Round 1: DME 1, SleepDaddy 0

SleepDaddy · Post by **SleepDaddy** » Tue Jan 03, 2006 8:21 pm

Well, I had my first appointment with my DME (Lincare) today and ended up walking out without any equipment.

The technician (not sure if this is an appropriate term) was nice enough and had the equipment (ResMed S8 Escape w/3i Humidifier) all set up for our (I took my spouse along as a witness to any crimes committed) session.

I told the technician that I had a few questions I wanted to go over before we got into specific equipment instructions.

First I wanted to know how much Lincare was going to bill my insurance company (Tricare Prime) and what my 20% co-pay would be. You'd have thought I had asked her to sing the fourth verse of the Star Spangled Banner! She said that Lincare didn't have that information and that I would have to ask my insurance company that.

I explained to her that I just wanted to make sure I know how much money it was going to cost me to either rent or buy the equipment she was providing, and that I thought that was a reasonable request. She left the room for a bit to ask the folks in the billing office, but came back with the same response.

Next, I wanted to know how I could obtain the machine of my choice, which I indicated was a Respironics REMstar Auto w/C-flex and a heated humidifier.

She indicated that all she had was a prescription to provide me with a CPAP set up at 10cm pressure and that I would have to have my Dr. write a new prescription saying I needed an APAP. She indicated she could not provide an APAP as that was not the therapy that had been prescribed.

I indicated that I wasn't really asking for a different therapy and that it was relatively simple to set-up an APAP machine to operate in CPAP mode.

She then responded that it was actually Lincare's policy not to provide an APAP when only a CPAP had been prescribed and that it really didn't have anything to do with what kind of "therapy" was being provided.

She then asked me how severe my Apnea was, and noted her surprise in how much energy I had! She also indicated that she was surprised that I actually new the names of the different models of equipment and that she doesn't usually deal with folks that are that knowledgeable.

At this point it became clear that this particular technician would not be able to help me. I explained to her that I wouldn't take possession of the equipment if she couldn't tell me how much I would have to pay for it. She then speculated that she thought the machine would cost something above $100 per month to rent and that my 20% co-pay would be something above $20 per month. I asked if that included the humidifier and she indicated that had to be bought outright and would cost about $250 so my co-pay for that would be around $50. I asked about additional items and she said that I would also need a hose that would cost around $30 and a mask that would cost over $100. However, she wouldn't commit to anything other than a rough guess as to what my costs would be.

At this point, I indicated that I wanted to talk things over with my Dr. as I knew that I could get the exact machine I wanted for $760 (including humidifier, hose, and bag). She said that was surprising as that sounded like a really good price.

I then thanked her for her time and left....

We'll see what happens in Round 2...I am still working with my insurance company to see if I can figure out a way to purchase a machine directly and still get reimbursed.....although I doubt I would go back to this particular DME as they didn't seem to have much in the way of useful information.

SleepDaddy

johnnygoodman · Post by **johnnygoodman** » Tue Jan 03, 2006 8:46 pm

Howdy,

I'm Sorry to hear that you didn't get what you wants. I'm happy to hear that your online education has you insisting on high end treatment options.

Which insurance do you have? Have you considered BillMyInsurance.com? They'll tell you if your copay payments will be lower than purchasing for cash upfront and will give you YOUR choice of equipment.

Good luck!

Johnny

SleepDaddy · Post by **SleepDaddy** » Tue Jan 03, 2006 9:03 pm

johnnygoodman:

Thanks for the empathy...as least after visiting this forum, I went in to my first DME visit with low expectations!

I have Tricare Prime (Retired Military) for my insurance.

Unfortunately, BillMyInsurance.com doesn't work with Tricare.

I am determined to be in charge of my treatment and won't let a DME stand in my way....

johnnygoodman · Post by **johnnygoodman** » Tue Jan 03, 2006 9:05 pm

Greetings,

You've got a great attitude! You are certain to get the right stuff. Please keep us posted on your progress.

Johnny

Darth Vader Look · Post by **Darth Vader Look** » Wed Jan 04, 2006 12:40 am

Good for you SleepDaddy. DME's only want to maximize their profits by specifying cheaper equipment and masks. Beware of the compliance packages too. They may call them something else but essentially they are an upgrade to the basic package but costs many bucks more and for nothing. I'm from Ontario, Canada and tried to get the Assistive Devices Program (part of OHIP - Ontario Hospital Insurance Plan) to okay buying my unit from CPAP.com but they will not go for it. So now I have to pay over double the price for the APAP that I want and have to go through a DME in Ontario. Try to save the government some money and they go all negative on you. Go figure. .

