New DME Procedures and policies

I am wondering if the following is happening in your own neck of the woods...

My main DME (besides VA, we won't go there) has a new policy where they are only selling Fisher and paykel masks... Not because the HMO will not pay for any other masks but they are only paying about 50% of the mask cost...

Take the RESMED Airfit P10, it costs $118 dollars, the DME buys it from RESMED for ?? We will say $80 dollars (I could not get there actual cost) Well the HMO says they will only pay $60 dollars, so now it costs the DME 20 dollars to give you a mask, then the HMO charges you for the deductible (in my case 20%) so I have to pay $10 dollars... the HMO/Insurance is only covering 40% to 50% of the mask and the DME's are getting the short end of the stick.... It's only a matter of time when DME will no longer carry any masks or charge full price with no insurance and we will be the one's paying for it in the end....


The HMO are also only renting machines now, if a machine cost $2000 dollars, the HMO use to pay for the CPAP Machine, now they only rent it from the DME...

Machine cost > $2000
Monthly rental x 24 months > $50
total paid to DME >$1200

Maybe this is the normal way of doing things but it has just changed here... My DME has literally cut there store and inventory in half, you use to be able to walk in and get a mask or machine not they order everything...

I think you are way high on your cost estimates. A good machine retails on line for under $900. Often on Amazon for under $600. Don't feel sorry for the DME. If they were losing money they would go out of business. The retail price the DME puts on things are sky high.....big mark-up.

You need to find a new dme.

It sounds like this outfit is intentionally flushing themselves down the drain.
By all means--LEAVE THEM.

I have CIGNA insurance, which contracts with CareCentrix to administer the DME supply stuff for them.

Then, CareCentrix has a network of "Authorized" private DME Suppliers who actually supply the equipment to the patients.

I have not had any problems getting whatever Mask I need/want so far. I used to use Crapria, but now use a small outfit called BP Gamma.

It really sounds like the DME Supplier is telling you a tall tale in order to pad their pockets. I say get away from them as fast as you can.

The one change I do see, and do not really know if it is something that is required by CIGNA or CareCentrix, the actual Supplier, BP Gamma, said that CareCentrix makes them "RENT" the machine to me for 6 months, and the insurance pays a monthly amount, and then after the 6 months, I own it.

That sounds weird to me. I have always owned the machine from day one in the past.

But they did give me a brand new machine so I guess I don't care that much.

As I said though, I don't know who REALLY made up that procedure, they all seem to lie so much.

Unless your HMO has a specific formulary for masks (some, like Kaiser DO), the DME who is contracted as the supplier must supply the masks prescribed. So I would file a complaint with your HMO and if you are limited to only that DME supplier, then file a complaint with the state agencies that regulate your HMO and the DME (may be two different agencies). You may have a right to go out of network at your HMO's expense if their provider cannot provide needs that they are contracted with you to provide--you can ask the state agency governing HMO's in your state and check the contract.*

If this is a Medicare Part C HMO, then you should also file a complaint with Medicare.

It may bolster your case if your doctor will specifically prescribe the mask you want and write "Dispense as Written" on the prescription.

*You would need to request an "Evidence of Coverage" (EOC) booklet IN WRITING from your HMO to see what their contractual obligation is to you. This is the actual contract between you and your insurer, but you've never seen this document unless you have specifically requested it. Look up DME, specifically CPAP and see what it says for CPAP coverage.

Another viewpoint.

Over the years I've seen many businesses of different sorts go down a similar path. Everyone of them eventually closed shop. Take this as a sign that your DME is under severe financial stress - probably they are under-capitalized at the moment and cannot afford to carry stock inventory. It's also possible that their source for F&P masks is the only one of their suppliers that will advance them credit.

Look at other parts of their operation: have they cut staff, too? Maybe no-one at the front desk? Shorter hours? Long-time staff have been replaced by new, inexperienced and possibly under-qualified staff? Unhappy and stressed staff? All are signs of of business that's having difficulty.

I'd start looking now for a new DME. If you like your current DME, you don't have to switch from them right now. But when it happens, be ready and make a smooth transition.

My 2 cents...

Hose_Head wrote: ↑

Thu Feb 15, 2018 9:10 pm

Another viewpoint.

Over the years I've seen many businesses of different sorts go down a similar path. Everyone of them eventually closed shop. Take this as a sign that your DME is under severe financial stress - probably they are under-capitalized at the moment and cannot afford to carry stock inventory. It's also possible that their source for F&P masks is the only one of their suppliers that will advance them credit.

Look at other parts of their operation: have they cut staff, too? Maybe no-one at the front desk? Shorter hours? Long-time staff have been replaced by new, inexperienced and possibly under-qualified staff? Unhappy and stressed staff? All are signs of of business that's having difficulty.

I'd start looking now for a new DME. If you like your current DME, you don't have to switch from them right now. But when it happens, be ready and make a smooth transition.

My 2 cents...

Hosehead makes some good points except that with an HMO you may have little or no choice of DMEs. I’m of the school of thought to put them out of their misery sooner rather than later so don’t hesitate to get your hmo to put the screws to them out of pity.

thanks for the replies, Interesting, I purposely did not say my insurance, some of you know from my previous posts I have Tricare and VA.. I have gotten masks from this DME through Tricare and its never been a problem until the govt sequester (budget cuts) and now a new HMO has taken over Tricare... Just to give some perspective, Tricare pays almost the same as medicare for equipment... Tricare pays 80% and we have to pay 20% of the cost of equipment, they have a set amount for each piece of equipment...

I do think this company is heading down the last ditch effort to stay open and really that sucks for all of us, they are a locally owned business, not a chain store.. That is why I have used them for the last 8 years, looks like I will need to find a new DME or bypass insurance and just buy the masks.. The number 1 problem is most places do not take Tricare because they do not pay normal insurance rates...

Here is the FAQ from cpap.com: CPAP.com is out of network for private insurance companies. Check with your private insurer to see if they will reimburse your purchase. Medicare, Medicaid and other government run healthcare programs will not reimburse CPAP.com purchases. Purchasing through CPAP.com is often cheaper than your copay and deductible through insurance.

That last statement makes no sense what so ever, I have looked at almost all the masks on cpap.com and I did not see any mask for under 15 dollars (I just got the P10 for a 12 dollar copay)

Cowboy Casey wrote: ↑

Fri Feb 16, 2018 6:39 am

That last statement makes no sense what so ever, I have looked at almost all the masks on cpap.com and I did not see any mask for under 15 dollars (I just got the P10 for a 12 dollar copay)

For most non government insurance the co pay comes into play only after the deductible has been met and that deductible could be quite high. Maybe not so much with Medicare or TriCare but with most traditional insurance plans. There are people out there with $2500 to 5000 deductibles before their insurance will even pay for a cheap hose much less a mask.

And then there is the allowance thing. For my Medicare I get one mask every 6 months through my DME.
Now if I use that allowance and in 2 1/2 months I spot a different mask I want to try I could pay my DME the $280 they usually charge or I can buy from cpap.com for $99. Guess which one I will buy?

This is why we tell people to do the math involved with their own insurance and any replacement allowances and see which way ends up being less out of pocket.