WHAT YOU NEED TO KNOW BEFORE YOU MEET YOUR DME Part I

This is part 1 of what I hope to be a series:  “I’ve just been diagnosed with apnea–now what????”

Sometimes you have your titration study (test with a CPAP mask to determine how much pressure you need to keep your airway open) on the same night as the sleep study (a “split-study”) or sometimes you have the tiration study on a second night in the sleep lab.  In either case, once you have had your titraiton study and the sleep specialist has determined the type of machine and pressure you will need, a prescription will be sent to a “DME” (CPAP supplier). 

DME stands for Durable Medical Equipment, and the term “DME” is sometimes used to describe the equipment (CPAP machines and masks, as in “I have 80% coverage from my insurance company for DME”) or the supplier (the company that provides the CPAP machine, as in “Valley Oxygen is my DME”).  Sometimes, “DME” is even used to describe the person who owns or works at the DME company, as in “my DME said . . . ”

A DME (company) is supposed to receive your prescription, help you find the best machine to meet your needs, help you find the mask that you are most comfortable in, educate you about these, and provide the machine and equipment.  DME’s are supposed to understand how your insurance works and have Respiratory Therapists (RT’s) who can help you have a good experience with the CPAP so you can be successful in your therapy. 

SUPPOSED TO

And in the real world . . .

Some DME’s actually work that way.

Most do not. . .

That’s the first bit of information you need to know before you meet your DME.  This is ‘Merica, folks, land of free enterprise and capitalism.  Every company must make a profit and their goal is to make the most profit they can.  If, in doing so, they can serve your needs, that’s great.  But your needs are not their main concern, except to the extent that meeting your needs furthers the DME’s profit.  It’s the American way.  And sometimes, it stinks!

If this sounds cynnical, it is.  Some people are lucky to stumble on to a great DME supplier that has a knowledgeable and caring staff who really make it their goal to make sure you are comfortable with your equipment  and that it’s working as well as possible for you.  Unfortunately, this is the exception rather than the rule.  Most DME’s simply want to sell you the equipment at maximum profit, document your compliance so they can get paid, and they hope never to hear from you again except when it’s time to place your order for replacement supplies.   And DME’s (staff) have been known to lie or be totally ignorant of the facts, just to make sure that they maximize their profits and get you the heck out of their hair.  So YOU must be armed with knowledge BEFORE you ever set foot in a DME’s storefront or sign anything on the dotted line.

Your first step will be to determine what insurance coverage you have for DME if any.  If you don’t have insurance coverage, RUN, don’t walk, to an online supplier unless you like paying 2 or 3 times more for equipment and supplies (a rare few DME’s will match online prices for the uninsured).  DME suppliers claim that they give better service than online providers, so it’s worth the extra money, but in almost every case that is simply not true.  So if you don’t have insurance, skip the DME entirely and order your equipment online from a reputable online supplier. 

Now, if your insurance is Medicare, you need to know whether you have traditional Medicare Parts A and B with a supplement/Medigap policy, or if you have Medicare Part C, also known as Medicare Advantage.  What I’m about to say about Medicare applies to traditional Medicare with a supplemental policy, NOT to a Part C Advantage Plan.  Those differ a lot, and you’ll have to figure out the ins and outs of your particular Medicare Advantage plan to learn what your DME coverage is yourself. 

Most (but not all)  private insurerance plans (purchased through an employer  or privately through a broker) follow Medicare guidelines, so I’ll talk about Medicare first. 

Medicare (traditional) pays 80% of the cost of a machine and all the supplies.  There are a few things you need to know:

1.  Medicare sets the price of the machine and then pays 80% of that, regardless of how much the DME wants to charge. 

     a.  Example:  DME charges $2500 for the top of the line machine.  Medicare does NOT pay 80% of $2500.  Medicare decides a reasonable price is $1200 and pays 80% of $1200. 

     b.  Medicare pays by HCPC codes.  These are billing codes, and the HCPC code for a CPAP machine is E0601.  You can look up how much Medicare pays for an E0601 machine in your state on the Medicare Website.  (It’s hard to find and I will post a link one of these days). 

    c. ANY CPAP or APAP machine (but not a bilevel or ASV machine) is E0601, from the dumbest brick of a machine without data capability or EPR to the top of the line machine with all the bells and whistles you could wish for.  Medicare pays one price regardless of which machine you get within the E0601 HCPCs code.  So the only one who really cares (besides you) about what machine you get is the DME.  If you get the bottom of the line brick, the DME makes a lot of money.  If you get the top of the line bells and whistles machine, the DME makes very little.  Guess which one the DME wants you to get? 

2.  Your co-pay is the remaining 20%.  Your supplemental/Medigap policy may pay all or part of that 20%.  Some supplemental policies pay more if you use a “preferred provider”.

3.  Medicare does not actually “buy” the machine, though it buys the humidifier, hose, filters and mask (all by different HCPCs codes).  Medicare requires the machine to be purchased on a “capped rental” basis.  This means that Medicare rents the machine for a period of 13 months.  At the end of the 13 months, the machine is YOURS. 

4.  Medicare requires the DME to prove “compliance”–that you are using the machine for at least 4 hours 70% of the time within a 30 day period.  For that reason, the DME will want to review your data card sometime within the first 30 to 90 days to confirm that you are using the machine.  If you do not meet the compliance requirements, Medicare will not pay.  For that reason, EVERY machine has compliance data capability.  So if you ask a DME for a “data capable” machine, be specific.  Make sure it has “efficacy data” as well as compliance data.  Another way to say this is to insist that there is access to AHI (apnea hypopnea index scores) and leak data. 

5.  Even though it is MUCH less expensive, Medicare will not pay for you to obtain a machine from an online supplier (except for the very few that are Medicare Certified).  Medicare pays only for certified DME’s, because Medicare has requirements (i.e. patient instruction, documentation of compliance, etc.) that DME’s must meet.  Medicare doesn’t have a way to regulate most online suppliers.  So you are stuck with a brick and mortar DME if you want Medicare to help pay.

6.  If you are having trouble figuring out how Medicare and your supplemental policy will work for CPAP equipment and supplies, you can get free Medicare assistance from your states SHIP (State Health Insurance Program in most states)  or HICAP (Health Insurance Counseling and Advocacy  Program in California)  program–the number for these agencies is on the back of your 2011 Medicare and You booklet, or you can find it on the www.medicare.gov website, or by calling 1-800-MEDICARE. 

Most private insurers work a lot like Medicare, but there can be infinite variations.  Therefore, if you are not on Medicare, it’s extremely important that you call YOUR insurer and ask the following questions:

A.  Does the insurer pay by HCPC code, or are only certain machines covered?  If only certain machines, does it pay more for some than others?  If the insurer covers only part of the DME’s cost, are you required to pay the difference between the insurer’s allowable cost and what the insurer pays, or between what the insurer pays and the DME’s retail price?

B.  Does the insurer purchase the machine outright, or require a rental period?

C.  What are your co-pays and deductibles?  This is important!  If a rental period spans more than one calendar year, your out of pocket expenses for co-pays and annual deductibles could easily cost more than buying the machine yourself online.  Or, if you will be changing insurers, you could lose the “credit” for co-pays and deductibles already made or have to change machines.  Make sure you understand all of this before you sign on the dotted line with a DME. 

D.  Does the Insurer cover only certain masks or all masks from the DME?  Again, does the insurer cover supplies (hose, filters, masks, cushions and nasal pillows) by HCPC’s codes or have a limited “formulary” for supplies? 

E.  Does the insurer require you to use only certain DME providers, or will it pay for any DME company?  Do you get better coverage if you go to a “preferred provider”? 

