Strange call with DME

I have just past my 3 month period with my CPAP. I have been using a Resmed Mirage Soft Gel nasal mask with good results but I do have chronic nasal congestion. I wanted to try a FFM to see if it would work better when congested. I was elegebile for another mask, per Medicare, & my DME likes to send 3 months of supplies at a time. I ordered a Quattro Air FFM, replacement cushions, & a spare heated hose for backup. I got the shipment on time today with 1 Quattro Air FFM, 2 replacement cushions & the hose but looking at their invoice they were charging for 3 cushions instead do 2. When I called to check where the error was I was told that they charged for an extra cushion to make up for the headgear that comes with the new mask which they can only bill headgear after 6 months. Does this make sense to anyone?

In my opinion, it says that they were being very helpful to you. Many would not be that nice.

G L Arnold

Who is your DME?

glarnold wrote:In my opinion, it says that they were being very helpful to you. Many would not be that nice.

G L Arnold

I never implied they were not nice & after all they are charging for it in a round about way. I just had trouble understanding the Medicare rules that state they will pay for a different style mask after 3 months but not the headgear to put it on.

Gryffandor wrote: I just had trouble understanding the Medicare rules that state they will pay for a different style mask after 3 months but not the headgear to put it on.

It's true. Medicare only pays for headgear one per 6 months. They do have a code for a mask at 3 months but they won't pay for headgear. Some DMEs bend the rules like yours did. Some DMEs just eat the cost of the headgear that they can't bill for...Some just won't let a person get a new mask except every 6 months.

It's Medicare and the government and makes no sense but that's the way it is.
Headgear is always billed out separately even if it is included in the sealed package.

Have you tried lowering your humidity setting to see if it helps the congestion (often does)?

Julie wrote:Have you tried lowering your humidity setting to see if it helps the congestion (often does)?

Afraid that won't help. This is a lifelong problem & not related the the machine. Add a deviated septum to the mix & the problem was not unexpected. I am just hoping a FFM will make life a bit easier.

Pugsy thanks for your reply. I should have known with the govt. involved common sense was not in the equation.

Pugsy wrote: It's true. Medicare only pays for headgear one per 6 months. They do have a code for a mask at 3 months but they won't pay for headgear. Some DMEs bend the rules like yours did. Some DMEs just eat the cost of the headgear that they can't bill for...Some just won't let a person get a new mask except every 6 months.

Why haven't the mfr's responded by offering masks and headgear packaged separately? Seems like this is pretty common with other products where Medicare makes the rules.

They could also offer two masks with one headgear and still meet the same restriction.

sc0ttt wrote:Why haven't the mfr's responded by offering masks and headgear packaged separately? Seems like this is pretty common with other products where Medicare makes the rules.

Actually mfr's do offer most mask packages without the headgear...it's the DMEs who choose not to stock those packages and tell you it isn't available...but it is.
Here's one example. If cpap.com can do it...the DMEs could do it but they either can't or won't do it for whatever reason they come up with.
https://www.cpap.com/productpage/mirage ... y-kit.html

That does seem strange, but probably the headgear and cushion are about the same cost?

I have a follow up question: So does that mean if an insurance plan allows a FFM cushion every month and a mask every 3 months, can you typically get both a cushion and a mask in that third month (three cushions and one mask in a three month period), or does the mask replace the cushion (two cushions and one mask)?

I'm still trying to even figure out what mine covers. My insurance says they don't have a schedule, its just as medically necessary, and their CPAP policy didn't include a schedule. The tech at the DME said I wouldn't need a new prescription each time, and that they would likely just approve it on the typical schedule. I plan to talk to someone in billing once I'm due for supplies, but wouldn't be surprised if I got another different answer. I want to maximize my allowed supplies at least at first as I don't have any extras since I just started and don't know how long stuff will last me. Thanks!

My DME said they don't stock separate headgear due to costs, so if I needed new headgear I'd have to get a new mask. It looks like my copay on a new mask is still less than paying cash for headgear though, but that assumes I'd be eligible for one. I read online here that the number of items they stock affects their reimbursements somehow, and it works out in their favor to stock less? I didn't really understand. Best wishes.

Gryffandor wrote:

Julie wrote:Have you tried lowering your humidity setting to see if it helps the congestion (often does)?

Afraid that won't help. This is a lifelong problem & not related the the machine. Add a deviated septum to the mix & the problem was not unexpected. I am just hoping a FFM will make life a bit easier.

Go to an ENT and have him scope your nose and airway in his office on the first visit. Get an opinion.

Depending on what you tell him during the interview, he may also want to run allergy tests.

They can do a lot for us these days. Time to do your part.

sc0ttt wrote:

Pugsy wrote: It's true. Medicare only pays for headgear one per 6 months. They do have a code for a mask at 3 months but they won't pay for headgear. Some DMEs bend the rules like yours did. Some DMEs just eat the cost of the headgear that they can't bill for...Some just won't let a person get a new mask except every 6 months.

Why haven't the mfr's responded by offering masks and headgear packaged separately? Seems like this is pretty common with other products where Medicare makes the rules.

They could also offer two masks with one headgear and still meet the same restriction.

They do, and most DMEs will sell a mask without headgear. IN this case, the person was getting a different mask, which would not work with the previous headgear, so they needed headgear at the same time.

When I first started, I got a second, different mask a month after the first one. I have no idea if my insurance covered two masks, or if they claimed the one was switched for the other. I really have no idea. At the time, I didn't know how it all worked, so I simply asked when my insurance would allow me to try a new mask, and they said I could get one.

A year later, with a different DME, I got a new mask, like my first one. About a month later, I asked if I could try the Oracle mask, and they said something about exchanging a mask. I explained that I didn't want to exchange a mask as I liked the one I had. But I wanted to try the Oracle and wanted to know how soon my insurance would allow it. She said something about it being no problem. They could do an exchange without me returning the first one. So, I think they documented it as a mask swap. Not really sure.

Apria actually shipped me a mask sans headgear at the 3 month point.
Now if only they would get reasonable about the credit card!
Now, my first ex-DME wanted to bill me for a mask minus headgear in order to sell me a mirage Quattro cushion!
This was because they were not content with the insurance payment for just a cushion.
That would also make my cushion interval 3months--for a ResMed cushion!
Needless to say, that was the end of my business with them.
No angry words, no throwing things, not even an explanation.
I simply "forgot" their location, phone number, etc. --and never returned.
I even took the matter to BCBS; who sided with S-mn-s!

ChicagoGranny wrote:

Gryffandor wrote:

Julie wrote:Have you tried lowering your humidity setting to see if it helps the congestion (often does)?

Afraid that won't help. This is a lifelong problem & not related the the machine. Add a deviated septum to the mix & the problem was not unexpected. I am just hoping a FFM will make life a bit easier.

Go to an ENT and have him scope your nose and airway in his office on the first visit. Get an opinion.

Depending on what you tell him during the interview, he may also want to run allergy tests.

They can do a lot for us these days. Time to do your part.

I'm not sure what lead you to believe I haven't seen an ENT & "done my part". Yes I have a deviated septum on the right. Yes, I have allergies & still have them after 6 years of treatment with little improvement. I also have TMJ which my ENT says agrevates my sinuses. He says surgery is the only option to improve my congestion & the chance of it being sucessful, in my case, is less than 50%. His opinion was confirmed by both my PC & my sleep doc. If you have any other suggestions I'd love to hear them.

Are you doing your part for TMJ?

http://www.mayoclinic.org/diseases-cond ... n-20043566