jimnsc Wrote:I have searched the forum over for the same questions I am about to ask with no luck. Of course that doesn't mean I didn't miss them. SuperSleeper wrote a very informative post about dealing with insurance carriers and DME's and my questions came about because of the post. I know you must have a prescription to buy any CPAP equipment so let's start there.
I understand I may not be able to get the "best" equipment due to an insurance decision or maybe even the severity of my OSA. This would ensure I would receive something less than what I've already drooled over on these web sites. As information my primary carrier now is Medicare and I also have a very good BCBS supplement.
First question: If I am willing and financially able, can I bypass insurance and a DME as long as I have a prescription?
Seems I could eliminate substantial rental fees for 6 months to a year (possibly) on a machine I wouldn't have purchased anyway.
I am the type person who buys the best (if I am able) to ensure myself future problems are usually not due to the equipment. I was the same way about golf clubs after buying my first cheap set. When I finally bought the best it was me that was the problem - not the equipment.
Second question: If I did bear all expense on my own at start-up, would it ensure that future mask replacements would be totally borne by
I only know at this point that my sleep study indicated I would be returning for titration (sp.) and was given no details on particulars after my first sleep session. So, why am I concerned with this type thing this early in the game? I want to start my planning early in order to be organized when those days come. I appreciate any comments I might receive on this post. I have enjoyed reading here.
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Dealing with Insurance, Doctors & DME
02-25-2012, 02:05 AM
02-25-2012, 02:06 AM
Hi jimnsc - welcome to Apnea Board!
Quote:First question: If I am willing and financially able, can I bypass insurance and a DME as long as I have a prescription?Absolutely. Get a copy of your prescription, and you can purchase a CPAP outright, bypassing any sort of government or insurance program.
Quote:Second question: If I did bear all expense on my own at start-up, would it ensure that future mask replacements would be totally borne by me?Now that's another story, altogether. Dealing with Medicare and not following all their rules might get you into trouble. Hopefully someone more experienced with Medicare can chime in here to help you.
In the meantime, some things to think about:
1. Does your Medicare provider require some sort of "reporting" to insure that you are remaining "compliant" with your CPAP therapy? (They sometimes have you bring in your machine (for older CPAPs) or have you bring in your memory card to prove that you're using the machine a minimum number of hours each night.)
2. If they issue you a basic no-frills CPAP, and require you to use their machine to remain compliant, and you instead choose to use your brand-new, fancy-dancy auto-CPAP with all the bells-and-whistles, this might cause ongoing coverage issues for you with Medicare.
3. But, as I've heard some say, "what they don't know won't hurt them"... so if they pay for a basic CPAP, you might want to take it, and then use your own machine... as long as they don't have some sort of mandatory "compliance monitoring" set up to insure that you're using their CPAP. That way you can continue to get supplies such as hoses & masks, and maybe filters if the two machines use the same size.
You probably read my other statements in other threads on this, but I'm pretty sure that if you convince your doctor that a new Auto-CPAP is "medically necessary", Medicare will cover it, as long as the doc writes the prescription up properly with a script for a specific make and model of CPAP.
Anyone else have thoughts on this?
02-25-2012, 02:10 AM
zonk Wrote:Hi jim would like to congratulate you on doing the research for new cpap prior to your titration as knowledge is important when dealing with doctors and DME ,here in sydney our system works slightly different than yours but can add my two bob worth that you ask your doctor to write a prescription for APAP and dispense as written (becuse apap has all the bells and whistles ,data capable so that you can get in charge of your therapy early on ,and it can also used in cpap mode ) the other thing might add that medicare pays the DME the same amount ,as all cpap/apap have the same code so the DME makes more more profit if he gives you the cheaper ones (no data capabilities ,lcd screen shows ahi , leaks mask fit etc ex S9 escape )and he makes less profit if he gives you the ones with all bells and whistles ex S9 auto set ,good luck .
02-25-2012, 02:28 AM
crayongrl Wrote:Total newbie here (just signed up), but I do know a little be about Medicare and commercial policies. I worked for Medicare (CMS) for 8 years doing med review for DME and I now work for a commercial insurance.
02-25-2012, 02:28 AM
jimnsc Wrote:I knew there were smart folks in this forum and I appreciate the comments. I got to thinking about my post and was concerned that you all might get the feeling I was trying to beat the system but I'm really not. I'm just concerned that I get good equipment and wanted to know what my options were. Thanks again - now off to research APAP. I almost hate to admit I haven't been there yet. 'Two bob worth' is a first for me - thanks Zonk. I may use that one to impress my friends, Thanks again, folks!
02-25-2012, 02:30 AM
zonk Wrote:I was about to start a new topic about how to deal with DME ,Doctors and Insurance as suggested but i did remember that been discussed before and searched for it and that would serve better purpose ,as it had good input by "Super Sleeper" and "crayongrl " .
02-25-2012, 02:30 AM
zimlich Wrote:I don't see why a DME would not bill Medicare for the mask and associated equipment if you provided them (DME) with a prescription.
02-25-2012, 02:33 AM
jeffy1958 Wrote:I'm almost 100% sure I cut all ties with my DME today by what I did with my S9 AutoSet. I down loaded "ALL" my information and have it stored on "MY" computer.
02-25-2012, 02:34 AM
02-25-2012, 02:35 AM
zonk Wrote:Get the fancy one .
zonk Wrote:Research Research Research
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