F.  What is the insurer’s schedule for replacement of supplies?  Many, but not all,  follow Medicare guidelines (2 nasal pillows or one mask cushion every 30 days, 2 paper filters every month. 2 foam filters every 6 months, 1 hose every 6 months, one new mask and headgear every 3 months). 

Now, if you have an HMO, all bets are off.  Often (but not always), HMO’s limit the type of machine you can get, the DME provider you use, and may have a limited “formulary” of masks and other supplies.  Medicare Advantage (Part C) plans often work this way as well. 

Why is all this important?  Because you want to walk into the DME armed with this knowledge so they can’t pull “stupid customer” tricks on you like this:

 You want a ResMed Auto S9 (the APAP with the most bells and whistles and the highest price of all the current machines).  The DME says:

     A.  “Your insurance doesn’t cover that machine.”  But you know that your insurer pays by HCPC’s codes and doesn’t care what machine you get as long as it’s under the E0601 HCPC’s code, and the S9 is. 

     B.  “Your prescription has to specify that machine.”  Actually, it does not.  Any prescription for a CPAP machine will allow you to get this machine, but this battle is often never ending with a reluctant DME.  The best defense is to have your doctor specify this machine and write “dispense as written” on the prescription. 

   C.  “You will have to pay $XXX dollars more if you want that machine.”  This is often untrue.  If your insurance covers any E0601 machine and sets an allowable fee, most likely this is NOT true.  But some insurance contracts allow the DME to charge over and above the allowable fee.  So you should know this in advance, AND ALWAYS CHECK WITH YOUR INSURER BEFORE agreeing to pay the extra fee (some people have saved hundreds of dollars they would otherwise have willingly paid by taking this advice!)

    D.  “Your HMO doesn’t cover that machine.”  In most cases, this IS true of HMO’s, but be sure you know if it is true or not before believing the DME on this one. 

For a list of data capable machines, see https://maskarrayed.wordpress.com/2011/09/19/data-capable-machines/ .   You should decide what machine or machines you want and are willing to accept before walking into the DME as well.  Armed with this knowledge, you won’t be a sucker, and you can’t be taken advantage of by your DME.

Responses

  1. This is absolutely great! I wish I had read something like this 5 years ago. Thank you for the many people you will help with this. As I have read several times on someones tag “knowledge is power” I really enjoy cpaptalk.com and all the knowledgeable people there. john

  2. Wish I knew some of this before we got the machine. Trying to figure if we (spouse) needs the auto type or not. After reading this and cpaptalk and sleep apnea forums, I guess we should be finding out how often we are to get replacements. Haven’t heard from doc or dme since we got the machine. 4 months after getting the machine, spouse has decided to try to use it. Thanks for posting. Looking for more! I feel like a sponge!

  3. I’m always happy to hear my posts are helpful. Thanks, Ava and John, for your kind remarks.

  4. Bless you, bless you for your most helpful blog re DME!
    Only 5 days in, and I’m wishing I’d done a little more research first.
    The Sleep Center gave me a list of DME’s but they acted like I had to choose one the night of my cpap titration test. I picked a guy already there who doubles as sleep tech and DME because he seemed like an intelligent and “nice guy” and he is, but I’m just now realizing that his experience could be better — didn’t know much about adding data collection software to machine! –and he does seem a bit reluctant to have me start customizing parts now that I’m experiencing problems.
    “Doubtful Tom”

    • I’m always happy to hear when this is helpful. Glad to see you become more knowledgeable to be your own best advocate.

  5. I am a new subscriber on the cpap forum. Currently I use a standard cpap machine but my doctor has writen a script for
    an auto cpap unit. I am trying to decide what to ask my DME
    to get for me. She has already informed me of a $120 upcharge
    for the Remstar Auto-M Series. You talk highly of the S9 but I
    notice you use the PR System One. These are the two machines
    I’m undecided about. Any advice would be greatly appreciated!

  6. Frank,

    First, DO NOT PAY ANY UPCHARGE before you check in with your insurance company. In most cases, insurers contract with DME’s to provide equipment under a particular HCPC’s code for a particular amount. The DME agrees to provide a machine under that code for the insurer’s amount and you pay whatever percentage of that approved amount is not covered by your insurance company. In most cases, it is FRAUD for the DME to charge you one penny more than the price they agreed upon with your insurance company. Some people refer to this as “balance billing” and in most cases, they are not allowed to do that.

    Now, that’s not always the case, but it is MOST of the time. Furthermore, NEVER, NEVER, NEVER take your DME’s word for what the insurance will pay or whether the insurance company’s contract allows the DME to charge over and above the insured price. Understand that DME’s lie. All the time. Do NOT trust your DME.

    I hope you realize that they are trying to “upcharge” you for an older and now discontiued model of the machine??? Are you sure you really want to work with this DME?

    The only way to know for sure whether this practice of upcharging/balance billing is allowed is to ask your insurance company. For an excellent example of how to handle this with the DME check this out: http://www.apneasupport.org/viewtopic.php?p=172055#172055

    Now, as far as machines, many people seem happier with the S9 Autoset for a variety of reasons–it’s supposedly quieter, has the option of a heated hose, and it’s LED screen is color, backlighted, and has a wealth of information on it compared to the PR System One. The PR System One is a good, solid machine, but the only reason I have that instead of the S9 is that my insurer is an HMO and I had NO choice. I got what Kaiser gave me, or I’d be paying out of pocket, and I cannot afford that.

    Be aware that the S9 machine is more expensive than the PR System One, and if your DME is already squawking about providing you with a PR S1 auto they are REALLY going to be unhappy about giving you an S9.

    Good luck!

  7. I was fortunate to get the PR System One auto from DME before I knew anything about apnea. Since then they have been fairly consistent with sending supplies,although I do have to call them.They didn’t like it when told I would be getting my own supplies.

  8. You are fortunate, John. Too many DME’s try to foist PR Plus machines and ResMed Escapes–neither of which is data capable.

    You have a right to buy your supplies from whomever you choose. The DME would like your lifetime repeat business, but many DME’s don’t do anything special to make you WANT to use them forevermore. Just be sure that you are not paying more out of pocket by getting the supplies on your own. No point in that since you may already be paying for the insurance.

  9. Well, I followed your advice and called my insurer (Anthem Senior
    Advantage. ) I knew that the machine they tried to sell me was a
    discontinued model ($120 upchg) and I explained all this to the
    supervisor who got on another line and talked to my DME. Seems
    like Anthem agreed with the DME that since the machine I wanted
    was more expensive the upcharge seemed reasonable!! When I
    asked what Anthem allowed for a CPAP and gave her the HCPC
    code she said that Anthem doesn’t use codes. After an hour of
    back and forth bantering I just ended the conversation so now
    I don’t know what my next step is.

  10. Well, as you notice I say over and over again that if you are on an HMO, as I am, the same rules do not apply. Anthem Senior Advantage is an HMO plan, so you are stuck with the DME provider and the way they deal with CPAP machines, in all likelihood. That’s one of the major downsides of an HMO. You give up a lot of control and choice for (supposedly) lower premiums. I have a System One because that’s my ONLY option for Kaiser HMO–fortunately, they agreed I needed an auto, but my co-pay was higher than it would have been with a straight CPAP machine.

    HMO’s negotiate their own prices with DME’s and they don’t necessarily reimburse by HCPC’s codes. The reason is that HMO’s do a LOT of business with the same DME (because their insured individuals have no choice of DME’s) and the DME cuts them some really good price breaks in exchange. So the DME can say to the HMO that they will provide the X machine at a good deal for the HMO, but not the Y machine. The DME makes a lot of money on volume and repeat business from the HMO and the HMO saves money by negotiating a hard bargain on the price. The only person who may lose is YOU, because the machine your HMO covers may not be the best for you as an individual.