Linda3032 · Post by **Linda3032** » Wed Jan 04, 2006 7:53 pm

Hi SD. I think you scored round 1 wrong - sounds to me like it was a draw. And good for you.

Have you talked to the Tricare representative in durable equipment department yet? That's the first important step.

I can't believe Tricare would have that different of rules for prime vs standard. Be sure to read what some of the other Tricare Prime members wrote, and even PM them if you have more questions.

My prescription was written as a CPAP. I bought a Remstar Auto and Tricare never questioned my reimbursement. Don't take no for an answer.

Good luck and keep us informed.

Linda

th · Post by th » Wed Jan 04, 2006 8:43 pm

IMO is not worth dealing with a DME and insurance. I would get your doctor to fax your prescription to an online store and get what you want. You sleep a third of your life and you are talking about less than $800 to get what you want and not what the DME & doctor wants you to get. From my own experince, I would rather pay out of my pocket than having to deal with the pain of a DME & insurance...this is only my opinion from past experince. Good luck, you will not go wrong with the RemStar auto W/CFlex.
th
https://www.cpap.com/productpage/respir ... ifier.html
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CPAPopedia Keywords Contained In This Post (Click For Definition): DME, Prescription, auto

SleepDaddy · Post by **SleepDaddy** » Wed Jan 04, 2006 10:42 pm

Linda3032:

I am still working my way through the Tricare bureaucracy! I have gotten to the office that has the nurses that actually approve the authorizations for DME....however I am waiting for a callback that may never come.

There are some differences between how Tricare Prime, Extra, and Standard handle DME.

TRICARE Prime:

Active Duty: No copayment
Retirees and others: 20% of contracted reimbursement

TRICARE Extra:

Active Duty: 15% of contracted rate
Retirees and others: 20% of contracted rate

TRICARE Standard

Active Duty: 20% of the maximum allowable charge
Retirees and others: 25% of the maximum allowable charge

For Tricare Prime I need an authorization to purchase DME that costs more than $500 or for any rental and reimbursement is based on the "contracted rate".

For Tricare Standard you don't need an authorization and reimbursement is based on the "maximum allowable rate"

These subtle differences may explain why you were able to purchase your machine outright and I may not be able to.

th:

I agree with you and am fully prepared to go for it on my own if necessary.

However, I wanted to run through the DME/Insurance route to see if I can get reimbursed for the equipment I want so I can have my cake and eat it too.

Also, I like challenges and find beating my head against brick walls to be character building!

Sleeper · Post by **Sleeper** » Wed Jan 04, 2006 10:47 pm

I had *exactly* the same go-round with Lincare... "PRICES?!? We don't got no stinking prices...." Turns out, of course, the only price they charge is FULL price... ditto on all the other DMEs I checked out, and yes not to mention the fact that they assume you know zip.

I went with a locally-owned DME for my trial rental and once that's up (soon!) I'll probably buy out-of-pocket and hope for the best with a reimbursement.

This is *part* of the reason we can't have universal healthcare; because the system is corrupt and favors health industry profit over and above everything -- including our very health. We really should start a letter-writing campaign to our legislators.

yardbird · Post by **yardbird** » Thu Jan 05, 2006 10:18 am

I had a 5 year old Respironics SoloLX that was ... well ... failure was imminent. I asked my insurance about replacement and got a huge run-around. BillMyInsurance was EXTREMELY helpful, but basically couldn't help because of my insurance company being such ****heads.

So... I bought out-of-pocket a REMStar Auto with C-Flex and heated humidifier and a new Swift interface. I think I figured that it all cost me around $880. (I'd have to go back and check numbers. I bought it from cpap.com and will DEFINITELY be a regular customer. The service is absolutely astonishing).

SO... if I get 5 years out of my new setup (I got 5 years out of the first one so I'm using that as comparison)... it costs me $14.67 a month. Fourteen dollars and sixty seven cents a month ... that's about $3.39 a week.

That kinda clinched it for me. Yeah it was a rather big outlay initially. But if I put $15 a month away, I can get a new mask every 3 months and a new machine every 5 years. If I can get the 50% "out-of-plan reimbursement" that I believe I'm entitled to, then that's great. If not... I can afford $15 a month to stay alive. It's really made that much of a difference for me.

