My attempts to secure BleepSleep DreamPort covered by insurance

[NorwichTerrier]

This is a long saga of my determined attempts to obtain the new BleepSleep DreamPort and have Medicare and Blue Cross Blue Shield cover it. So far, I have been unsuccessful.

I have been contacting my Home Care Provider regularly to see if they can obtain the BleepSleep DreamPort for me. Finally, I was told that their reluctance was based on the likelihood that what Medicare covers would leave them out of pocket for a large chunk.

Today we had another conversation, and I asked if they could special order it, and I would pay the difference of what was not covered by Medicare and Blue Cross/Blue Shield. Not possible, as it is illegal.

I called Direct Home Medical yesterday, and was told they did not file insurance, but I could do it myself. Probably also not possible because of the phone call I had with Medicare.

If I were, in fact, lucky enough to find a Home Care Provider willing to cover the BleepSleep DreamPort, I would have to have all my medical supplies ordered from that same provider, which would require a doctor's prescription to change. Medicare said that the codes I was given by BleepSleep allow for the following: A7033 allows for 2 boxes of the ports per month. A7034 allows for a new part piece every three months. When Medicare says "allows for" they do not mean they will cover it in full, which explains the reluctance of providers to order the BleepSleep DreamPort for their customers. Medicare gave me the name of an approved provider in Coldwater, Ohio, which happened to be a hospital that has a DME section. The lady I spoke with said the same thing - no one is willing to do special orders like this, as they will be out of pocket.

So, my next call was to Blue Cross, Blue Shield, asking for any suggestions. Long call in which I found out nothing new or helpful, except the Associate was going to send me a list of CPAP Providers. Probably nothing will come from that.

I wish I could just order it to try for myself, but I am really unable to pay $80 per month for the ports, without any coverage at all, and no provider that I have found seems willing to order it. It is like a Catch-22. I do hope that BleepSleep is working on making this more readily available to people who need to have it covered by insurance.

Has anyone else who wants to use this wonderful new product found it similarly difficult to impossible to obtain through their insurance? Has anyone been lucky enough yet to find a provider who will cover it with Medicare and a supplemental insurance? If so, I would most definitely love to hear that news.

At this point, I am almost ready to throw in the towel, and suck it up with my current mask. I hate defeat.

[Islandwoman]

I would suggest logging in to Medicare and searching for a new DME that coordinates with Blue cross and starting over.

[Dreaming1]

Give em hell!

[NorwichTerrier]

Islandwoman said: I would suggest logging in to Medicare and searching for a new DME that coordinates with Blue cross and starting over.

My problem isn't coordination with Blue Cross, which is my supplemental, and Medicare and BC/BS has always worked smoothly together. The main issue is that no Home Care Provider at this point wants to offer the BleepSleep DreamPort, as in so doing, they will be out of pocket for the amount NOT covered by Medicare, which I understand their hesitancy in this respect. And, the sad part of it is, I would be more than willing to pay the difference, but that isn't allowed, either.

I'm open for any suggestions from anyone, short of robbing a bank.

[Rexlan]

Am I missing something ???? Looks like the thing is $109 ... why not just buy it and be done?

I think the pads will be the real cost. Looks like $75/month and I don't think any insurance will pay for a disposable.

[NorwichTerrier]

Relaxan wrote: I think the pads will be the real cost. Looks like $75/month and I don't think any insurance will pay for a disposable.

And, you are absolutely correct - the pads are the items that would be cost prohibitive. If it were a one-time purchase of the $109 part, that is doable, although insurance should cover it, but paying $80 per month out of my own pocket on something that should be covered by insurance just isn't in my budget, when all my other cpap supplies to date have been fully covered. And, the $109 item should be replaced when necessary.

Let me mention here that I am not a greedy so and so, but I pay a hefty amount from my retirement income on insurance - over $100 per month for Medicare and approximately $568 monthly on Blue Cross/Blue Shield (since my husband is not yet of Medicare age), so I need to make maximum use of my insurance whenever possible.

[Pugsy]

I think the pads will be the real cost. Looks like $75/month and I don't think any insurance will pay for a disposable.

Insurance (including Medicare) will indeed pay for the disposable ports. It's the same HCPCS billing code as the disposable nasal pillows that Medicare allows 2 per month.
Insurance pays by HCPCS billing code....name or brand doesn't matter.
Medicare will allow the same dollars for the ports as they do for the nasal pillow. The problem is suppliers are afraid that the cost if they special order the box of ports is going to cost them more than insurance (or Medicare) will allow as an allowable charge and providers who are participating members with Medicare can't accept any more than what Medicare allows.

Right now the brick and mortar DMEs aren't stocking the Bleep...big hurdles get them to get out of the dark ages and try something new.
When they special order something they usually will just order from some place like cpap.com and while I don't remember the exact allowable amount for a replacement nasal pillow...I am pretty sure it is less than $40 and if that is the case there is zero profit margin.