    Before committing to paying this upcharge, you should calculate your out of pocket costs for the deductible(s), co-pays, and up charge and see if it comes close to what you can get a machine for online. I hear the Devlibiss has some very nice machines for reasonable prices, and if you can have a data capable autopap for not much more than your out of pocket costs with Anthem it will be worth it to have what you want.

  11. Thank you for this much needed information. I unfortunately have already made many of the “cardinal” mistakes that your blog warns us about. I thought I was knowledgeable however at the time I was upset about my condition and they (DME) took advantage of this. I have no insurance and paid cash for a Pro System 1 w/humidfier that they recommended, then was told a month later that I really needed a Bi-pap machine. They told me they would work with me on a return on the former however after many visits and calls that never materialized. Since they could not help me I ceased going to them and after finding the “Cpap.com” forum embarked upon my own apnea treatment journey. I appreciate this information and those that are willing to share their experiences for the betterment of us all.

  12. Wow, sorry you had such a terrible experience! DME’s are supposed to help us, but they sometimes act like the scum of the earth. They really take advantage of people who are reeling from a new diagnosis and who are in no position to advocate for themselves at that point.

    Have you looked elsewhere for Bi-Pap like online suppliers, Cpapauction.com, second wind.com, and even careful use of craig’s list???

    • I will give those a sites a shot. Once again, thank you for your help.

  13. Jan,

    I’m amazed at the wonderful amount of information you’ve put here! Well, I really shouldn’t say “amazed” (LOL!!) since I’ve enjoyed reading your excellent posts on cpaptalk.com for quite some time.

    Thank you, thank you, thank you for providing such great guidance for newly diagnosed people who are about to receive CPAP equipment.

    Laura (“rested gal” on cpaptalk.com )

    • Thanks for your feedback!

  14. Any thoughts on Soft Weaver Mask

  15. Thanks for all this information. I’m going to try for the S-9 VPAP Auto w/ H5i Heated Humidifier. Also will try for a Hybrid full face mask or a Mirage Liberty full face mask.
    I have Medicare. My secondary insurance is “Tricare for life”. My insurance has covered all my doctors visits including my sleep lab visits so far.
    I’m also considering the S8 VPAP Auto 25 BiLevel machine as my second choice.
    Again thank you so much. There is so much to learn.
    cm6961

  16. Hi Chuck,

    From what I understand, Tricare for life is usually easy to deal with as far as coverage and runs pretty much along the lines of Medicare–but VPAP’s require a high level of documentation for medical necessity, so make sure that all the paperwork is in order.

  17. Just found this today after posting yesterday about DME’s and how to change them. I’m hoping I’m not going to get into a mess with changing DME’s after a new Bipap was delivered yesterday. The new DMs said to get Dr and documentation over ASAP before the billing goes in.
    The new DME has therapists who come to the house or i can go there and they can ck the masks machines etc. Last nite with new machine and mask that blew hubby and I out of bed this am…………..and me sleeping all day just did it. I have a live to live and they aren’t going to keep me from doing it. At least the sleep Dr and staff are and hope they will be supportive.
    Thanks for this great post i just stumbled on.
    Judy

  18. All I can say is THANK YOU! I got reamed by a DME and now I can tell u it won’t happen again! I have been on CPAP for the last month…but I have had the machine for 2 yrs. you and cpaptalk have enabled me to change my pressure to a livable setting and I feel GREAT! I have had no new parts for the two years but plan on starting to get them…I have insurance and will take whatever they want to send……some time when I have more time I will tell you just how badly I was reamed…..thanks again!

  19. Thanks for this informative information. Today I was visited by my DME(I am a new user of CPAP). He dropped of an S9 Escape. I decided not to use it tonight because I wanted a data recording model like the S9 Autoset. So the battle begins. Its after hours at me DME but I left a message asking if they can swap this Escape for a data recording model. I’m sure I’ll be getting an ear full of what this website posted about. Being new and not knowing these things and the way they operate put us at a large disadvantage.

    Take care all…….

    • Glad it was helpful, Rob. Rob contacted his DME the next day and they swapped out his machine for a data capable one without argument. Let’s hear it for good self advocacy!!!!

  20. This helps me alot. Thank you very much.

  21. Oh I wish, I wish, I wish that I had done some research and found your blog before getting our CPAP machines! My husband and I were both recently diagnosed — although I had also been diagnosed approx. eight years ago. My experience with that DME, machine, mask and settings was so bad I quit using it after a short time. I didn’t adapt well to the mask and I think the settings were wrong. You’d think that I would have done some research the second time around, wouldn’t you? But I had no idea there were CPAP boards/forums and so much helpful information from CPAP users.
    I knew I’d never go back to my original DME because from what I can remember, he simply handed me a machine, gave me a choice of 2-3 masks and explained how to wear the mask and turn the machine on and sent me on my way. I don’t think I ever slept a full night though using the mask/machine. The mask was uncomfortable and felt like torture and my throat was always so dry. I (stupidly) never realized that I should have gone back and kept going back until the settings were correct. I thought that I was the problem, not the machine.
    Well, recently (eight years later for me) when husband and I were both diagnosed a friend of my husband told us about CPAP2GO in Milwaukee. They have a 30 day mask gurantee. You can try as many different masks as you want within the first 30 days before choosing the one you like best.
    When we went in to CPAP2GO the DME was very nice and showed us different machines. We ended up choosing the Fisher & Paykel because our bedside tables are very small (big bed in a very small room) and I liked the way the water chamber could easily be lifted out and easily cleaned. It’s approx. the same cost as the S9 (which she also showed us) and it’s a data recording model. I hope that we made a good choice. What do you think about the Fisher & Paykel?
    As for the masks…my husband is happy with the second one he tried — the Swift FX — but he is expeiencing 9% (?) leaks because his mouth opens during the night. He tried a chain strap but can’t get used to it. He has a full beard which greatly limits the masks that will work for him.
    He’s going to check with his doctor and see if the pressure could be turned up a bit so that even with the mouth leaks he will still get the 9 (setting) that he needs.
    My first mask was the Swift FX for Her. I experienced HORRIBLE nasal irritation from the silicone pillows. Mostly around the outer edge of my nostrils and just inside. I even got tiny sores that were painful and throbbed during the night. It felt like my nostrils were on fire.
    It also seemed like the “width/thickness” of the barrel (from nose to lips) was too wide and it felt like my nose was being pushed upwards the whole night. The barrel was sitting right on my lip and felt like it was going to cause sores there too.
    The Swift FX for Her headgear was very comfortable to sleep in and although I was in pain with my nostrils, I managed to keep the mask on all night. I used it for 4-5 nights, hoping that my nostril irritation would lessen, but it didn’t.
    Today, while reading your blog — and especially your wonderfully written Swift FX Fitting Guide — I realized that I didn’t have my Swift FX headgear fitted properly and I was also probably using the wrong size pillows.
    When I experienced all the problems with the Swift FX I thought maybe I was allergic to the silicone pillows, so I tried a nasal mask — ResMed Mirage FX for Her. That mask sealed, well but it seemed like it was very close to my eyes/tear ducts and sometimes air leaked into my eyes.
    The Mirage FX for Her also caused me jaw pain — just on one side. I am a side sleeper and I sleep on my left side. When I used the nasal mask every morning I would wake up with pain in my right jaw. It would take a long time — hours — to subside and it would still be tender in the evening when it was time to put the mask on again.
    I tried loosening the side straps, especially the right strap, when I was laying down but it didn’t help.
    So I went back again to CPAP2GO to try a different mask. I am currently trying the Respironics GoLife for Women (nasal pillow mask) and those silicone pillows aren’t irritating my nostrils at all. So I don’t think that I have a silicone allergy. The pillows/barrel are also angled away from my lip so it doesn’t sit on/against my lip. But the cheek straps aren’t real comfortable. The cheek straps are fuzzy covered plastic (?) and they aren’t as easy to sleep on (for a side sleeper) as the wonderfully soft and comfortable Swift FX soft silicone side straps.
    I have three days left on my 30-day mask trial so I may go back and re-try the Swift FX for Her again now that I’ve read your tutorial about exactly how to fit it properly.
    I am a bit anxious because I only have three days left before my 30-day mask trial runs out and I want to find the best possible mask for me so I will keep using the CPAP machine.
    One last thing I’d like to mention. My husband and I have been using our CPAP machines for almost a month and neither of us have noticed any difference in being more awake in the morning and less sleepy during the day. I thought within a few days we would have noticed a difference — especially being more awake in the morning, but we haven’t.
    We mentioned this to the DME and she said that sometimes it takes a couple months of using the machine before noticing a difference.
    My husband has moderate sleep apnea — he supposedly stopped breathing 30 times an hour during the sleep study — you’d think he would have noticed a difference in his wakefulness almost immediately after using the machine.
    I only stopped breathing 16 times an hour. I haven’t noticed any difference in being more awake in the morning since using the machine. We both sleep the whole night with our masks/machines. I get at least eight hours of sleep.
    What do you think about this? Could we possibly need more pressure? Both of our machines are set at “9” per the doctor’s prescription.
    I’m sorry that this is so long. Thanks again for your wonderful blog and thanks also for any feedback you can give me. I deeply appreciate you taking the time to blog about your experiences with CPAP and DMEs.

