Medicare and Masks

Unfortunately this is not an Apria lie, this is a new rule set forth by Medicare to and I quote "stop fraud". Source, well I work for a DME. I know that means I will be dismissed by most here. Never the less Medicare recently completed an Audit with my outfit and stated that since the referral did not request a specific mask style Full face, nasal, or pillows that these items are not considered medically necessary. Yet the device is, have fun trying that.

Now the only thing I will say is that medicare allows the DME to dispense with a generic Rx but will not allow the DME to submit a claim until a new Rx has been received with the specific HCPC code associated with the mask used by the patient. Apria may have decided to not dispense as it is proving to be exceptionally difficult to obtain a second referral as well as the time restrictions associated with claim submissions.

Medicare has denied what I would imagine is hundreds of thousands of claims in surprise audits for this reason alone, and I know DME = bad here but try and remember when you are trying to call your local DME or having issues with service that they are still a business with expenses and people that need to be staffed and when your insurance or in this case the government employs these tactics to not pay claims the patient also suffers.

If you hate the Aprias, Adapt Healthcare, and Lincares consider writing your local politician. Ask them to end the never ending regulation for DME and PAP therapy. The big guys are so bad because they have monopolized the industry. They don't need to provide patient care when they have non compete contracts, when they are privately bought by a hospital group. As a patient myself I believe we should all have the right to choose a DME provider that meets our expectation, not be forced to work and depend on these monopolies.

End rant.

DRC09,

Thanks for your insight on the Medicare Guidelines. I was not aware that their were different HCPC codes for different "Types" of masks, and that Medicare was performing audits and demanding the specific codes.

That does explain why my local Apria office wants a Rx for a specific mask.

Geez, not sure why Medicare cares what type of ask I want or need. I think that many patients have a nasal mask AND a FFM for times when they are heavily congested.

I guess I can ask my Doc for a prescription for a FFM and then change write one for the nasal mask 6 months later.

Unfortunately this is not an Apria lie, this is a new rule set forth by Medicare to and I quote "stop fraud"

Well, that sucks. I haven't had DME coverage in about 10 years, I just buy my own masks from our hosts at cpap.com or "parts" from Amazon and eBay. Since the masks last a LOT longer than the Medicare replacement schedule, it's not that expensive to do this and it's certainly worth not having the hassle. But I was kind of looking forward to some Medicare coverage when I become eligible later this year. I guess it's still worth it for a more expensive FF mask once or twice a year, and I will continue my current practice for my every day mask.

So, "Mask of patient's choice" is no longer acceptable?
That kind of makes it harder to get started successfully.