I'm not in any way suggesting that you stop attacking your insurance possibilities from as many angles as you can. But, for me, it came down to treatment NOW or wait until they wear me down and make me conform to their overpriced equipment and KICKBACKS... yes KICKBACKS to the doctor for every patient the DME distributed equipment to.

Now *I* am in control of my treatment. There's some responsibility there, but in all honesty I can say I'm treating myself better than THEY did and with the assistance of a VERY good primary care physician, I still am being monitored by my doctor. Just not my SLEEP doctor.

Your mileage may vary, but this is working for me at this point. Just thought I'd relate that.

tombiowami · Post by **tombiowami** » Thu Jan 05, 2006 10:44 am

I also would say that you scored more than the DME. I just had a sleep study and was diagnosed with apnea. Had a DME calling me before the doc even wrote a prescription. They stated it would be 500$ for something, no brand names or masks known. This was after I was getting some cool 'discount' and they were upfront they would be charging my insurance much more. They then called me back saying it was actually a $1000 because they got the discounts mixed up. O give me a break.

I then came to this site and found relief from this BS. Much useful information on the forums and sales site. I called the insurance site here and they said they were considered out of network, but that I could file afterward. Called my insurance (cigna) and they said they would cover 55%. I faxed my prescription over, and with next day air got the machine and stuff the next day from cpap.com.

Pretty much plug n play, no need for DME instructor at all!

The total bill was about 1100 but I got exactly what I wanted.(420e, humidifier, software, 2 masks, cigarette lighter adapter cable, disp and reusable filters, snuggle hose) Even if the insurance does not pay like they should, it is worth it to go through this site just for piece of mind.

My DME just called again yesterday, left a Voicemail that they had worked out a 'special deal' and now the price was back to $500, ha ha ha ha.

Tommy

snork1 · Post by **snork1** » Thu Jan 05, 2006 7:53 pm

It sounds like it was a CLASSIC interaction of a knowledgable consumer with a DME and insurance company.

Its also amazing how much better the service AND prices are when buying on-line.

I have yet to be able to get an answer ahead of being billed on how much I will be paying, from the DME OR insurance. They just assume you have no options and will pay whatever they dom well plan to charge you for whatever junk they are going to unload on you.

Sad state of affairs, but your interaction was certainly quite typical.

sthnreb · Post by **sthnreb** » Thu Jan 05, 2006 8:09 pm

I guess you are all fortunate you can fight for your money back from insurance companies. Mine only payed a flat $2500 lifetime for OSA. They don't care how you spend it. After a sleep lab test and high priced DME's before you learn much about OSA, that amount is gone. It's then all out of pocket and you go online to find out how bad you had got taken. The DME wanted $3400 for an obsolete bipap duet. I could have pulled their teeth easier than getting a price from them to buy it. After they used up all the money for rental, then they gave me a price to purchase. I did get to keep the mask as they couldn't sell a used mask. I could have purchased 2 bipap pro units and had $200 left over to pocket at their pricing. So, I have a lot of respect for the people who find this and other forums and get informed early. I now have the Bipap auto and have been using bipap fo about 4 years now. Good luck with your insurance, they should pay their obligations. It's strange how they will pay a DME so much and balk at you spending less and getting more online.

nodding off · Post by **nodding off** » Thu Jan 05, 2006 10:26 pm

There are plenty of good, caring dmes out there that don't try to rip out your eyeteeth. Get rid of Lin-doesn't-Care. They are horrible. I dumped them twice, once initially, and again when they bought out my dme a couple years ago. They were going to charge my insurance over $2000 for a machine!

SleepDaddy · Post by **SleepDaddy** » Thu Jan 05, 2006 10:57 pm

Well, I finally got a call back from Tricare today and the news was pretty encouraging.

They still need my pulmonary Doc to submit an authorization request before I can obtain my equipment (just fax a prescription and a short form).

However, once I have the authorization, I can purchase my equipment directly (any xPAP will do) and then submit the a copy of the prescription and equipment invoices and they will process for reimbursement (my max co-pay will be 20%, but may be less if the items I buy are below their allowable cost).

So if this actually works, I can purchase the APAP, humidifier, and mask I want from CPAP.com and still get reimbursed from my insurance. I guess I can have my cake and eat it too without the assistance of a DME.

Maybe the Christmas spirit is lasting a little longer this year!

Machine	Mask

Additional Comments: Resmed AirCurve 10 VAuto BiLevel with HumidAir

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Mask	Humidifier

Mask	Humidifier

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