    • Wow! You brought up a lot of issues!

      First, I’m glad you found this blog and I hope it will be a good resource for you.

      As for the F&P machines, my first question is which model? The Icon Novo is not data capable, so it’s not much more than a brick that blows air. You state that your husband is having mouth leaks and neither of you feels better yet–data can help determine why that is. Without data, you’re flying blind. Even with data capability the F&P models are problematic because currently there is no way for you as a CPAP user to access detailed data charts. You can download your own detailed charts on ResMed, Philips REspironics, and Devlibiss machines which are fully data capable. At this time F&P Icon software is not available to patients. As far as price, F&P machines are MUCH cheaper than ResMed S9 autos and Elites. It’s just that most insurers pay the same flat fee, regardless of which machine and model you get. So for the DME, they make more profit on the F&P, less on the ResMed. Your DME was correct that for you (assuming you have insurance coverage) the F&P was the same price as the ResMed because your insurer sets the allowable fee. But for the DME, they make more profit on the F&P–that’s probably why you were steered in that direction. Do you prefer to have something that looks good on the nightstand or something that can really help you dial in your therapy so that you do reap the benefits of the treatment?

      Your DME can, though, and it sounds like you have a good DME now who will work with you to download your data and help you problem solve. So if you are not feeling any better (understanding that it takes time once you are getting therapuetically good treatment–that is your AHI’s and leaks are both low), then your DME should be able to look at the data and make recommendations to you and your doctor about how to optimize your treatment. You can ask for printouts of the data, and on CPAPtalk.com you can post your data and ask for advice about how to tweak your treatment (CPAPtalk just changed servers, and they are currently having a lot of technical issues, but those will hopefully be cleared up soon).

      Now, about the mouth leaking. If your husband is losing air through his mouth, he is not getting adequate treatment. There has to be sufficient air pressure to splint open the airway. He’s not getting that. So there are a variety of things to do, but increasing pressure won’t help AT ALL, unless the reason he is opening his mouth in the first place is that the pressure is inadequate. The only way to tell that is to see what his AHI is when he’s NOT leaking. If one chin strap didn’t work, he might try another, he might try mouth taping (difficult with facial hair), or he may simply need to try another mask–a FF mask or a hybrid. BUT, before abandoning the Swift FX, there’s one more thing he can try–training himself to sleep with his tongue on the roof of his mouth. This can seal off the airway from the mouth, reducing pressure in the mouth that causes the mouth to open or the lips to leak. It’s free and relatively easy to learn (practice all day unless you are eating or talking). The most important thing is to stop the mouth leaking, because none of the data is reliable and the treatment won’t work if the air is going out of his mouth instead of down his airway to keep it open. I would guess this is why he is not feeling any better yet.

      As for you, my guess is that your biggest problems with your own mask were because it was not fit properly. Sounds like the Go Life is working well for you. You might want to check out http://www.padacheek.com. The owner, Karen, has a variety of padding products that will prevent the pressure you are experiencing from the straps. (she also makes barrel covers for the swift FX to make the nasal pillows much more comfortable). If you don’t see what you need on her site, email her and she will work with you to come up with something that will work–she’s great to work with! You might also look at changing your bed pillow. I use one of those tempurpedic neck supporting pillows. It has thick neck rolls along the long sides to support the neck, and a “ditch” where your head is supposed to go. As a side sleeper, I sleep so that the mask is in that “ditch” and my head is supported by the top roll, so that there’s little pressure on my face where the mask touches the pillow. I wish I had a picture–it’s really hard to explain that! Maybe it’s time for Toby bear to demonstrate.

      As for that 30 day trial–the mask manufacturers give a 30 day trial for EACH mask–so I would argue that you have 30 days from the date you were given your current mask. Now your DME seems to be pretty good and helpful, so you may not want to push the issue, but if the issue is your comfort and COMPLIANCE with the CPAP, it’s worth arguing. Once you find an ideal mask, if you can get to the point where you use your CPAP all night every night, CPAP2GO will have you as a customer for life and make back whatever it spends on making sure you have the right mask. However, if CPAP2GO is a mail order supplier, they do have a right to limit returns because of the expense of postage back and forth. In that case, you may need to purchase a new mask to start the 30 day trial period over again.

  22. I read this entire page (THANK YOU!) but I don’t understand one of your core concepts:

    “…If the insurers contract with DME’s to provide equipment under a particular HCPC’s code for a particular amount (WHICH IS MY CASE). The DME agrees to provide a machine under that code for the insurer’s amount and you pay whatever percentage of that approved amount is not covered by your insurance company. In most cases, it is FRAUD for the DME to charge you one penny more than the price they agreed upon with your insurance company. Some people refer to this as “balance billing” and in most cases, they are not allowed to do that.”

    Here’s what I don’t get. All parties concerned know that there’s a whole range of possible prices for eligible machines, and one must assume that the “approved amount” strikes some kind of balance between covering “cheap machines only” costs and covering “the sky’s the limit” costs. So, playing the devil’s advocate here, why indeed should the DME effectively lose money by my insisting on a top of the line model and his not being allowed to “balance bill?” For example if you go by cpap.com’s lineup of 15 apap machines there’s a 200% price difference between the lowest and highest cost machines! Something’s not computing!

    Looking forward to your explanation (as I’ll be buying very soon).

    • If you go out to buy a car, you–as an individual–are free to negotiate a price. If you go to buy something at the grocery store or department store, you are free to compare prices from one store to the next, stock up on sales, use a coupon, buy or not buy, etc.

      Purchasing medical equipment and supplies with insurance is very different. You don’t have much choice of vendors (sometimes none at all), someone else sets the price and how much you will have to pay out of pocket, and you have a need that must be met–this type of purchase is usually not optional in the traditional sense. I can do without that filet mignon or fancy dress, I can’t do without my machine and mask if I’m to maintain my health.

      There are contractual relationships involved. If you have durable Medical equipment coverage through your insurer, your insurer is contractually bound to provide that equipment, though you may have to pay a deductible and/or co-pay (also contractual). The insurer may have contractually guaranteed to you that your out of pocket expenses for DME would be limited to a certain amount. In most (not all) cases, the insurer contracts with the DME to provide your equipment at an allowable fee, made up of the insurer’s contribution and your deductibles and co-pays. Generally, the insurer requires the DME to provide an E0601 machine for $X. The insurer doesn’t care if it’s a dumb brick or a fancy APAP machine. To the insurer, an E0601 is an E0601.

