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decided on a machine... providers wont order under insurance or current prescription
#11
My $0.02 and worth every penny:

A modern ResMed AirSense 10 AutoSet has an "EPR" setting that can reduce exhale pressure by up to 3 cm-h20. Poor man's BiLevel/VPAP. Start with that. If it's proven you need more than 3 cm-h20 exhale pressure reduction, worry about it then. I imagine there is an equivalent Respironics machine.

Depending on how your insurance works with co-pays and deductibles, it might be cheaper to buy the machine outright online. Paying cash, you can save a few bucks by buying the last generation ResMed S9 AutoSet. It has identical functionality to the latest A10 other than the built-in modem. You can also buy an S9 AutoSet used with a 1-year warranty and save even more. An A10 with ClimateLine hose will be about $900 new on the internet. A used S9 AutoSet with humidifier and ClimateLine heated hose will be about half that.
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#12
(04-19-2015, 03:17 PM)cpap_anonymous Wrote: Hi all. Thanks for explaining. I haven't heard any of this from the insurance, dr, or dme provider.

the prescription did request the model I requested, but set only for a specific pressure. The Dr was ok with that part at least. Since my treatment doesn't require it that is where the provider is balking at I guess. Still the out of pocket cost if I want it is still 5k. I told the dme to cancel the order and I would look into my options. This one was the only one willing to order it though so I am not sure why I can't get it for less than that.

In the mean time I am going to make my current machine last as long as I can.

Thanks for explaining everything that the Dr and dme provider should have at the beginning.

As Paula suggested, find another supplier that is in network with your insurance company first. The reason is, that no matter what the supplier charges for retail price, the supplier has a contracted amount with the insurance company and they cannot charge more than that. Then, based on your insurance policy, you may have to pay 20% (or whatever your insurance policy dictates after a deductible; I have never had a deductible for DME supplies and machines but I have read that some policies do). Even if you have a deductible, the supplier cannot charge you more than the contracted price they have with your insurance company and you should not be paying full retail price.

Find another supplier and stay away from Lincare and Apria if you can.
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#13
(04-19-2015, 03:17 PM)cpap_anonymous Wrote: the prescription did request the model I requested, but set only for a specific pressure. The Dr was ok with that part at least. Since my treatment doesn't require it that is where the provider is balking at I guess.

Am I reading this right? You only "need" a CPAP. Set to a fixed pressure of 13? Basically entry level would do for treatment? But you got your doctor to write an Rx for the top of the line, full-board Auto Bi-PAP? And you don't need it now - but just in case you may need it some day?

Am I missing something?

OMMOHY

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#14
It seems to me if the doctor writes for an automatic, he should prescribe a range of pressures, rather than a single pressure, which the insurance company could potentially use to justify only a manual model.
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#15
@ohmy... based on my treatment requirements since i started 4 years ago, yes i will need the extra bells and whistles. while i dont have the exact need right this second, i will eventually.... like in the next year. and surgery is not an option for me so there is that.

if you are willing to float the cash, i will be more than happy to "settle" for a machine that does what i need only for the short term and get a different machine when my treatment changes... as i will then be able to "justify" a new treatment.

i should just move to texas where everyone is apparently rich and can buy these things at the drop of a hat....

thanks everyone for the info. i will continue to discuss and try to make my current machine last as long as i can.
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#16
(04-20-2015, 10:10 PM)cpap_anonymous Wrote: @ohmy... based on my treatment requirements since i started 4 years ago, yes i will need the extra bells and whistles. while i dont have the exact need right this second, i will eventually.... like in the next year. and surgery is not an option for me so there is that.

i should just move to texas where everyone is apparently rich and can buy these things at the drop of a hat....

I am curious how/why you/your doctor thinks you will need the "extra bells and whistles", whatever you/your doc think are extra bells and whistles and how it is determined that you will need them in a year. Maybe you need to tell more of your story to help us understand why you/your doctor thinks you need a different machine "in a year or so from now".

When I was on cpap auto, it was obvious within a month or two that I needed a different machine and I had a new sleep study titration only with a vpap machine. I have used that machine for 15 months now with pretty good success although I still wake up around 3 times per night (about every 2 hours). I don't know why I wake up that often but I also don't know what to do about it because I KNOW I do NOT need an ASV machine.

You give Texans more credit than you should as most of them are no where near rich and I presume they have insurance to help them out.

I can't imagine any DME that would take a chance on giving you a machine that may be rejected for payment because you didn't meet the criteria. I sure wouldn't take the chance on that one.
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#17
Money 
(04-20-2015, 10:10 PM)cpap_anonymous Wrote: i should just move to texas where everyone is apparently rich and can buy these things at the drop of a hat....

I don't think it's so much that people are rich in Texas as that providers don't gouge. Machines seem to be cheaper from providers there for whatever reason. 5K seems steep for any kind of machine. I was only charged ~$1000 for my ResMed 10 Auto by a provider here in Ontario, Canada and it's done the trick for me. Unless your insurance specifies that you can only purchase from certain pre-approved providers, I'd shop around for a better deal.
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