(SOLVED) Question for those who own their CPAP equipment

[Rexlan]

UPDATE: 4-18-19

Much to my surprise I received a second check from BCBS for the remainder of my claim for the Dream Station APAP. Apparently after I called and said I intended to file an appeal (which I had not done yet) they took a second look and decided to re-code it and allow $719, exactly what I claimed) for it and paid me 50% - still treating it out of network.

If the DME's aren't lying to me about selling me a machine then BCBS is correct for treating it as out of network - my bad. BUT I am pleased to have made them do the right thing.

I am still going to visit with the DME and see if I can get another machine for the aggravation!

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If you purchased your own equipment (I did a Dream Station) has your insurance reimbursed you for it (less co-pay) or have you tried to claim it for insurance? I have Blue Cross Advantage plan. My Dr.s nurse has BCBS regular (not advantage) and they paid for hers.

I sent in a claim and they miss-coded it and also treated it as out of network. None of the DME's in network will sell any equipment and none in the state that I can find so I "thought" that the insurance had to treat it as in network - not so they tell me.

The code for the equipment is E0601 with a UU modifier and shows as eligible once every 5 years.

BCBS coded it as A7030 with the RR modifier. That code is for a full face mask (LOL) and added the RR modifier to make it a rental out of network. They gave me a whopping $71. Calling them is like talking to a brick wall.

Medicare pays BCBS about $10,500 annually (for every one) and I pay them another $1,200 getting very little in return. Seems wrong and now I am PO'd about it so I intend to give them chit so they can explain it, hopefully to a 3rd party.

Pointers, experience welcome and appreciated.

Thank you

[salinas212]

While I can't answer your questions OR better your observation I can offer that mayhaps you can apply your av quote to this/them and simultaneously the rest of us. It is after all accurate, apt, timely and best I've seen in a blue moon!

[LSAT]

If you purchased your own equipment (I did a Dream Station) has your insurance reimbursed you for it (less co-pay) or have you tried to claim it for insurance? I have Blue Cross Advantage plan. My Dr.s nurse has BCBS regular (not advantage) and they paid for hers.

I sent in a claim and they miss-coded it and also treated it as out of network. None of the DME's in network will sell any equipment and none in the state that I can find so I "thought" that the insurance had to treat it as in network - not so they tell me.

The code for the equipment is E0601 with a UU modifier and shows as eligible once every 5 years.

BCBS coded it as A7030 with the RR modifier. That code is for a full face mask (LOL) and added the RR modifier to make it a rental out of network. They gave me a whopping $71. Calling them is like talking to a brick wall.

Medicare pays BCBS about $10,500 annually (for every one) and I pay them another $1,200 getting very little in return. Seems wrong and now I am PO'd about it so I intend to give them chit so they can explain it, hopefully to a 3rd party.

Pointers, experience welcome and appreciated.

Thank you

If you have a Medicare Advantage Plan.......Why did you purchase your own equipment??????????

[Janknitz]

Medicare (even Advantage plans) does NOT cover outright CPAP purchase. They only cover a capped rental (at the end of the capped rental period, it's yours). That's why you found that "none of the DME's in network will sell any equipment"--if you are on Medicare they must follow Medicare rules.

So if you bought the machine outright, you can't expect any reimbursement from Medicare or BCBS. I hope you didn't overpay.

[bdouglas52]

I have BCBS Medicare Advantage and they only do a 13 month capped rental as mentioned. I can only use one of the Medicare approved suppliers for my area and pay a 20% monthly of the Medicare approved rental price (about $13.00 in my case). I would be surprised if they reimburse you.

[Rexlan]

Update:

I called around to the in-network DME's and one said they would sell me the equipment and that BCBS would pay 80%. My share @ 20% would be ~ $227 (seems excessive so I am suspicious). I am going to visit them and see if this is really the case. I know the gal there and am confident she will give me the straight talk - plus we may actually get a pre-authorization to test it. I am happy to spend BCBS money.

