Insurance Tips

Depending on the type of insurance you carry, there are different plans of attack to get your backup equipment. This process takes some serious determination and patience but the rewards are too beneficial to you and your child's life.  Moving the Cough assist from place-to-place was not what the product was intended for - they even hit that point home by not providing a carrying handle on the device.

First, establish a contact:

cough Assist CA 3000

The first thing you need to do is request a Case Manager or Case Handler or Case Consultant from your insurance company.  There are many names for this position, but it's basically a single individual that oversees your individual case.  Contact your Case Manager (you may have to leave a message and wait for a callback). This Case Manager should be your advocate to get the equipment you need.  

Make sure you always refer to it as your "backup" equipment rather than "secondary".  Secondary sounds like excess and lacks the medical necessity the word backup portrays.

Second, know the state of your current device billing:

Let's briefly discuss your DME (durable medical equipment provider) and how they bill for a cough assist device.  There are generally two ways to bill this device.  1.  A lump sum payment - meaning you own the device from day one   2. A lease rate - meaning you pay a certain amount per month/quarter/week until the equipment is fully amortized and then you own it.  Check with your DME to see if you've fully amortized.

If your primary equipment has already been paid-off so you are no longer billing insurance, you have a greater chance of getting a backup approved.

Third, on the phone with the Case Manager:

Let them know what your intentions are:

I'd like to get a backup cough assist machine - it's the most critical medical device we have since it is the only thing that can clear a mucus plug.  Having this piece of equipment go down would mean my child could choke and die at any second.  This device is so critical to my child's care that we cannot wait the one or more hours for our DME to deliver a replacement.

This statement is true for those of us who have experienced a sudden mucus plug.

Next ask what you need to do to get one pre-authorized.  You will likely have to get your Pulmonologist to write an additional prescription which you will to have fax or mail to your DME.

Fourth, the prescription:

Call your local Pulmonologist or physician and have the script written then faxed or mailed to your DME.  If your insurance company didn't pre-authorize or agree with the third step, then have them also write you a letter of necessity for the backup device.  You can then fax or mail this letter to your Case Manager directly to reinforce what you told them on the phone.

Fifth, and hopefully final:

Call your local DME and make sure they know you are pre-authorized and give them the direct number of your Case Manager.  This can take a day or two for them to get in contact so be patient.  If you have not received a follow-up in a few days, be persistent. 

BiPAP specific backups.

You can try the above method with the BiAPAP device at the same time or a month or two apart.  The best option for a BiPAP is to get your Pulmonologist or physician to write a prescription for a backup device and a letter of necessity to present to your Case Manager before approaching your Case Manager.

When you do contact the Case Manager you can simply state: 

My Pulmonologist wants my child to have a backup device.  How do we get this done?

If you have Medicaid, and already use a Trilogy 100 BiPAP, then approval should be fairly easy.  The Trilogy 100 is also a ventilator and per Medicaid rules, you should always have a backup ventilator.  The only exception to this is if your DME is billing the Trilogy to insurance as only a BiPAP.

Another method is to have your Pulmonologist classify your child as BiAPAP dependent since they should be using this device more than 12 hours per day (this is more true for Type-1 SMA children).  9-10 hours per night asleep and a 2-3 hour nap during the day equals 12 hours. 12 hours us generally the cutoff for determining dependancy.  The classification is just something to let the insurance company know how important the role a BiPAP plays in the quality of your child's life.

It should be much easier to get approval once you have obtained this classification.  This is something you can relay to your Case Manager when requesting the backup BiPAP.