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[CPAP] Insurance / Getting first CPAP
#1
Hi Everyone. About a month ago I was diagnosed with Sleep Apnea, with a 40.4 AHI. The doctor submitted my information to a home medical equipment supplier for a CPAP, and these guys have been ridiculous. After a week of no word, I called and they hadn't submitted anything because they "were waiting" (without asking) for more info from the doctor. Fast forward 3 weeks and a LOT of phone calls, they've been telling me they're still waiting for my insurance to get back to them.

Today I called my insurance company to see what's up, and they told me they approved the CPAP on October 5th. Feeling super frustrated with the Medical Supplier, I asked if at this point if I went with a different company (or bought one myself only and submitted a reimbursement request) if anything else would need to be submitted, or do I really need to stick with the first place. She said nothing else needs done, I can go wherever and get one and be covered.

I called my doctor and explained to them, and they said they'd call the supplier and tell them. I said no, I'm sick of these guys, I want to go somewhere else, and please just tell me how I can get my prescription. It became obvious pretty quickly they don't want that. She went into a long thing about how much longer it'll take, they'll have to call and cancel this request insurance already approved, and then send me elsewhere who will have to do everything all over. I said no, I don't even want you to send me anywhere. I already got the name of a different place from my insurance. This put her into an even bigger tyrant about "yes, but all this extra time/work, she would cancel my insurance request, blahblahblah."

In the end, I told her if this company of theirs calls me TODAY, then fine. Though I might have been lying about that. I'm pretty frustrated, so I'm here asking advice. If I were to go to a different supplier, or just buy one online myself, how much do I really need to supply them with and am I really adding that much longer to my wait?
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#2
If you are paying for it yourself and re-imbursing through your insurance, all they need is your prescription. Supplier #2 (see top of page) have some good deals.
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#3
What is the name of the home medical supplier that has been so difficult?
If your insurance says you will be covered using another supplier, then there is a large Supplier List at the top of this forum. Supplier #30 even bills insurance, so that makes things easier. You should obtain a copy of your prescription to keep for your personal records, and to facilitate any purchase. Also get a copy of your sleep study and recommendations. Finally, you should ask your doctor's office if they have a financial arrangement with the troublesome DME that might be a conflict of interest. It is puzzling whey they appear to want you to use this particular supplier.
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#4
(10-28-2016, 12:18 PM)Sleeprider Wrote: What is the name of the home medical supplier that has been so difficult?
If your insurance says you will be covered using another supplier, then there is a large Supplier List at the top of this forum. even bills insurance, so that makes things easier. You should obtain a copy of your prescription to keep for your personal records, and to facilitate any purchase. Also get a copy of your sleep study and recommendations. Finally, you should ask your doctor's office if they have a financial arrangement with the troublesome DME that might be a conflict of interest. It is puzzling whey they appear to want you to use this particular supplier.

First Choice is who has been dragging this out.

It felt for sure to me there's some sort of kickback with these guys and the doctor. I got that feeling as soon as I asked for my prescription.

So it sounds like the lady at the doctor I talked to really was blowing it out of proportion with how much it would set me back to not go First Choice.
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#5
Your insurance probably has the in-network provider list online, or at least available with a call. Get it and call around to find who will fill your order quickly. It seems you should not have to wait 23 days to fill a prescription that has the insurance approval. Have they even scheduled an appointment with the RT for dispensing and training?

Another thing to check with insurance is whether a rental period is required, or if the insurance will pay to purchase.

Finally, get the machine you want. I don't know what is on your prescription, and you may not either. Get it. If it does not specify auto-CPAP or a pressure range, beware of getting a low-end machine and/or one that does not produce full efficacy data. Try to get the Resmed Airsense 10 Autoset, or Philips Dreamstation Auto. Call the supplier and ask specifically what brand and model they intend to dispense. Don't go to an appointment to pick up a brick. Take your business to the supplier that will fill your need with a good machine.
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#6
(10-28-2016, 12:54 PM)Sleeprider Wrote: Your insurance probably has the in-network provider list online, or at least available with a call. Get it and call around to find who will fill your order quickly. It seems you should not have to wait 23 days to fill a prescription that has the insurance approval. Have they even scheduled an appointment with the RT for dispensing and training?

No! these guys are terrible. I haven't even talked to them once. I've been calling the doctor's office and they call them. Insurance said I have a 50% co-insurance, and the coverage is the same anywhere I go.

I guess I just really wanted to know how much this nurse was saying about how bad it would be if I don't use their place is true, and it sounds like I have my answer. The only other thing I'm balking on here is the office is kinda far. I want my paperwork and RX, but would like to be able to get it later, and just get this CPAP machine already.

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#7
Hi rjbbjr,
WELCOME! to the forum.!
I wish you good luck with getting your machine and dealing with insurance.

Hang in there for more responses to your post.
trish6hundred
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#8
(10-28-2016, 02:07 PM)rjbbjr Wrote:
(10-28-2016, 12:54 PM)Sleeprider Wrote: Your insurance probably has the in-network provider list online, or at least available with a call. Get it and call around to find who will fill your order quickly. It seems you should not have to wait 23 days to fill a prescription that has the insurance approval. Have they even scheduled an appointment with the RT for dispensing and training?

No! these guys are terrible. I haven't even talked to them once. I've been calling the doctor's office and they call them. Insurance said I have a 50% co-insurance, and the coverage is the same anywhere I go.

I guess I just really wanted to know how much this nurse was saying about how bad it would be if I don't use their place is true, and it sounds like I have my answer. The only other thing I'm balking on here is the office is kinda far. I want my paperwork and RX, but would like to be able to get it later, and just get this CPAP machine already.

If you have a 50% copay, you need to buy from an online provider to save as much as possible, and file an out-of-network claim. It usually pays half as much as in-network, but even if it's nothing , you will save money and the balance will apply against your deductibles and maximum out-of-pocket. Get your prescription and see if you need a CPAP. 99% chance that is the case, and I'd be willing to bet on it. If so, go to Amazon and search for "DreamStation Auto CPAP DSX500T11 w/HT humidifier and heated tube" which currently sells for $419. That is a complete unit, and all you need to do is add a mask. Your supplier will charge over $2K for that unit including humidifier, hose and filters. You just saved $1300. Get a mask from the supplier, or if they still don't cooperate, buy a "Resmed Airfit P10" on amazon for only $68. Your supplier will charge over $300 for the headgear, frame and cushion. You just saved another $ 120. Don't play the game. You can do this tonight.
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#9
Just wanted to give a quick update on this... That day I told the DME they have to call me (Friday), Monday, and Tuesday passed with no call. They dropped the ball for a month. I can't possibly beg anyone to let me spend $1k more than that.

I had to go out of town for a family emergency last week and Wednesday finally got around to calling the doctor's office. After more complaining, the doctor himself got on the phone, and I explained EVERYTHING and he was totally cool about it. I told him I want to order online, and he said that's fine. Completely different than talking to the nurses.

So I ordered and I'll just file a claim with insurance myself, and last night was finally my first CPAP night. If i comment on that I will in another thread, but night #1 produced 1.5 AHI, so I'm tentatively happy.
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#10
based on our profile, it looks like you got the Airsense 10 Autoset. Great choice! Glad to hear you took matters into your own hands. Good luck.
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