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Seemingly Low contract rate for E0601
#1
So, first of all, I'm very grateful to have found boards such as this. Insurance companies and Medical providers seem to deliberately work to keep patients in the dark.

I was actually diagnosed with Obstructive Sleep Apnea 4 years ago, but due to several insurance issues that took over a year to clear up, I was unable to follow through with followup study w titration and have remained untreated. Condition has seemed to get worse and I finally decided to tackle this again but I plan to be FAR more informed in all aspects, especially insurance coverage.

I've had an in-home sleep study and been asked to return for another in lab study with titration (95811). In preparation, I've been doing research on CPAP machines and 95811 Sleep Study to determine my insurance coverage. Luckily the study is 100% of eligible expenses, but the contract rate for E0601 with my insurance seems low at only $368.97 for the local DME. 

All the articles I've read seem to be from years ago and indicate far greater contract rates. I'm concerned that for $368.97, obtaining a decent data-capable machine may be extremely challenging. The ResMed AirSense 10 AutoSet seems to go for over $800 on amazon alone. Am I missing something? Are there other codes that might tack on to this to bring the total reimbursement up for the DME?

Thanks

G
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#2
E0601 is the code for all CPAP machines. Insurance pays the same whether you get a brick or a fully data capable machine like the Resmed Airsense10 Autoset. You need to be clear that you will not accept anything less. DMEs make more money by supplying bricks. If you can, get the Dr. to write the prescription for the machine you want.
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#3
Not sure how your insurance works but with medicare they charge per month for 13 months. Depending on the state the CPAP is around $40.00 and than they add an extra charge of around $15.00 for the humidifier. So that would be around $715.00 total. The DME pays less than half that wholesale.
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#4
I checked again with my insurance company. They cover E0601 and E0562 for purchase (they do not require rental). I also had them compare a couple of different DME's contract rates and am AMAZED at the different contracted rates for the same code.

Location 1 
  E0601: $368.97
  E0562: ? (Forgot to ask on the first call)

Location 2:
  E0601: $1473.98
  E0562: $612.52

Location 3:
  E0601: $368.97
  E0562: $115.86


Location 2 is part of the same group that my provider is with. It's unfortunate that my experience with that provider has been less than ideal so far, but at least I can go into the conversation on what equipment I want knowing the details. Hopefully, I will be able to strong-arm the DME into providing the machine I want. This thing is likely to be part of my life for a long time... I'd rather get it right the first time.

G
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#5
(08-09-2018, 04:46 PM)Gaurhoth Wrote: Hopefully, I will be able to strong-arm the DME into providing the machine I want. This thing is likely to be part of my life for a long time... I'd rather get it right the first time.

It might not be necessary. Kaiser prescribed me an A10 Autoset **specifically**, rather than an APAP. But Kaiser is an HMO that is its own DME (but I don't have DME coverage...)

While the insurance reimbursement code may be the same for all CPAPs, I'm wondering if the *prescription*, a separate thing, can be brand and model specific since they are in my case.
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#6
(08-09-2018, 04:46 PM)Gaurhoth Wrote: Location 2 is part of the same group that my provider is with. It's unfortunate that my experience with that provider has been less than ideal so far, but at least I can go into the conversation on what equipment I want knowing the details. Hopefully, I will be able to strong-arm the DME into providing the machine I want. This thing is likely to be part of my life for a long time... I'd rather get it right the first time.

G

Don't strongarm the DME get your doctor to specify the machine e.g. E0601 Resmed Airsense 10 Autoset
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