Anyone recently had Medicare pay for a nasal pillow???? How much did they allow and then pay 80% of???

What we need right now until we can get the brick and mortar DMEs on board is an online seller who will file insurance in lieu of payment up front for the Bleep. There aren't a lot of online sellers who will file insurance but there are a few...we just have to get some of them to come on board. I am sorry but I don't have a list of who all is stocking the Bleep but I will ask Stuart if he knows of any that will also file insurance for the patient and accept assignment.

[NorwichTerrier]

Pugsy (bless her heart) said: What we need right now until we can get the brick and mortar DMEs on board is an online seller who will file insurance in lieu of payment up front for the Bleep. There aren't a lot of online sellers who will file insurance but there are a few...we just have to get some of them to come on board. I am sorry but I don't have a list of who all is stocking the Bleep but I will ask Stuart if he knows of any that will also file insurance for the patient and accept assignment.

That would be so helpful.

In January - the price turned in by Medicare for a nasal mask for me was $52 (come on now - get real, people as you will have to prove that one of these nasal pillows really costs $52). Medicare allowed $30.40, and they paid $23.83, then Blue Cross/Blue Shield picked up the rest of the $30.40.

The reason I said "Get real" was because I purchased on eBay a Respironics DreamWear Gel Pillow Mask Cushion Small NEW Replacement S for $9.95 plus $3.74 shipping. That was the best deal I found, as I wanted to try this, which is similar to the one I have, but no plugs for the nose. I imagine mine is the same price as it is similar in design. I just saw two like what I am using selling for $7.99 and another for $10.50 plus shipping. I'm sure these are items that people just didn't use, but still, I cannot believe one of those costs $52 anywhere in the universe.

The CPAP Shop has one listed like I purchased on eBay for the special price of $34, with their regular price being $40. I am not sure what all that means, but I think the prices turned in to Medicare are absurd.

And, if an online seller were kind enough to do that with the insurance, one would have to transfer all supplies to that seller, and it would have to be an approved facility by Medicare. I guess if they were able to file, then they must be an approved facility. And, one would still have to transfer over to that online business, by first getting a doctor to give a prescription to them.

[SDBud]

This is a long saga of my determined attempts to obtain the new BleepSleep DreamPort and have Medicare and Blue Cross Blue Shield cover it. So far, I have been unsuccessful.

The Bleepsleep website SAYS their stuff IS COVERED by Medicare. If it ISN'T, sue the bastards.

[NorwichTerrier]

SDBud commented: The Bleepsleep website SAYS their stuff IS COVERED by Medicare. If it ISN'T, sue the bastards.

And, BleepSleep is correct in that their products are covered by Medicare, but covered and fully covered are two different things. If, for example, my Home Care Provider orders it for me, and submits the price it is being charged for these items to Medicare. For example, if the Home Care Provider pays $149 for the supplies, but Medicare will only allows $100. It doesn't give the Home Care Provider much incentive to order these for me if it will be out of pocket $49 for each order.

[Pugsy]

And, BleepSleep is correct in that their products are covered by Medicare, but covered and fully covered are two different things. If, for example, my Home Care Provider orders it for me, and submits the price it is being charged for these items to Medicare. For example, if the Home Care Provider pays $149 for the supplies, but Medicare will only allows $100. It doesn't give the Home Care Provider much incentive to order these for me if it will be out of pocket $49 for each order.

They are covered supplies with appropriate HCPCS codes just like any other cpap mask or equipment or whatever out there.
Meaning Medicare will "allow" what Medicare allows for that particular HCPCS code. Medicare doesn't care what someone might buy or have to pay for something...they allow what they allow and that's it.
The reason we see so much pie in the sky billing is suppliers trying to get Medicare to allow more....instead every year Medicare reduces the allowable amounts for pretty much everything.
It's not just Medicare...it's any insurance. Medicare happens to be the really low ball allowable amount in most cases.
Any DME that has a contract with any insurance company has to be happy with the contracted allowable amount. If not they make the choice to eat the non profit or simply not offer the product.

So Medicare will pay but they only pay what Medicare allows and don't give a hoot what it might cost the supplier...sigh...

I am running into a similar situation with my own DME only he is throwing up some really stupid hurdles in the mix but I haven't given up on him yet. I plan to be permanent thorn in his side..

So yes...Medicare will pay for it just like they would for any other similarly HCPCS billed coded item....but getting the DME or supplier to offer it seems to be the biggest hurdle.
Special orders from places like cpap.com won't cut it but everyone remember...that $40 is retail...not wholesale. DMEs can buy wholesale and I am not privy to wholesale pricing. They (DMEs) just aren't wanting to commit to buying wholesale....they could but they just haven't got on board yet. That's why I plan to be a thorn in my DME's side...hopefully painful enough and annoying enough for him to just place an order wholesale.

If I hear of an online retailer who will file insurance in lieu of up front payment who is selling the Bleep....you will be the first to know.
Maybe I am being stupidly optimistic but I feel that with time someone online will get on board and be smart enough to realize that it will sell and they can make money on it and still file insurance...I can only hope.

