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Replacement machine hassles
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DCwom Offline

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Post: #1
Replacement machine hassles
So my System 1 started to randomly turn off after about 6 years, time for a new machine I figure, simple right?

I'll cut to the chase, I got my new DreamMachine yesterday and its a rental with a 90 day compliance requirement? I've got 6+ years of documented compliance with the Dr and the insurance is treating me like a new CPAP patient, the DME had to come to my house and "instruct" me in use, cleaning, etc. My yearly visit to the sleep Dr is about 8 months away but the insurance says I have to have a return visit within 60 days for compliance.

This is my 1st replacement, is this the norm? Have others had this happen?
03-31-2016 03:08 PM
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justMongo Offline

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Post: #2
RE: Replacement machine hassles
Sounds like US Medicare. And, many insurance companies follow Medicare guidelines.
So, this is "the norm."

I beat the norm (in a sense) by buying my second machine out of pocket.

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03-31-2016 03:16 PM
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FrankNichols Offline

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Post: #3
RE: Replacement machine hassles
Agreed, sounds like it is based on Medicare (actually CMS) requirements. There is a large non-compliance rate with some DME and in order to cut costs (buying equipment that users don't use) CMS established standards. Unfortunately, as with most things in very large organizations - they look for 1 size fits all approach. In your particular case it would seem obvious that the doctor has your records should be able to simply write a script for the new device. In your case that makes sense, but where do they draw the line and how much does it cost to evaluate each situation. It is much easier (read less expensive) to make a few go through an unnecessary process than to try to design a system that would handle all possible combinations of situations. 300,000,000 people can be a bear to work with efficiently.

Our medical system is way broken with huge amounts of bureaucracy and crazy requirements by insurance companies having been forced on doctors and hospitals over many decades. CMS is one step in trying to bring some rational savings to the program.

Not much you can do except pay yourself or follow the requirements setup by the insurance companies.

It see this as very similar to a few years back I was homeless and working as a cashier in a convenience store. I chipped a tooth and not having insurance I called everywhere trying to find someone to just pull the tooth for me - a procedure I could almost afford of about $100. But, no one would/could (even teaching dental schools) I first had to go in for a first time visit and have a full mouth X-ray and evaluation - $250 to $350. Then they would schedule another appointment to extract the tooth (if it was bad enough they would do it on the first appointment). Also, if there were "other" problems found on the X-rays they would have to deal with those also. So, I could get a single tooth extracted for the low low price of only $300 or $400 - about 2 weeks salary for me. The reason was obvious. No that the doctors are bad guys, but they had rules to follow or they could not get insurance...

I am not a Medical professional and I don't play one on the internet.
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I'd Rather Be Sleeping
03-31-2016 03:36 PM
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robertbuckley Offline

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Post: #4
RE: Replacement machine hassles
Be it insurance or Medicare - it appears that they are treating you as if you were a "new" to treatment patient rather than an "established". Many of the DME reps do not know the different standards, or the DME itself uses the most difficult to meet standard out of an abundance of caution to protect themselves in case of an audit by the insurance company or CMS. Having the one "highest" criteria standard also means that the individual rep cannot make a mistake by applying a lower test for compliance. A pain in the ass for us
FYI - the Medicare guideline and requirements (in part) for a new machine or for supplies:
=====
Beneficiary Entering Medicare
If the patient had a PAP device that was originally covered by another insurance company and now requires a new device or supplies under Medicare, the following are required prior to billing:
1. Qualifying sleep study that occurred prior to the Medicare effective date.
2. Face-to-face patient evaluation with the treating physician after the Medicare effective date that indicates the patient’s diagnosis of OSA and the patient continues to use the PAP device.
3. A new prescription.
There is no trial period for patients qualified under the Beneficiary Entering Medicare or Replacement PAP requirements.
However, if the patient had a CPAP unit previously and switches to a bi-level or vice versa, the patient must qualify for the new device following the new set-up guidelines.
=======
While one would think that this is a one time thing when you enter Medicare, the DMEs are generally making you go through the same routine if you switch between DMEs, or sometimes the beginning of each new year. Arguing with them is like talking to a brick wall.
You ask if anyone has had a similar experience? I will go even better - changing DMEs the beginning of this year back to one that I had even used previously under Medicare - I had to fight with them over NOT wanting a replacement machine (I have a perfectly good 3 year old Auto ASV and a BiPap auto Aflex for back up). My reasoning was not totally altruistic, as Respironics has not yet updated their product line with a Dreamstation that has the Auto ASV capabilities, and I would rather wait until they do. You can only get a replacement every 5 years. But they kept trying to get me to take a new machine and I kept telling them no.
Best advice I can give is know the rules, pick and choose the fights, know when to stick to your guns, and when to fold. Good Luck.
04-02-2016 12:04 PM
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SaldusMiegas Offline

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Post: #5
RE: Replacement machine hassles
(03-31-2016 03:08 PM)DCwom Wrote:  So my System 1 started to randomly turn off after about 6 years, time for a new machine I figure, simple right?

