clinic tomorrow to discuss the results of my sleep study. im sure he will prescribe a cpap machine. this leads me to worry about my crappy insurance. i have already talked to one dme that takes my insurance and all he did was gripe about dealing with that company. he also told me they will only pay for one kind of machine and one kind of mask. my question is, what if my doctor prescribes something else? what if i get stuck with a crappy bottom of the line machine? is there anything i can do about it? i wonder if all dme places will tell me the same thing? no onwe in the town im from will even take this insurance.
sorry about the lack of capitalization and punctuation. doing this from my phone and it doesnt work so great for this sort of thing.
Views: 371
Replies to This Discussion
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Permalink Reply by Amy on
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Insurance can dictate the machine you get but it will work and it will have the basics you need. It may not have some of the newer programs that may make the machine quieter but it should be okay.
As to the mask. It is true that the company may encourage a company to use the lowest end mask however if the doctor orders a specific mask they have to supply it. Most likely they will not have it in stock and give you a different mask and then never give you the new one. If you have the money I might invest in buying one privately.
Unfortuantely when you have a managed care plan they do have a lot of say over your brand of machine.
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Permalink Reply by Mack D Jones, MD, SAAN on
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There are no crappy PAP machines. They all have their proponents. I used to call the CPAP machine the "C-CRAP" machine because it was a one pressure machine and we are not a one pressure human beings. (and having to return to the sleep lab for PAP titrations is not to my liking for many reasons). But there a lot of people out there who have been using their CPAPs for years and who swear by them (how can I argue with that).
I favor APAP with bilevel, but that's just me. A humidifier is not necessarily a luxury, some must have it. I do believe we all may be headed for SV or ventilator backup machines in the future, but that's another subject.
BTW, some DMEs have a lot of returned machines, practically brand new, that they will sell at a big (negotiable) discount. Don't be shy about asking about them if you are strapped for cash.
The biggest problem is the mask fit. You've got to try as many as you can to find the one that is the most comfortable for you. That perfect fit is out there, don't give up.
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Permalink Reply by Chip Smith on
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Insurance should only be able to dictate whether or not you are responsible for any out of pocket expenses through your copay or deductible ... not what machine you receive.
You should ask your doctor/clinic for the names of 3 DME companies who service your area and then do your homework to figure out which machines you would like or at least find acceptable. If you then call the DMEs up and have an open conversation with them about what you would like, I would bet that you'd find at least one in that group who is willing to work with you.
Good luck!
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Permalink Reply by Allison Keller on
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Wow, this is a very inspiring answer. Thank you SO MUCH!!!
Andy said:Hi Allison,
Your last post was about an hour ago, so 'm hoping you're on your way home with good news!
Unfortunately, this whole apnea/CPAP thing is frustrating, but not impossible.
I've had relatively good experience with my doctor, insurance company, and DME, but not without problems.
I won't repeat my story here (you can search on this site, if you'd like) but I will tell you this. When it comes to the doctor and the insurance company and the DME, remember this phrase: "No means 'Not yet.'"
When the insurance company tells you, "No, you can't get that machine." it only means you haven't talked with the right person yet.
When the DME says, "No, that's the only mask you can have." it only means you haven't talked with the right person yet.
Just remember, the insurance company wants to pay out the minimum possible, and the DME usually wants to do the minimum work possible.
I had to talk with three or four people at my insurance company until I finally obtained a schedule of allowable payments from them. I had to ask the same person five times, before she would finally tell me that I would own the machine after a few months. I had to talk with four people at the DME before I could get them to send me the supplies I wanted.
Now that I have this all figured out, I order replacement masks, tubing, filters on the day the insurance company allows payment, whether I want/need them or not. That way, if/when they ever stop paying, I've got supplies that I need.
Bottom line is, it's your health, and you're going to have to push for what you need and want. Don't believe anyone when they say "no" just keep asking until you get "yes."
Please let us know how your appointment went, and please keep in touch. Especially if you're having any trouble.
Good Luck!
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Jennifer is totally right I am also an RT and a mgr of a DME company look for a DME that will work with you so that you are successful and compliant with your equipment.
Jennifer said:What the DME company means is that most insurances are not going to pay for a machine with "bells and whistles" on it. Tehre is no need for it. There are some insurance companies who do state a specific manufacturer though. As for masks I have never heard of an insurance dictating a specific mask type....these are coded items and the insurance pays for it via code..not mask type. It seems you DME you are working with is not very knowledgeable. I work in DME in sleep as an RT and we do have difficult insurances but they they all will pay for a machine and mask. You may want to find another DME if at all possible. If you aren't able to, don't take their initial word...fight. I fight all the time for my patients to get the equipment they need and that should be the job of your DME company.
Any other questions let me know.
