Picking a DME -- What is Best

[me50]

Medicare approved DME Medicare and your supplement will pay for your cpap and supplies. Non Medicare approved DME its all out of your pocket. You also must meet Medicare compliance for Medicare to pay the rental for the 13 months.

I am medicare and I went out of network and my insurance still paid but it was a lower %.

[Mosquitobait]

However, I'm uncertain about your comment that Medicare won't allow my primary care doctor to provide a CPAP machine and supplies to me. I'll follow up on this, but the healthcare organization that my doctor works for is an integrated non-profit health care provider that provides home health care equipment to patients through its "Aurora at Home" division. I spoke briefly with an Aurora at Home representative a couple of days ago and i understood (possibly incorrectly) that they could be my DME provider and that Medicare would cover 80% of the cost of my prescribed equipment and supplies. The general logic of prohibiting a for-profit healthcare organization from prescribing DME and then selling it for a profit makes sense, but I wonder if there's an exception for situations like the one I'm describing.

For example, could the Mayo Clinic provide a CPAP to a patient under a prescription written by a Mayo doctor?

Anyway, I'll check into this further (I have an appointment with my doctor this week) and report back.

Thanks for the guidance and good suggestions.

If you go to this Medicare this medicare Site, you can enter your zip code and then click on CPAP to find out what your choices are. Those are your ONLY choices if you want Medicare to pay for it. If you have the Medicare Advantage coverage, which is an HMO or PPO, then call them directly to ask them where you can go (they sometimes have wider networks, but more limited selections of machines. Because of the actions of a few, Medicare has thrown patients under the bus to save money. Unfortunately, their major choices are just as crooked as the crooks they were trying to avoid.

As to Mayo, no real advantage there unless you live in the Rochester area and use their local DME, American Homepatients. I'm sure that particular DME is stellar because to get on the bad side of Mayo there would get you blacklisted to hell.

ANY DME can provide you a cpap, but if you want Medicare to pay for it, then you are stuck with Medicare's choices.

edited to add: Let me add one other point. It is true that doctors can appeal to Medicare to make exceptions. For the amount of paperwork, I think it would likely be limited to someone who needs a specialty machine (i.e. one specific for say COPD) or someone who is homebound and unable to meet appointments. It could be that if you are a homebound person, that they are exempted, but I'd make sure Medicare has approved your purchase before you sign anything or take a machine with you.

[me50]

I was going to suggest a DME but not sure it would be in everyone's area so I obliterated that message.

[2PAPs]

I have an HMO which requires that I use Apria. Apria charges full MSRP. But when I pay 20%, it doesn't mean that my HMO is paying the full 80% to Apria. They are getting a significant discount. The discount must be significant because I didn't have any compliance requirements nor did I know that there was such until I found this forum.

During my five years of Dx, I have not changed my HMO. My coverage has changed. I have had 20%, 50%, no cost to me, and CPAP items not covered. When I had no cost, I ordered on time and all that I was allowed. That stocked me up when I then fell into not covered items. I still needed some things, which I found elsewhere and got good at it.

[Mosquitobait]

I have an HMO which requires that I use Apria. Apria charges full MSRP. But when I pay 20%, it doesn't mean that my HMO is paying the full 80% to Apria. They are getting a significant discount. The discount must be significant because I didn't have any compliance requirements nor did I know that there was such until I found this forum.

During my five years of Dx, I have not changed my HMO. My coverage has changed. I have had 20%, 50%, no cost to me, and CPAP items not covered. When I had no cost, I ordered on time and all that I was allowed. That stocked me up when I then fell into not covered items. I still needed some things, which I found elsewhere and got good at it.

Your 20% is supposed to be based on what your insurance company is paying. I'd contact your insurance company or look at your paperwork and find out exactly what they are paying. Contact your DME and tell them that you are paying far more than your 20% and you want this corrected and applied to your bills. There's a term for it - I think it's double billing.

