New machine choices

[sc0ttt]

Insurance pays by HCPCS billing code...not by brand...not by model.
They pay the same for a bare bones basic no data brick as they do for a full data apap.
DMEs know this and that's why they will often dispense the model that they make the most money on.

OK, so in my breakdown below - the base price is just fluff of course, but the insurance adjusted price would have said the same number for Plus, Pro, Auto, or BiPap? Boy, that's not obvious. Can't really blame the DME for playing the cards they were dealt, they would probably have lost money if they gave me an Auto.

[Pugsy]

Can't really blame the DME for playing the cards they were dealt, they would probably have lost money if they gave me an Auto.

I doubt they would have lost money. They may not have made as much as they want but they wouldn't have lost money.
It's not like APAPs cost double cpap only or anything near that.

All insurance (and this includes Medicare) pay by HCPCS billing codes for anything...not just cpap stuff.
While you may have seen it itemized like it was I can guarantee you that the insurance bill would have included the HCPCS billing code and maybe some notation as to what the equipment was.

HCPCS codes are universal.

This is a common Medicare replacement schedule below and the HCPCS billing codes that are used. Most insurance will abide by the allowance time that Medicare goes with but some might not....but they all use the same coding.
Brands are never used and specific masks are never mentioned. A full face mask is just a full face mask...not a Quattro or Simplus or whatever. Insurance pays the same no matter if it's a ResMed (which usually is more expensive) or some no name off the wall brand.
When DMEs give out the "your insurance won't pay for it" that's not necessarily the true story.
Note the last item on the list...E0601..it just says cpap and an apap is a cpap with an additional mode of operation.
APAPs are a "continuous positive airway pressure" machine that just happens to have auto adjusting capabilities for that continuous pressure.

[Wulfman...]

Insurance pays by HCPCS billing code...not by brand...not by model.
They pay the same for a bare bones basic no data brick as they do for a full data apap.
DMEs know this and that's why they will often dispense the model that they make the most money on.

OK, so in my breakdown below - the base price is just fluff of course, but the insurance adjusted price would have said the same number for Plus, Pro, Auto, or BiPap? Boy, that's not obvious. Can't really blame the DME for playing the cards they were dealt, they would probably have lost money if they gave me an Auto.

The same for CPAP/APAP machines, but others, including Bi-level machines have different codes.
This is the current list as far as I know.

Codes have changed as of January 2003.
These are updated codes are used to bill insurance and government plans for CPAP items.

* E0601 RR is CPAP rental.
* E0601 NU is CPAP purchase.
* A7034 is CPAP nasal mask, including all nasal masks, Nasal Aire, Breeze, Spiritus.
* A7032 is CPAP nasal mask cushion.
* A7030 is CPAP Full Face mask.
* A7031 is CPAP Full Face mask cushion.
* A7044 is CPAP Full Oral Interface.
* A7046 is CPAP Humidifier Chamber.
* A7037 is CPAP tubing, long and short hoses.
* A7038 is CPAP disposable filter.
* A7039 is CPAP gross particle (foam) filter.
* A7035 is CPAP headgear.
* A7033 is CPAP nasal pillows.
* A7036 is CPAP chinstrap.
* E0561 NU is CPAP Passover Humidifier
* E0562 NU is CPAP Heated Humidifier
* E0470 RR is BiPAP rental.
* E0470 NU is BiPAP purchase.
* E0471 RR is BiPAP-ST rental.
* E0471 NU is BiPAP-ST purchase.


Other CPAP items are listed under E1399, which is miscellaneous.

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Den

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[Rob K]

No respect or disrespect is also a very big problem on the internet. People aren't given the benefit of the doubt or any initial respect very much these days. People don't have to talk face to face and can hide behind a fake name. This forum is far better than a lot of places I've been. Even on the good forums you'll always have those certain people that will make assumptions and say anything they want. They make themselves look bad by being uncivil. Civility is not something of the past. It's still a good thing.

It does suck for the rest of us when people take advantage of insurance. I see how it happens though, because insurance costs a ton and people are trying to get their money's worth.

When I first got my equipment I was so amazed at the high prices from the DME that I called my insurance company several times telling them that they are getting screwed by the DME. Their response every time was that this is the way things are. They didn't seem to care.

Everyone should take care of their treatment above all else. That's what's most important to me. We can't use the money when we are dead.

[sc0ttt]

I doubt they would have lost money. They may not have made as much as they want but they wouldn't have lost money.
It's not like APAPs cost double cpap only or anything near that.

All insurance (and this includes Medicare) pay by HCPCS billing codes for anything...not just cpap stuff.
While you may have seen it itemized like it was I can guarantee you that the insurance bill would have included the HCPCS billing code and maybe some notation as to what the equipment was.

HCPCS codes are universal.

OK, the point that wasn't connecting is that the code (for any particular insurer) has one and only one dollar value associated with it. "We pay $X for line item Y" instead of being just a description with a flexible payment amount depending on other factors. Clear as water now, thanks Pugsy.


At the time I purchased, the equivalent CPAP.com prices were:
Auto $639
Pro $573
Plus $369

So my insurance company pays $436.50 for line item E0601 NU.
And "Your insurance won't pay for that" really means "Your insurance line item for E0601 is less than we're willing to sell it to you for."
I was fortunate to not walk away with a brick.

[palerider]

Plus, Pro, Auto, or BiPap?

no, because bipaps are a different billing code, but SE, plus, pro and auto are one code, bipap pro and auto are another, and autosv an S/T are a third.