Jennifer
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Permalink Reply by Clueless in Redwood Shores on
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In addition to Andy's excellent advice, may I share with you that I managed to persuade my insurance company to reimburse the purchase of a gray market machine on the Internet which resulted in a lower cost to them than (over)paying the "in-network" provider of DME which offered crappy machines at exorbitant rental prices...
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Too late for now - but - for those newbies who haven't received their equipment yet:
Ask your sleep doctor (or your family doctor if your sleep doctor won't cooperate) to include: "access to Leak, AHI and AI data" and "full face, nasal cushion, nasal pillow or oro-nasal mask of patient's choice" on your equipment order (script).
Any licensed doctor can write a CPAP script. If your family doctor isn't sure just give him a copy of the sleep doctor's script so that he can write one the same except w/the above additions.
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I work as an RT for a national DME co. You should have a wide selection of masks and cpap machines no matter what insurance you have. I know with our company, there are masks that are preferred because we get better deals on them, but the pt still has the right to choose what is right for them and we eat the difference in cost..it's not passed on to the pt..the ins company sees a mask as a mask depending upon the code, not the particular mask. The mask is truly the most important component of the equipment. However, CFLEX on the Respironics units or EPR on the ResMed units is really important when you are on a pressure greater than 10..it makes a tremendous difference in the ability to exhale..ask your dr to write the order specifying those perks on your order. Also, a humidifier is very important..If you don't get one and have allergy-type symptoms, you are too dry and need a humidifier. You can also have a burning sensation in your nostrils and you won't want to use the equipment..Remember, your life depends on this so fight for what is best for you..the dme company can't force you to take a cheaper unit..they are just trying to increase their profit..if the doctor orders a specific unit for you, they must provide it. I wish you the best. Using cpap is life-changing and worth the fight.
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Permalink Reply by Julia on
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My insurance only covers the machine after the $5000 deductible is met, so basically, there is no coverage. I had to find one being sold through Craigslist. It is against eBay rules to sell prescription equipment, however, you can purchase parts there, like hoses, filters, head straps, and pillows (but not put together as complete pieces). My doctor also gave me a sample of the mask I used successfully in my sleep study. This was really a nice thing to do for me. My cpap machine is an older model that only shows compliance, but it works and I am sleeping and feeling much better. I know it would be nice to have all the sleep data, but I feel the important thing is that I am using it and it is working. Good luck!!!!
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Permalink Reply by Mark Andrew Hixson on
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I've read some of your post and i understand your frustration. Do me a favor, this is no joke or scam, i am a cpap user i also own a dme company and a online internet dealer....1800CPAP.COM Call me tomorrow and i will work a price out with you that you will be very happy with. Just call 1-800-274-1366 and ask for mark. Give whoever answers your number and i will return your call. I really like this forum and it would be cool to help someone out. If you have already got a machine feel free to call for advice and i will tell you how it really is........ We could bill your insurance as well but i promise you will be better off just paying for it.....
Allison Keller said:Sitting in the waiting room now. It is appointment time. Will post results tonight from home or later from the phone if I have time. THANK YOU ALL FOR YOUR REPLIES. You have helped me keep from worrying about this too much. I think I will go to a different DME. I believe that is sound advice.
Wish me luck!
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Permalink Reply by Dr. Farhad Hakimi on
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Hi Allison,
You concern is legitimate; however, you should know that even a top of the line CPAP can be very difficult to wear and fall asleep with. I would like to introduce you to an alternative to the CPAP machine, to relieve your sleep apnea. An oral device can be worn at night to open your upper airway and allow you to breath easily and sleep comfortably. The VIAdmd oral device is custom fitted to each individual. This appliance is covered by most medical insurances with a diagnosis of sleep apnea supported by a sleep study. To find out more information about the VIAdmd, please visit our website at:www.viadmd.com.
Hope this find you well
Best,
Dr. Farhad Hakimi
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With all do respect how can you recommend something like this to a patient you've never saw. You don't know what her study looks like and more importantly you don't know that she is going to fail at CPAP.. Controversial comment? Don't mean to offend anyone but i find that very strange...
Dr. Farhad Hakimi said:Hi Allison,
You concern is legitimate; however, you should know that even a top of the line CPAP can be very difficult to wear and fall asleep with. I would like to introduce you to an alternative to the CPAP machine, to relieve your sleep apnea. An oral device can be worn at night to open your upper airway and allow you to breath easily and sleep comfortably. The VIAdmd oral device is custom fitted to each individual. This appliance is covered by most medical insurances with a diagnosis of sleep apnea supported by a sleep study. To find out more information about the VIAdmd, please visit our website at:www.viadmd.com.
Hope this find you well
Best,
Dr. Farhad Hakimi
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