[PaytonA]

Apria has a unique method for checking and verifying compliance. In the middle of a phone call or discussion about ordering supplies or something they will ask, "Do you use your PAP for at least 4 hours a night and over (X)% of the time?" When you answer in the affirmative that is their compliance verification. That question is even included in some of their automated phone calls.

They apparently get away with it.

Best Regards,

PaytonA

[me50]

I have an HMO which requires that I use Apria. Apria charges full MSRP. But when I pay 20%, it doesn't mean that my HMO is paying the full 80% to Apria. They are getting a significant discount. The discount must be significant because I didn't have any compliance requirements nor did I know that there was such until I found this forum.

During my five years of Dx, I have not changed my HMO. My coverage has changed. I have had 20%, 50%, no cost to me, and CPAP items not covered. When I had no cost, I ordered on time and all that I was allowed. That stocked me up when I then fell into not covered items. I still needed some things, which I found elsewhere and got good at it.

Your 20% is supposed to be based on what your insurance company is paying. I'd contact your insurance company or look at your paperwork and find out exactly what they are paying. Contact your DME and tell them that you are paying far more than your 20% and you want this corrected and applied to your bills. There's a term for it - I think it's double billing.

apria is a real winner when it comes to billing the VERY short time I was with apria (I left because of all their mistakes....not just billing errors). You can't try on masks in their office. At the time I was using Apria, my insurance paid 100% of everything.

I went out of network and got my supplies that way. My insurance company told Apria my information to switch me over to them (needless to say I was beyond p****d) and I told my insurance company that. I got a letter from Apria saying they would not send out supplies to me because I owed them around $12 (remember, my insurance paid 100% of everything). I laughed so hard, called Apria and said this is why I left because you can't get your stuff together so note my OLD account never to call me again. I will NOT use your services. Then I called my insurance company and told them to NEVER, EVER give my contact information to any provider. If I want to use them, I will find them and contact them myself!

[Mosquitobait]

apria is a real winner when it comes to billing. the VERY short time I was with apria (I left because of all their mistakes....not just billing errors) when my insurance paid You can't try on masks in their office. So I went out of network and get my supplies that way. My insurance company told Apria my information to switch me over to them (needless to say I was beyond p****d and told my insurance company that. I got a letter from Apria saying they would not send out supplies to me because I owed them around $12. I laughed so hard, called Apria and said this is why I left because you can't get your stuff together so note my OLD account never to call me again. I will NOT use your services. Then I called my insurance company and told them to NEVER, EVER give my contact information to any provider. If I want to use them, I will find them and contact them myself!

This and many other complaints is why we're not using Apria. I wouldn't go to Lincare either, but Medicare severely limited the choices to only 2 that my brother could get to (he is homebound and driving this far is hard enough). Medicare added another option just yesterday that is 8 miles away. I may consider going there.

Ok. I read this on the Medicare page:
However, there are a few exceptions, like if you use a "grandfathered" supplier or if you get items and supplies from doctors or hospitals.

So definitely, there is a possibility that the Aurora place can handle your business! I'd enquire (and get it in writing when ordering) that they either take assignment or give you a definite on the percentage.

[drgrimes]

AndyB, not sure if this is practical but you might try calling each of them and ask if they have any technicians or whatever they are called, that are actual CPAP users.

My experience, it's like going to Weight Watchers and talking to a genetically skinny girl about weight loss. If you can find an user, then they will most likely be more helpful and knowledgeable than the non-users.

My DME is wonderful. The owner and his assistant are both big time CPAP users and are a wealth of advice and suggestions.

[AndyB]

Lots of great info and ideas in this thread -- thanks everyone!

I'm seeing my primary care physician this week to get his recommendations and a prescription. I'll update this thread after I find out what he and the Aurora folks say will work under Medicare (I'm under "Original Medicare" and in an area where CPAP devices and supplies are covered by Medicare's DME Competitive Bidding Program).

We'll see . . . never imagined what twists and turns this would involve . . .