      The DME can choose to enter into the contract with the insurer or not. If the DME agrees to the contract with the Insurer, it generally agrees to accept the allowable fee the insurer has set for any E0601 machine as the amount it will receive for an E0601 machine. The DME usually agrees either explicitly in the contract or impliedly by state or federal law to collect on that amount. In some cases, the DME does not agree to do so. If permitted by state law and the patient’s insurer doesn’t require a contracted (preferred) provider so the patient may use any provider, the DME may charge more, but that doesn’t mean that the patient has to accept that higher amount. The patient can walk out and find a provider who WILL accept the insurer’s reimbursement rate.

      Medicare is unique. Not every DME provider agrees to “accept assignment”, but if they won’t accept what Medicare will pay, they have to inform the patient up front and issue something called an “Advance Beneficiary Notice” letting the patient know that they will have to pay more than the Medicare amount. If I were a patient in that situation, I’d walk out of that DME and find a DME who will accept Medicare assignment. I’m not going to feel sorry for that DME’s profit margin. Other DME’s want my business and are willing to accomodate my wishes.

      Profit is more than just a single sale. A person who uses CPAP will have a lifetime of needs for supplies and for replacement machines. If a DME treats me well for the long haul, that DME deserves my business. The DME may not make as much at the beginning, but over the length of the relationship that DME is going to make a lot. If you are looking at CPAP.com, you will see that those RETAIL prices are in most cases lower than the Medicare reimbursement rates for the same machines. Many insurers base their reimbursements on the Medicare schedule. So I don’t buy the fact that DME’s are losing money by accepting the insurer’s rate for a more expensive machine. Generally the DME’s get more from insurers than you would pay out of pocket for a particular machine on CPAP.com. The extra money is supposed to cover support for the patient and maintenance for the machine. Some DME’s actually provide this and earn their money, others do not. Don’t forget that support needs generally lessen over time, but reimbursement rates don’t go down.

      Bottom line is that DME’s would not be doing this if it wasn’t profitable. Clearly they ARE making a profit, as they remain in the business and I believe that big companies like Apria and Lincare must be paying dividends to their shareholders. They do HUGE volumes with some of the major insurers–for example, in my area, Apria has the exclusive contract for Kaiser–that’s a LOT of regular, repeat business over the long term. An Apria employee complained to me about the slim profit margin they get from Kaiser (Kaiser dictates the machine you get, you have no choice and can’t ask for a more expensive machine, BTW), but she was totally out of line. Apria chooses to do business with Kaiser, it can choose not to as well. Not my problem! I, the patient, have NO choice if I want Kaiser to fulfill its contractual obligation to me to provide a machine for my health issue.

      In the big picture, DME’s can choose not to do business with insurers and provide machines if they are not making enough money at it. So far that has not happened to Medicare for example, which suggests to me that they are making a profit, because they definitely are NOT in the business of philantrhopy, as much as they would like us to think so.

  23. Wonderful explanation, thank you!

  24. Hi my name is Lee. I have a question for you and I hope you can help me. You seem to be very knowledgeable about this subject. I have the same machine that you have. Sometimes when I use the machine I have horrible nightmares. Not about the machine or mask or anything to do with it but really terrible things that feel very real when they wake me up. This is causing me to not use the machine long enough each night to be compliant with my insurance companies guidelines. And in turn causing the dme to be on my case about it. My question is and it may be a dumb one but I need to know for sure. Can the dme tell by the downloads they do if when I wake up in the middle of the night from a nightmare if I just let the machine run for the rest of the night without wearing the mask. I can’t afford to pay for the machine out of my pocket. I don’t want to lose it because I do really need it. And I do use it as much as I can take it. If you know for sure please let me know. Thank You in advance.

    • Hi Lee,

      First, yes the data will show that you were running the machine without actually using it, so that’s not a very good strategy. You can see the data yourself by going to cpaptalk.com and looking for sleepyhead software. It might be very helpful for you to see the data that’s recorded, and you might find what is triggering the dreams you’re having.

      You may be having nightmares you can remember because you are getting deep REM sleep for the first time in a long time. I get very vivid and disturbing nightmares too. I found that they are lessened in frequency as time goes on, but they still happen sometimes. I seem to have the worst nightmares when I sleep in a warm room–maybe my brain is more active when it’s warm. You might try keeping your sleeping environment cooler and sleep with lighter bedding and pajamas.

      Now, not using the machine is not helping anything. You were prescribed the machine so that your body would get enough oxygen to protect you from the bad effects of obstructive sleep apnea–heart problems, stroke and other brain issues. The machine doesn’t work unless you are using it, trying to fool the DME is just fooling yourself into believing it’s OK to sleep without the machine and it is NOT. You must use it EVERY time you sleep, for the entire time you sleep. You are not doing your body any good by only sleeping part of the night with the machine on.

      If the dreams are really disturbing, talk to your doctor. There may be medications you can take, but consider using medications carefully–all have side effects and even if we don’t like the dreams we need real REM sleep to heal and repair our bodies. But you need to understand that sleeping without the machine is NEVER an option.

  25. I feel worse on my Resmed S9 than without any machine — by worse I mean that although the machine shows few centrals and is quiet to use, comfortable, I wake up with tachycardia and also can’t breath. I have central sleep apnea and keep being told that the S9 is for both obstructive and central.
    Any ideas on that?

    Oh – – My first doc said that I don’t “fit the mold” of what a “central sleep apnea person” would be although I had 90 centrals during my test, so he said I didn’t have central. Ditto. second sleep guy, though my test showed centrals. Now at the third place the doc said he’d believe the docs before the tehcs — went back with the actual strips from my test and then doc 3 says, yep. Those are centrals.
    hmhmhm.

    Anyway, he said BUT the S9 seems to have helped you – you are having few centrals. My questions was, how does the s9 detect and then FIX/react TO THE CENTRALS and he didn’t know — I’m wondering if it shows fews because, well, it doesn’t detect them and then doesn’t fix them?
    Since I feel worse I REALLY WONDER — sorry for being so wordy.

    • Colleen, your question is beyond my scope. I suggest you register at cpaptalk.com and BE SURE TO PUT YOUR EQUIPMENT IN YOUR PROFILE, then ask your question there. There are people on that board who deal with centrals and can answer your question based on the equipment you have.

      Most importantly, you need to state WHICH S9 model you have as there are many different models. It may be that the settings are not ideal, or it may not be the best machine to treat your issues. Sometimes you need a different type of machine–a BiPAP or an ASV, but your insurance may require you to “fail” CPAP before they will cover the more expensive machine. The people at CPAPtalk.com are better able to answer your questions.

  26. This is good information and I wish I had read it before going to the DME! I did not know that I had any choice about the machine or how to choose one. The salesperson set me up with the equipment and told me I had a copay of $261, which I had to pay that day to take the equipment home. I said “That’s for today but I need to know what this would cost me in the long term, if I decide to keep the machine. I had a bad experience with a DME provider in the past, for a TENS machine, where they told me it would never cost me anything out of pocket, then later billed me for $3,000. It took me months, many letters and going to the Better Business Bureau for the state their headquarters was in, to force them to cut it back to a few hundred dollars.” She said “This is all it will cost you.” I said “No, I mean the TOTAL cost to me for the machine, ever.” She said “This is all: $261.” It sounds naive now, but I did not know what the machines cost. I ended up having to pay $1500 for my copay for the machine and first set of tubes, mask and all plus on-going co-pays for replacement hoses, mask and other parts.

