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Are "Up Charge" Costs Legal in NY for a better Machine?
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2Tim215 Offline

Preferred Members-2

Posts: 283
Joined: Oct 2012

Machine: S9 ResMed AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Swift FX Nasal Pillow - Medium
Humidifier: ResMed H5i w/Climate Hose
CPAP Pressure: 6cm-12cm
CPAP Software: ResScan SleepyHead

Other Comments: OSA, Fibromyalgia, Rheumatoid Arthritis, Osteoarthritis, Gout, PTSD, & Meralgia paresthetica.

Sex: Male
Location: Finger Lakes Region, NY

Post: #1
Are "Up Charge" Costs Legal in NY for a better Machine?
I have been working hard on learning more about my sleep disorder and trying to figure out why current treatment hasn't worked (approx. 22 months). It seems that the machine may be the culprit and the only way to know is to switch. There is no doubt I need an AutoPap from all the information I have learned and as I shopped around for one I find most DME's aren't being honest with different reasons why I don't need one. Recently I found a DME who has the AutoSet but says there is an, "Up Charge"! Is that legal in NY when the S9 AutoSet is the same insurance code for an S9 Escape, E0601?

Tim
Finger Lakes Region, NY
(This post was last modified: 11-11-2012 06:02 PM by 2Tim215.)
11-11-2012 06:00 PM
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archangle Offline
Wiki Editor
Advisory Members

Posts: 3,159
Joined: Feb 2012

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: ResMed Swift FX
Humidifier: ResMed S9 H5i
CPAP Pressure: 16-20
CPAP Software: ResScan SleepyHead EncoreBasic

Other Comments: Happy PAPper

Sex: Undisclosed
Location: USA

Post: #2
RE: Are "Up Charge" Costs Legal in NY for a better Machine?
Rather than "government illegal," it's probably against their contract with the insurance company if they're an "in network" provider.

It might be "government illegal" as well, depending on state law, and whether the state regulators care.

However, they are probably not required to provide an AutoSet, just a CPAP that fulfills the requirement of the the prescription. Writing "Dispense as written" doesn't obligate the DME to provide that model either, but they may not legally be able to dispense another model of machine.

Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
11-11-2012 06:22 PM
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2Tim215 Offline

Preferred Members-2

Posts: 283
Joined: Oct 2012

Machine: S9 ResMed AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Swift FX Nasal Pillow - Medium
Humidifier: ResMed H5i w/Climate Hose
CPAP Pressure: 6cm-12cm
CPAP Software: ResScan SleepyHead

Other Comments: OSA, Fibromyalgia, Rheumatoid Arthritis, Osteoarthritis, Gout, PTSD, & Meralgia paresthetica.

Sex: Male
Location: Finger Lakes Region, NY

Post: #3
RE: Are "Up Charge" Costs Legal in NY for a better Machine?
Thank you for the reply. They are a "in network" provider that I obtained from the insurance companies web-site. They wanted me to sign a waiver for I believe $2000.00 if the insurance company denied the prescription. I have a Customer Care worker that totally understood my position and is behind me in getting the new machine. We are working now on a Pre-approval. It would seem if they are contracted with the insurance company they should fill whatever prescription they receive if it is an item they stock in an area they specialize in. But all of this is new to me as I haven't really dealt with this type of situation before.

Tim
Finger Lakes Region, NY
11-11-2012 06:38 PM
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