My problem started with the oxygen equipment so I "assumed" the rental would be the only option for the CPAP as well. Looks like I may be wrong. I am in the appeal process with BCBS now over the oxygen concentrator purchase and they treated it as a rental, out of network @ 50% reimbursement so I am asking for a MONTHLY reimbursement now. I think there is a good chance I will prevail on this. They just PO'd me and the $$ really is not important. It is no wonder chit is out of whack. They will actually pay a DME $136/month for 36 month for the exact machine I purchased for $594 - almost 10x the cost.

I purchased the machine because I was told by 2 DME's that the rental did not vest any ownership in the equipment which was eligible once every 5 years. It is cheaper in the end to purchase.

I paid $599 for the Dream Station with heated humidifier, heated hose and a soft case, delivered to me.

I am going to follow up with the DME and will report back with the "real story"

[Goofproof]

Anything the DME will tell you, I guarantee will be a "REAL" Story! They tell Whoppers! Jim

[bwexler]

I have been on Medicare advantage plans for 9 years now. I always inquire about how they treat DME, especially XPAP. I usually get a blank stare. I then obtain the evidence of insurance book and read exactly what it says about DME. My current plan as well as the previous plan are VERY clear, I will never own any DME they help pay for.
When I called Crapria and asked what my copay would be for the AirCurve 10 ASV, I was told the only way to find out is to process the order and wait for the answer after delivery.
I bought a lightly used one from a member here and all is well. I own my machine I know what it cost me and I did not have to do battle with Crapria or my insurance.

[Pugsy]

I have been on Medicare advantage plans for 9 years now. I always inquire about how they treat DME, especially XPAP. I usually get a blank stare. I then obtain the evidence of insurance book and read exactly what it says about DME. My current plan as well as the previous plan are VERY clear, I will never own any DME they help pay for.
When I called Crapria and asked what my copay would be for the AirCurve 10 ASV, I was told the only way to find out is to process the order and wait for the answer after delivery.
I bought a lightly used one from a member here and all is well. I own my machine I know what it cost me and I did not have to do battle with Crapria or my insurance.

My Advantage plan is also very clear. I would never own it and I would pay a 20% monthly co pay forever. It wasn't always the case but it is now. People really need to get their Evidence of Coverage and go over it with a magnifying glass. Not all Advantage plans are identical....so people really need to see what their plan says and not rely on what someone else's plan does.
And every year even the same Advantage plan they have been using for years can change on how they pay for something...just because last year it was the 13 month rental doesn't necessarily mean that it is the same this year. That happened with the plan I was using...for years it was 13 month rental then it changed to perpetual rental 3 years ago.

Now I have heard that sometimes they will let you do the 13 month thing but think about it..if you were a DME what would you rather have happen....have someone pay for 13 months or forever?????
Sometimes it really is more cost effective to say to hell with the insurance and just buy your own.

[Rexlan]

Thanks to everyone for chiming in. I am going to try to get to the DME this week and will see exactly what is what.

As Pugsy says our various plans can change year to year and certainly from different carriers. I was using Humana and just this year switched to BCBS. I plan to switch back next year. Humana was much more helpful and direct. BCBS - call 4 times and you will have 3 different answers as at a minimum!.

[Janknitz]

I called around to the in-network DME's and one said they would sell me the equipment and that BCBS would pay 80%. My share @ 20% would be ~ $227 (seems excessive so I am suspicious). I am going to visit them and see if this is really the case. I know the gal there and am confident she will give me the straight talk - plus we may actually get a pre-authorization to test it. I am happy to spend BCBS money.

My problem started with the oxygen equipment so I "assumed" the rental would be the only option for the CPAP as well. Looks like I may be wrong. I am in the appeal process with BCBS now over the oxygen concentrator purchase and they treated it as a rental, out of network @ 50% reimbursement so I am asking for a MONTHLY reimbursement now. I think there is a good chance I will prevail on this. They just PO'd me and the $$ really is not important. It is no wonder chit is out of whack. They will actually pay a DME $136/month for 36 month for the exact machine I purchased for $594 - almost 10x the cost.