[babydinosnoreless]

In January - the price turned in by Medicare for a nasal mask for me was $52 (come on now - get real, people as you will have to prove that one of these nasal pillows really costs $52). Medicare allowed $30.40, and they paid $23.83, then Blue Cross/Blue Shield picked up the rest of the $30.40.

The reason I said "Get real" was because I purchased on eBay a Respironics DreamWear Gel Pillow Mask Cushion Small NEW Replacement S for $9.95 plus $3.74 shipping. That was the best deal I found, as I wanted to try this, which is similar to the one I have, but no plugs for the nose. I imagine mine is the same price as it is similar in design. I just saw two like what I am using selling for $7.99 and another for $10.50 plus shipping. I'm sure these are items that people just didn't use, but still, I cannot believe one of those costs $52 anywhere in the universe.

The CPAP Shop has one listed like I purchased on eBay for the special price of $34, with their regular price being $40. I am not sure what all that means, but I think the prices turned in to Medicare are absurd.

It is not just medicare. *rant mode on *. My dme bills $75 for a cushion...insurance pays $29.33. I pay $5.87 so they are getting $35.20 for a cushion that costs $10 on Amazon. Its utter bs. I reported it to the insurance company, who shrugged and pretty much said well you can switch DME's but you can't buy off of Amazon unless you want to pay out of pocket. Which btw I did do on those little filters they were getting nearly $4 each for but I can buy a 15 month supply on amazon for under $10. Trouble is for the bigger stuff adds up and I just can't afford to do it for everything.

Then there is the machine rental. My husband bought me for xmas a low hour good used bilevel machine as a backup from user LSAT (shamless plug for a honerable seller)
for about what the dme charged my insurance company for set up and one months rent. I reported that too. Insurance doesn't care they are getting screwed. They are still paying each month until October and I have a copay on that as well. Tried switching dme's but quickly found out that others on my list are even worse crooks. I wish I was independantly wealthy and could tell ALL of them to eff off! Ok rant mode back off.

Thank goodness for the terrific people here who have helped me get my settings right and have pointed me in the right direction on other stuff, sent me masks to try etc. I am trying to pay it forward helping others when I have extra stuff to share. Which reminds me...I have a mirage activa ff mask with a couple of sealed cushions if someone needs it please send me a pm.

[NorwichTerrier]

Same heading - new subject.

How important is mask fit and resulting mask leakage? You've probably answered this question multiple times, but I need to pose it, as I have been having recent issues with some leakage in the last couple of days. I was good at the start of using my new machine - with 100% most days, but last night it was 97% and I think the night before 98%. I have been guilty of ignoring mask issues in the last couple of nights, and just letting it sit where it wants so it doesn't interrupt my attempts to sleep and cause me even more insomnia. On the opposite end of the spectrum, otherwise, I have been recording therapeutic (under 5) AHI results. My question then, would be whether to just not be concerned with these leaks. I have also been getting used to a new pillow, which is about twice as thick as my previous one, so this may account for some of the leak issues - or not.

Thanks you for your thoughts.

[Pugsy]

How important are mask leaks???
For me it depends on
1...do those leaks wake me up??
2...just how deep into large leak territory do they go?
3...just how long do I maybe spend in large leak territory?

Any leak that wakes me up I want to fix because it disturbs my sleep. Anything that disturbs my sleep is unwanted.

Relatively minor short term leaks that I sleep through I shrug my shoulders and move on no matter how big.
Prolonged large leaks I evaluate on a case by case basis and look for are they happening every night or is it a one off bad night kind of thing.

Since ResMed machines are actually able to decently respond and record up to 35 L/min excess leak...that is my own personal line in the sand where I might sit up and take notice if I happen to go over 35 L/min.
The 24 L/min line is ultra conservative in my mind and I don't even bat an eye if the worst it went to was 30 L/min.

I learned a long time ago that going to extraordinary measures to get a near perfect leak line seemed to have a more negative effect on my overall sleep quality than the relatively minor large leak was having....so I adopted the shrug my shoulders approach unless prolonged and deep into large leak territory and happening every night.
I discovered that for the most part with the P10...when I started seeing big leaks every night...it was time to shrink the headgear or get new headgear. That always seemed to fix my prolonged, frequent large leaks.

[Dog Slobber]

The reason I said "Get real" was because I purchased on eBay a Respironics DreamWear Gel Pillow Mask Cushion Small NEW Replacement S for $9.95 plus $3.74 shipping. That was the best deal I found, as I wanted to try this, which is similar to the one I have, but no plugs for the nose. I imagine mine is the same price as it is similar in design. I just saw two like what I am using selling for $7.99 and another for $10.50 plus shipping. I'm sure these are items that people just didn't use, but still, I cannot believe one of those costs $52 anywhere in the universe.

While I don't doubt that there is some gouging going on. But comparing the price of a product sold, by a business to the price by an individual on eBay is has no relevance.