I'll cut to the chase, I got my new DreamMachine yesterday and its a rental with a 90 day compliance requirement? I've got 6+ years of documented compliance with the Dr and the insurance is treating me like a new CPAP patient, the DME had to come to my house and "instruct" me in use, cleaning, etc. My yearly visit to the sleep Dr is about 8 months away but the insurance says I have to have a return visit within 60 days for compliance.

This is my 1st replacement, is this the norm? Have others had this happen?

Hi DCwom,

I would call the Doctor and the insurance company if you have not done already. Sounds like they are already in the loop, but if you have been working solely through the DME, call the insurance company and ask what they require. Maybe showing them recent compliance data can meet the requirement so they can buy you the machine outright. Maybe the Doctor can fax records that make it a non issue altogether.

If not, then oh well jump through the hoops and the data will be an artifact of doing what you already do, right? In that case maybe you can meet the compliance and Dr appt requirement in 31 days (30 days of compliance data and a Dr appt right after you meet it) to cut this bogus rental scenario short.

BTW, would love to read a few words on your thoughts and experience of six years in therapy.

Saldus Miegas

p.s. congrats on the new machine. I'm only a year into this myself but guessing that you will love it compared to whatever the noise level and data capabilities of a six year old machine were.
04-02-2016 02:05 PM
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joelrk35 Offline

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Post: #6
RE: Replacement machine hassles
(03-31-2016 03:08 PM)DCwom Wrote:  So my System 1 started to randomly turn off after about 6 years, time for a new machine I figure, simple right?

I'll cut to the chase, I got my new DreamMachine yesterday and its a rental with a 90 day compliance requirement? I've got 6+ years of documented compliance with the Dr and the insurance is treating me like a new CPAP patient, the DME had to come to my house and "instruct" me in use, cleaning, etc. My yearly visit to the sleep Dr is about 8 months away but the insurance says I have to have a return visit within 60 days for compliance.

This is my 1st replacement, is this the norm? Have others had this happen?

I had the same issue about 6 months ago. Just suck it up and go see your doctor because it is cheaper to pay an office visit if your insurance doesn't cover it, than buy a new machine on your own.

My DME was only 4 miles away so I just went to them to show me the workings of the new machine. If you live too far from your DME they will send someone to your home which should be covered by your insurance, if you have met your deductible or you may have a copay. Insurance companies make you jump through hoops for any service, a sign of the times. Oh-jeezSmile
04-02-2016 03:33 PM
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Mosquitobait Offline

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Post: #7
RE: Replacement machine hassles
Some of this depends on how the DME does business. My local Lyncare office only makes house calls if you are homebound. The local supplier that I want to switch to doesn't do home visits at all unless you are also an oxygen patient. Since we only have 3 to deal with because of the wonderful Medicare Competitive bid area completely limiting choices, those are my only choices since I won't deal with Apria at all.


As others have said, for compliance for a new machine, you have to have a second visit at the doc's office within 60 or 90 days. I know it's annoying, but you have to jump through hoops if you want someone else to pay for your durable medical equipment.
04-02-2016 06:00 PM
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archangle Offline
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Post: #8
RE: Replacement machine hassles
Lots of people get expensive stuff from Medicare or insurance not intending to use it and then resell it. This may be part of the reason for compliance checks and followup visits.

Someone locally is putting up signs offering to buy unused diabetes test strips. Obviously working with insurance scams.

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.
04-03-2016 04:08 PM
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FrankNichols Offline

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Post: #9
RE: Replacement machine hassles
(04-03-2016 04:08 PM)archangle Wrote:  Lots of people get expensive stuff from Medicare or insurance not intending to use it and then resell it. This may be part of the reason for compliance checks and followup visits.

Someone locally is putting up signs offering to buy unused diabetes test strips. Obviously working with insurance scams.

I completely agree with you, I however do not know what the solution is, since the "lots" appear to be a minority and the majority of people, like me use Medicare correctly, and we paid for it our entire lives. People that abuse the system should be arrested, and charged with fraud. In my case I live in Florida. The Governor of Florida was CEO of the phara company that was charged with the largest medicare fraud in history. And he was then elected as Governor... hmm, so, which is worse, a politician that gets away with a billion dollar fraud or a unemployed junkie that takes a few hundreds of dollars of medicare benefits and buys drugs or food with it...

I honestly don't have a solution, but I do know that medicare is the most respected healthcare system in the world. It is paid for by it's users and has the lowest rate of fraud of most other systems in the world. So, maybe CMS is doing something right.

Maybe we should related this conversation into the Off Topic area, It is trending into a political conversation that most probably are not interested in here. I think you have some very good points and I would be interested in hearing more.

I am not a Medical professional and I don't play one on the internet.
Started CPAP Therapy April 5, 2016
I'd Rather Be Sleeping
(This post was last modified: 04-03-2016 05:02 PM by FrankNichols.)
04-03-2016 04:34 PM
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Phill Offline

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Post: #10
RE: Replacement machine hassles
Interesting comments Frank, I would reply but as you say this is probably not the right area.
04-04-2016 10:30 AM
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