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Medicare and Medicaid-who picks CPAP
#1
My mother has a sleep study scheduled and she is on Medicare and Medicaid. If she is diagnosed to need a CPAP can she pick the machine she gets? I preferably would hope she get the same as me I can help her with, since I know how to use mine.

Thank you all for your help!Thanks
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#2
(02-11-2014, 08:30 PM)Franklyspeaking Wrote: My mother has a sleep study scheduled and she is on Medicare and Medicaid. If she is diagnosed to need a CPAP can she pick the machine she gets? I preferably would hope she get the same as me I can help her with, since I know how to use mine.

Thank you all for your help!Thanks

I don't know who picks the machine; I would think that the doctor would say whether they get cpap, cpap auto, vpap but I have not clue. I would suggest you or your mom call Medicaid and ask. It used to be and most likely still is that Medicaid has to pay first and medicare picks up the difference if there is one. A lot of places, at least where we live, won't accept Medicaid. Best thing you can do is call and ask.
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#3
I would think it would be determined by whatever brand your medical equipment provider stocks. So if that's Resmed, that's what would get paid for. If you have a specific supplier in mind, call them and ask how it works. The doc issues a prescription and should be happy to have whoever you choose fill it.
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#4
I,m guessing ... whatever the doctor write on the prescription
Medicare pay for CPAP by billing code E0601 which include bricks, data capable machines and APAP
Nudge the doctor to specify the type of the machine on the prescription, example ... ResMed S9 AutoSet (not Escape Auto) pressure range 8-12, H5i and ClimateLine, mask of choice and dispense as written
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#5
From what I have picked up in the last couple of weeks, typically the sleep doc writes the prescription for the treatment which may include APAP or BiPap settings.

The DME then offers machines CONSISTENT with the insurance company's policies, with an APAP machine being usable by a CPAP only prescription.

DMEs are (partially) motivated to offer the cheapest machine consistent with the prescription because most insurance pays a set rate for the machine no matter what the brand or model.

I have been told that my DME (American Home Patient) is really good because they offered me a choice of the 3 top APAPs with humidifiers and heated hoses and no need to argue.

The rep even acted a little surprised that I would wonder if they were going to give me a good machine.

Sweet Dreams,

HerbM
Sleep study AHI: 49 RDI: 60 -- APAP 10-11 w/AHI: 1.5 avg for 7-days (up due likely to hip replacement recovery)

"We can all breathe together or we will all suffocate alone."
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#6
My sleep doctor wrote "ResMed S9 Auto Set" on my prescription (which also included the settings he wanted to treat my apnea). My sister's sleep doctor told her he was only familiar with Respironics machines and so ordered one for her. Maybe it depends upon which brand your sleep doctor is familiar with. It's a mystery to me. Your mother is lucky to have someone like you who is interested in helping her.
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#7
Yes, any doctor who wants to can write a specific prescription, but from what I hear many (most?) do not unless maybe it is a BiPap or other advanced machine.
Sweet Dreams,

HerbM
Sleep study AHI: 49 RDI: 60 -- APAP 10-11 w/AHI: 1.5 avg for 7-days (up due likely to hip replacement recovery)

"We can all breathe together or we will all suffocate alone."
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#8
A typical Rx might read: "Bilevel. 14cm-H2O / 9cm-H2O. Mask of choice."
The DME will provide the cheapest machine they can acquire that meets the above Rx.
Medicare and Medicaid provide a fixed payment regardless of the machine's price.
Medicare actually pays for a 13 month rental; and after 13 months, the machine is deemed to belong to the patient.
You might get a doctor to write for a specific machine -- then the patient might have to pay out-of-pocket for the machine.

DMEs seek to maximize profit. They certainly will not take a loss. If the patient wants a machine for which they will be compensated less than their cost -- the DME can just say,: "Sorry, we cannot fill that Rx." And of course, they will seek to provide a machine that maximizes their profit.
Medicare pays much less than most private insurers.

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#9
If the doc writes a script for a resmed auto or respironics auto and writes to dispense as written and the person has medical insurance, the DME cannot charge the difference in the price to the person that is insured. The DME has a contract with the insurance company that they must go by. As has been mentioned here before, there is one code for CPAP machines to include the escape, elite, auto, etc. (I am only familiar with Resmed so I am using their machines as an example). It is true that they will get paid the same amount no matter what machine they provide and most will try to provide the one that maximizes their profits. Even with Medicaid and medicare, they get paid by Medicaid first and then medicare picks up the remaining balance. The question is, how much will the DME get paid by Medicaid and since Medicaid has to pay first, it is a concern because so many docs now are refusing to take Medicaid.
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#10
A lot depend on the doc and insurance. I have a Medicare Advantage policy. The original doc perspiction specified a F&P Icon. When I went in for my one-moth review I told the Nurse Practitioner that I didn't like the Icon menu and asked if I could switch to the S9. She wrote a note to the DME and they swapped machine. Unfortunately, it appears that not all cpap patients receive that kinds of cooperation from providers.
"Sometimes the magic works . . . and sometimes it doesn't" -- Chief Dan George in the movie Little Big Man
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