Rule to live by: NEVER, NEVER, NEVER, EVER, EVER EVER believe ANYTHING a DME says. When you had your conversation with this DME, did you mention that your BCBS is a Medicare supplement??? Because BCBS does NOT get to change Medicare rules. The only exception is if you or your spouse is still working while on Medicare and you are insured through an Employer Group Health Plan and BCBS is the primary payor because the company the benefits are from has more than 20 employees.

You might do well to get your Evidence of Coverage as suggested above (EOC--it's the contract you have with your insurer that you've never seen unless you specifically request it) that will spell it all out and might also help you see if you are going to win that appeal or not. If it's in the EOC, BCBS MUST follow what's written there.

For some reason the Medicare.gov pages are showing error messages today so I can't point you to the pages at that website, but this booklet is useful: https://www.medicare.gov/Pubs/pdf/10116 ... nefits.pdf Check out page 23:

You pay 20% of the Medicare-approved amount for the machine rental

[LSAT]

All these posts have got me thinking since I am eligible for a new machine in a few months...I called my DME and she verified the my United Healthcare Medicare Complete plan was still 13 month rental. She estimated that my total 13 month payments would be about $120, No other qualifications except that I need a new prescription. She also told me that she has been emailing my primary care physician every year for a prescription so she can continue to sell me supplies. I never knew she was doing that....In fact...I have rarely ever talked to my PCP about CPAP.....I rarely order any supplies. Actually, she said that if a DME was charging a perpetual rental, they were taking advantage of the client. Who knows??? I have been using this local DME for 8 years and I trust them....We'll see when I buy a new machine this summer.

[FtStWUaCGBtS]

My first machine a lot of years ago was with a DME, and my insurance company was so happy about it. DME charged Insurance almost 3 thousand bux. I had to pay in monthly the entire 12 months to a tune of $1473.28. It wasn't until later that I found the same exact machine online brand new in the box for the sum of 499.99.

I am not going to say I'm a genius here, but a DME is NOT your friend. They exist only to make obscene amounts of money on any SUCKER who will play with them. So for my part I buy everything out of pocket. It sux that my insurance will obviously trust a thief (the DME) but will not give a penny to help an honest Man, just trying to get by.

That is my finding and synopsis of both DME's and Insurance. Using CPAP for around 18 years. I'll be 65 in September, I'll see if the big "Medi" will do better by me. Am not gonna hold my breath.

[Rexlan]

Rule to live by: NEVER, NEVER, NEVER, EVER, EVER EVER believe ANYTHING a DME says. When you had your conversation with this DME, did you mention that your BCBS is a Medicare supplement??? Because BCBS does NOT get to change Medicare rules. The only exception is if you or your spouse is still working while on Medicare and you are insured through an Employer Group Health Plan and BCBS is the primary payor because the company the benefits are from has more than 20 employees.

You might do well to get your Evidence of Coverage as suggested above (EOC--it's the contract you have with your insurer that you've never seen unless you specifically request it) that will spell it all out and might also help you see if you are going to win that appeal or not. If it's in the EOC, BCBS MUST follow what's written there.

For some reason the Medicare.gov pages are showing error messages today so I can't point you to the pages at that website, but this booklet is useful: https://www.medicare.gov/Pubs/pdf/10116 ... nefits.pdf Check out page 23:

You pay 20% of the Medicare-approved amount for the machine rental

I have read that brochure and the DME knows my plan is medicare advantage type .... so we shall see.

I also know that every DME has told me there is no way I own the equipment at the end of the capped rental (13 months in this case). I will get to the bottom of it, hopefully soon.

The good news - I have only been using 40 days and with great success. average AHI is <2 and I am definitely sleeping a LOT better. Uncomfortable but well worth it so far. I have mine set of 5 min and 12 max. Average seems to run around 9-10

[Rexlan]

I got the check today !

Modified first post w/details