    The price they billed my insurance for the ResMed VPap Adjust H5i S9 Series, with heated humidifier was $8500! After reading this article, I wonder if that was a greatly inflated price, versus an online purchase. It is a Bi-Pap machine, which may be more expersive. The other thing the DME company did was that, after three months of renting the machine to me, they told me that my insurance had decided to purchase the machine, so that resulted in my having to pay the entire $1500 at once or work out a payment plan with them. Later, when I talked with my insurance company about the large co-pay, they told me that they would have kept renting the machine for a year, at which time it would have been paid for but were told by the DME that I had chosen to purchase the machine after three months. The total copay would not have differed but I would have been able to pay rental copays, a “little” ($200 or $250 a month) at a time. I just went ahead and paid it, as it had to come out of savings either way. For someone paying out of monthly income, it might have made a big difference.

    Now I am going to be dealing with the DME company, trying to get other masks to try. But this time, I will know that if they say I can’t have a certain one, to not just accept that. I will first find out from my insurance what they allow and how they code it.

    They also told me that someone would be calling to check on my satisfaction with the products and I would get a call when it was time to re-order supplies. Neither happened. I waited for their call and finally called them and found out I need to initiate each order and allow 10-12 days to receive the items. I am not unhappy with my machine but I do feel the salesperson was deceptive. It was my word against hers as to what she told me so I decided it wasn’t worth a big hassle, knowing that they were billing me for what my insurance said I did indeed owe.

    • There are good, honest DME’s out there, but this is not one of them! Unless your insurance limits your choices in DME’s, I’d suggest going elsewhere for your supplies from now on. Call your insurance company and ask what DME’s are “preferred”.

      You should also ask your insurer if they will reimburse you for using a mail order CPAP supply company and submit the bill yourself–some insurers will do that. Out of pocket costs should be less, and they are MUCH easier to deal with. All you have to do is send them a copy of your prescription.

      • This website provides really good information I should have read before getting into nightmare with the DME. I have a similar situation with skabq. I got an auto CPAP from my sleep doctor’s office because they said my insurance company would cover 100% the equipment. I tried several times to use CPAP but could not fall asleep even with sleep medicine. So I stopped using it in the first month but forgot to return it within 30 days. A few month later, I got a letter from my insurance company that $1,500 DME claim from my sleep doctor’s office was rejected due to insufficient documents provided. So I thought that DME price was $1,500 and called the doctor’s office to ask them to send additional documents to the insurance company. I also told them that I could not use CPAP and wanted to return it.

        However, what I realized later is that total price of the DME is almost $7,000 and the doctor’s office claims almost $600 every month (Code E0601 & E1399) for 10 month. I called Auto CPAP company to check the retail price and it is just $1,000. Upon my several request, doctor’s office said I was not allowed to return the equipment because 30 days has passed although I do not use it.

        It looks like I need to pay most of the $7000 if insurance company does not cover it. Even if insurance company covers the cost this year, I need to pay more than 50% of the $7,000 in the next year when new deductible starts because of spread claims through 10 months. On top of existing insomnia, I cannot sleep because of this DME nightmare!

        Can someone give an advice for me to get out of this ugly situation? I cannot afford $7,000 for the device of $1,000 which is totally useless to me.

        Thanks,

      • $7000 plus $600 a month sounds fraudulent, especially if your insurer covers CPAP 100%. I would call your insurer and ask for help.

      • Nothing about pricing makes anything fraudulent. It’s no more fraud then a restaurant that charges $25 for a hamburger. Is it ridiculous? Absolutely. But that is how the insurance payers play the game. High charges are directly the result of insurance payers insisting on more and more “discount” off the MSRP. As a result the MSRP keeps increasing. Some providers set it at 5 to 6 times what they expect to receive from the insurance because of the outrageous discounts insurance payers expect. Most barely pay more than the cost of the item. Medicare pays less than $500 at this point, and other insurance payers are following their lead. Expect cheap Chinese knockoffs to be the norm very soon.

        But the problem here is that now the patient above does not have the payer to negotiate for the discount on their behalf. The insurance is not paying because the patient is not using it. And that is a good reason not to pay.

        Secondly, code E1399 is not reimbursable by an insurance payer, unless it is associated with a repair part (it’s a DME misc code). So the patient should not be charged for that on a new machine.

        Third, how do you “forget” you have a CPAP device that you did not return? More likely the person kept it because they thought they were getting something for free. Amazing how it becomes more important to return it when the money might come out of their pocket! Except now it’s too late to return.

        Lastly, this is why most insurance payers don’t like doctor’s offices providing DME equipment. They should have followed the patients compliance, billed the insurance on a timely basis, and accepted the return if the patient did not meet compliance requirements within the first 3 months.

        However, if the patient had no intention of using it within a short time of receiving it, I would refer them back to my statement above — how you forget you have a CPAP device??

      • Peter did not “forget to use” his CPAP or that he had no intention of using it. You are putting words in his mouth. “I tried several times to use CPAP but could not fall asleep even with sleep medicine. So I stopped using it in the first month but forgot to return it within 30 days.” He tried to use it but got NO SUPPORT from the doctor/DME. then when he missed the return “deadline” he was charged outrageous overpriced trumped up fees. Medicare gives people 90 days to meet the 30 day compliance requirement, recognizing that it takes some adjustment. This was a crooked sleep clinic all around.

        I agree that sleep clinics have no business acting as DME’s. it’s a terrible conflict of interest and people should run, not walk, as far away from that situation as possible. In some states it’s illegal for a doctor to refer you to a DME in which he has an interest.

  27. Your article was the first I read on this subject after doing a Google search. I just received my prescription, but haven’t been contacted by the DME yet.
    Your article lead me to CPAPtalk.com and apneasupport.org. Both are helping me learn what I need to know in order to make wise decisions when dealing with the DME.
    I thank you for taking the time to write this blog. I feel empowered and ready for the road ahead. God bless!

    • Thanks!

  28. I called Apria today because there is a specific mask that I wanted (CPAP Pro). I was told by the manufacturer that they had a contract with Apria. My insurance is Carefirst Blue Choice HMO. Apria told me that they only “offered” certain masks to Carefirst patients and the mask I wanted wasn’t one of them. I asked them if Carefirst dictates what brand/typ[e of equipment they will pay for, I was told no. In spite of that, April will still only offer equipment from one supplier. My sense is that I was being “offered” only what had the most profit. I moved on to the next supplier on the list, Lincare and am waiting for a call back as to whether they can get me the mask I want. I haven’t even tackled the machine yet.

    • Because Carefirst is an HMO, they may have a “formulary” of masks, much like Kaiser does. These HMO’s negotiate very favorable pricing with the DME’s because they give the DME a lot of volume business and therefore carry a lot of clout. However, the DME may in turn want the HMO to have only a limited formulary they contractually have to supply to the HMO’s patients, because of the profit margins.

      “I asked them if Carefirst dictates what brand/typ[e of equipment they will pay for, I was told no”. This may or may not be true–you’d have to ask Carefirst. NEVER rely on what a DME tells you without confirming it yourself.

      Fortunately, it sounds as if you have more than one preferred provider with Carefirst. With Kaiser, Crapria is the one and only, and Kaiser has a very specific formulary.

      Kim, good for you, it sounds like you’re taking charge! ;o)

      Be sure to read https://maskarrayed.wordpress.com/2010/04/27/realistic-goals-and-expectations-are-key-for-cpap-success/, it will help.

  29. Thank you so very much for your information on DME purchasing.
    Tho it may be to late to make changes on my DME CPAP I may be able to makechanges on our zDME hospital bed.

  30. I didn’t say he forgot to use – I said how do you forget you have it? This is actually very typical. Patient is non- compliant, doesn’t return it, and then is surprised they get a bill. I sympathize with not realizing that the insurance won’t pay if you don’t use it. But I can’t believe he forgot to return it.

    Another tip – don’t sign a delivery ticket if it has no price on it.

  31. Thank you much, Ltrs. Now I understand much more what is actually going on. This website really helps me how to resolve this situation:

    I would not have bitten the hamburger if had known its price was $25. The restaurant did not tell me the price and just said it was free and good for my health. I also did not understand a rule that I need to pay it if I do not eat a whole burger. The restaurant gave me just 3 min to return the bad burger.

    There is NO free lunch!!

  32. Thank you for this great information. I had just completed my split sleep study and received a call from the Dr office informing me that the Dr has written me a script for CPAP machine. I found the website CPAPtalk.com, but this blog really help me with information before the DME contacts me about the equipment. Thank you for sharing your knowledge and experiences with those just starting down this road.

    • Glad you found it helpful.

  33. This is a wonderfully helpful post. Thank you!

  34. I have a new VPAP machine that has efficacy data capability . . . but my doctor refuses to have the DME enable it. He doesn’t want patients “diagnosing” themselves. I don’t want to change any pressure settings, just be able to monitor how well mask/machine are working–just as I regularly check my own blood pressure. Do I have legal rights under HIPAA to access data on my machine?

    • You don’t need ANYONE’s permission to access your own data. It’s yours and belongs to YOU.

      Go to http://www.cpaptalk.com. Join the forum and ask for some help in accessing the data. There’s software available for free to help you do that.

      You don’t have to tell your doctor or DME that you are doing this. If you feel that all your doctor is doing is keeping you in the dark and feeding you BS, you are not a mushroom. Find a doctor who understands the value of a patient who is engaged in her care.

  35. Well, I may not need permission, BUT I can’t enable efficacy data myself —it’s programmed by the DME technician. However, I will give both the tech and doctor a really hard time if they refuse my request to activate. (I had assumed I’d have the capacity when I picked up the VPAP last week.) Meanwhile, I’ll try to find a doctor more willing to make me a partner in my own care—it’s difficult because I live in a small town. I’ll let you know how it turns out. (I don’t want to bother getting software when the data is right there in the machine!)

    • Yes, you CAN access the data yourself, that’s what I’m trying to tell you. You can either look at it “onboard” by learning the “secret handshake” for your machine (the trick to get into the clinical menu is quite simple–for example, on Respironics machines, just dial in “setup” then hold down both buttons at the same time for about 10 seconds). And with software, you can download your data onto your computer and see every detail. If you ask on CPAPtalk, you’ll be given links to the clinician’s manual and to software so you can read your data card on your computer.

      This is YOUR health and nobody cares more about it than you. Your DME and doctor may have told you that only the DME can program and access the efficacy data, but it’s not true. They don’t want you to know the truth because they are more concerned about being able to charge you for each change and printout than let you participate in your own healthcare.

  36. Thank you for your advice. I appreciate it . . . though I’ve already googled for tips on how to access efficacy data on the Res Med VPAP. I’ll continue searching, but I do want to let the doctor know what I expect from HIM. I think it’s my right to know (under Patient’s Rights). I don’t think he’s so mercenary—it’s more that he’s old and has that old-fashioned notion that “doctor knows best.” (But I know even good doctors don’t always know best for individual patients — in the past, with other doctors, I could have been killed or at least my health compromised—if I hadn’t researched drugs I had been prescribed.)

  37. Whoopeee! Res Med works the same. Thanks so much for the information. I held down the button and the LED came up with a AHI of 4.5 —something that pleases me. I told the doctor that my goal was to have an AHI under 5 . . . and he had said his goal would be under 11. I really DO need a new doctor. I wouldn’t even have gotten the new sleep study (hadn’t had one in 7 years) . . . that showed I now have central apnea in addition to obstructive. I do very much like the new VPAP machine!

  38. p.s. I meant I wouldn’t have gotten that new sleep study if I hadn’t insisted. . . . and then he had ordered an apnea test (which I did NOT need) rather than the titration study. Fortunately, the director of the sleep center agreed that my medical records showed I did indeed have sleep apnea . . . and it was the titration study that I needed.

    Thank goodness for this site. We really need to be proactive patients!

    • Awesome! Keep working at it, with the data you can see what’s happening and try to fix things like leaks that may be impacting your numbers. Ideally, you want to see numbers in the 1 to 2 range. Or less ;o)

  39. Great blog page. I’ve learned so much reading this. My spouse and I just purchased a small DME and I’m trying to make sense of the wacky billing system that I’ve acquired. I learned more from this page than I did from the previous owner in a month of training.

    The main thing I’ve learned is that there are right and wrong ways to take care of your patients and do business. I’ll be doing right, even if it means making less money.

    • Roxy, you’ve picked a hard business, and I wish you luck. There’s definitely a niche for DME’s who are fair and supportive to their patients–some people are willing to pay out of pocket for good service and a DME who doesn’t lie or play games.

      Hopefully you’ve done your research and understand what you’re up against with competitive bidding. I hope it goes well for you.

  40. Thanks, competitive bidding has come and gone in our area and the general consensus was that reimbursement was so low that it wasn’t worth it. Our company only deals with out-of-network ppo and cash. I’ll be also doing internet sales as soon as I get the website up to snuff.

    The books “looked” really good, but further scrutiny has revealed a certain amount of unethical behavior that we will not be continuing. Hopefully, we can be honest and still pay the bills.

    Fingers crossed (& hard work).

  41. It’s always nice to know of honest, good DME’s. Are you doing other DME besides CPAP?

  42. I’m in my second week of CPAP therapy and would like to swap out my machine (remstar auto 560P) for the ResMed Auto S9 mainly for the screen. (I can’t read the pressure on the screen when it’s on. I’m very hands on in my care, have the software, and have figured out how to change settings, etc., so I can finally breathe with the nasal pillows on–a whole other story.) I’m on a great Medicare Advantage plan, and was lucky enough to avoid Apria as a DME. My insurance co (HMSA in Hawaii) is pretty useless as to what’s what on CPAP issues and couldn’t really answer any of my questions. Do I have a chance of getting this swap? I’d even be willing to return the remstar and just buy the S9 online out of pocket if needed. How should I approach this? Supplies issues still tbd.

  43. So relieved to find this site. I was just prescribed a ResMed S9. What parameters can the computer card measure? The DME won’t tell me. My biggest problem is insomnia. A recent sleep study revealed sleep apnea, but I was only able to fall asleep after taking a cocktail of medications. I don’t experience apnea when I’m awake, so it can appear as if my sleep apnea has been cured. A sleep study some time ago revealed that I did not sleep, just as I had told the sleep disorders specialist. With no evidence of apnea or restless leg syndrome I was told I had no problem. Another doctor gave me a prescription for Trazodone which provided relief for years, but its effectiveness has now worn of.f My story sounds so unlikely I don’t have much hope that a physician will believe me. This is the worst that I’ve felt, and I’m becoming desperate. Any advice please!

    • Pam, go to http://www.cpaptalk.com and ask around for a copy of Sleepyhead. That is free open source software that will allow you to read the data on your card. What you can see depends on WHICH ResMed S9 you got. If you got the Escape there’s no data other than hours of use. If you got the Escape Auto, there’s a little data besides hours of use–mostly AHI and pressure readings. You only get full data with an Elite or AutoSet. When your DME doesn’t want to tell you what data you can get, that’s probably because 1) Your DME doesn’t know because they don’t care about anything but hours of use; 2) Your DME doesn’t want you to know that you can access other data (or they don’t know that you can); or 3) they don’t want you to figure out too quickly that they stuck you with an Escape brick.

      Ideally, NOBODY should experience apnea when they are awake. If you stop breathing when you are awake, something is seriously wrong! So lack of apnea when you are awake has NOTHING to do with whether or not you have sleep apnea.

      You should understand that CPAP treats apnea, it does not cure it. So using CPAP for a little while will not improvve your condition to the point where you don’t have to use it any more. You will always need CPAP. Some very few people have apnea only because they are overweight, and weight loss means the apnea is under enough control that they no longer need CPAP, but that is actully pretty rare.

      You probably feel rotten because of the sleep apnea. So the best advice I can give you is to use your CPAP every night, all night and whenever you sleep. Learn to check your data to make sure that your therapy is optimal for you. And then you should start to feel better soon.

      Good luck!

  44. The DME took my 85 yr old mothers cpat machine due to non-compliance she was in the hospital and nursing home for over 60 + days cpat machine put on her each night by hospital staff and she had to use nursing homes cpat machine . We explained we could prove legal proof of all they still took the machine now she must do another sleep studies , 85 with pacemaker,copd, etc DME says cpat machine disc shows only (1) hour of use since May 2014. From all that I am reading she should have owned machine by now this is the second time they said they were coming to get machine ,1st time they actually did . They will not allow us to provide documention of compliance , now they have machine so how can we prove it;s them not my mom. I am begining to beleive Medicare Fraud. Help Please

    • I’m so sorry to hear that.
      A few suggestions:
      1. Let her doctor know what the DME did. Ask the doctor to intervene.
      2. Call 1-800-MEDICARE and file a complaint against the DME.
      3. Call your local newspaper’s health or cconsumer reporter and see if they will run a story about what the DME did.
      Good luck.

  45. I know this is rather late but I had a question, if your insurance does not have DME coverage is it possible to buy a supplemental insurance that does? I know some of the older grandfathered kaiser plans have this particular issue and I’ve been told by customer service the best that they can do is suggest to get a new plan during open enrollment.

    • I’m not aware that you can just buy DME coverage, but its a good question to ask Kaiser. I think you can still take advantage of Kaiser pricing for DME if you purchase at Apria. Kaiser contracts for very low prices through Apria, so you may still pay very little compared to their “public” prices. Whatever you do, do NOT pay the full retail prices because that’s where DME’s will really take you. Look online for DME suppliers (like cpap.com) or consider second hand like http://www.secondwind.com or even Craigslist (buyer beware–you have to be extremely careful on Craigslist). Sometimes a guy named “STL Mark” sells brand new machines for very good prices on http://www.cpaptalk.com–you can try pm’ing him there.

  46. Just a question. In CA does the Dr need to issue a Rx for each individual CPAP supply item such a chin strap, nasal cushions, head straps, filters, etc or is it just required for the CPAP pump and mask.?

    • Does CA stand for Canada or California?

  47. So happy to have found You!!!! I’ve just been called by my DME (Lincare) and told that my usage does not comply with with Medicare requirements and that they will not pay for my machine…they told me I only used the machine 2 hours last night but that is not correct…the machine sleep report said I used it 7.6 hours..is it possible there data is not accurate??..what could be wrong…please advise..they want me to return the machine..!!! or pay for it!!! …or start the whole process over again with a new sleep study in order to get them to pay for the machine….any advice would be appreciated

    • Sorry to take so long to reply, I hope this is still in time to help. HOW is the DME accessing your data? Are they doing it over the air, or from the SD card in your machine? If they are doing it over the air, there may be a problem with data transmission or perhaps they are mixing up your data with someone else’s. If they are reading your card, they could again be mistaking your data for someone ese’s. I would take the card in to the nearest Lincare office and ask them to read it and print it out and SHOW you the data. Meanwhile, take a printout of your Sleepyhead data and if there is a significant discrepancy ask them to explain. (They may claim that there is no validity to Sleepyhead). A mix up on their part is the most likely explanation, but don’t take it lying down (no pun intended!).

  48. i read your article a month ago. i am with Kaiser and sadly their choice is Apria. when trying to set a time or date to get my oxygen or nebulizer supplies i have called them to make their jobs easier. whoops, what a mistake. if i say i have an appointment and what time i need to leave they arrive ten minutes later than my must leave time i gave them, block my driveway, sit there and finally get out when i walk up and laugh at me. if i try to read the contract they take it and my supplies away. they deliver my supplies to a weekenders house on a different street and address, then call me a liar when i call to let them know i haven’t received the delivery. i have contacted Kaiser member service. they resolve the issues i have with apria without consulting me. they state they have sent me letters. i found out two days ago that the resolution was that Kaiser sent an FYI letter to apria stating that a client is not happy with them. grrrr. i have purchased my own oxygen concentrator and nebulizer equipment. i will get a compressor and tanks when/if i can afford them. apria told me when they were charging me money, (i have 100% pay coverage by my insurance), that if i didn’t pay them whatever they wanted they would take my life support equipment away. i am posting this to all sites i can so those who have similar issues will know that Kaiser member services is not helping you.
    i was told flat out that i have no choice, as long as i am with kaiser permanente i will have to use apria. i am going to reread your post.

    • There’s a reason they are nicknamed “Crapria”. You DO have the choice to pay for your own stuff, then you can buy it anywhere you want, but that’s not feasible for most people. Kaiser is actually your DME, Apria is merely the supplier. If you want Kaiser coverage to pay for DME, then you have to get it through Apria.

      Remember you can always file a complaint with the state agency in your state that regulates managed care. It may get you any satisfaction, but Kaiser does have to respond to such complaints.

      • I have been up the last 3 hours reading through all of these posts. I’m not blog savvy so am unsure if I was supposed to post this reply under a new thread but this is the most current one and since I am about to make a long overdue appointment with my doctor to figure out if I have sleep apnea. I need to know how to proceed. 1. Get the sleep apnea diagnosis either through a home test or lab study ( I have kaiser in southern Cali BTW) 2. Call Kaiser to find out about DME coverage and ask critical questions you outlined above 3.If study results in positive diagnosis – Kaiser will write prescription for cpap machine ( I have no choice in machine maybe but will request specific machine to be written on prescription if do or at least one with efficacy and compliance data I can access) 4. Have titration study to learn to use machine.
        5. Go to cpaptalk.com to continue reading forums and educating myself.
        Some of your posts were from 6 years ago. Which machine do you currently have or what is one of the better models today if still not the Redmed vpap s-9 series?

      • If you are with Kaiser, your first step will be to ask your doctor for a referral for the sleep apnea clinic. You will be scheduled for a take home sleep apnea class. They usually require you to attend a group meeting where you will be instructed in how to use the take home test that night and return the apparatus the following day. Then you will wait a few weeks for results. If you are found to have sleep apnea, you will have to attend another group meeting, where you will be instructed in how to use a loaner APAP machine for home titration, and you will be fitted for a CPAP mask. You are expected to use the machine for one week and then return the machine to the clinic. Based on the results of the titration study, the clinic will determine whether you are eligible for an APAP or a basic CPAP, and a prescription will be written. You will need to check with Kaiser to find out your DME coverage. Kaiser has one DME, Apria, and if you want Kaiser to pay for it you MUST use Apria. You can get only the machine and mask that Kaiser orders for you. You can try asking for a particular model of machine, but it may or may not work. Kaiser used to deal only with Respironics machines, but I was recently given a brand new ResMed Airsense AutoSet, so it seems like that’s their new machine. (I love mine). I never had a ResMed VPAP S-9, so I’m not sure where you got that info. VPAP is a very specialized machine if you have severe and complex apnea.

        Since you are in a different region, there may be differences in what your Kaiser system requires, but generally this is how it works with Kaiser. It seems like all the Kaiser’s in the US are contracted with Crapria to provide the equipment and supplies.

        Good luck with your process.


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