Masks, headgear, insurance and replacement policies

TGregg · Post by **TGregg** » Mon Mar 05, 2007 1:50 pm

Hey all,

My DME gave me paperwork that clearly shows a 3 month replacement policy for masks, and 6 for headgear. They show about $111 for masks and about $33 for headgear.

But they tell me that I can only get the pads after three months, not a new mask. They say "Mask" means the pads, and "Headgear" means the straps and the hard plastic parts of the mask.

I'd sure like to get a backup mask, maybe try a different one.

OTOH, they make money by supplying me with gear and charging my insurance. So it seems to me that they would be delighted to ship me a new mask if they got paid to do it, which makes me think they are telling the truth.

Any ideas? I'm gonna give my insurance a call (Aetna), but thought I'd check here first.

Linda3032 · Post by **Linda3032** » Mon Mar 05, 2007 4:47 pm

I think your DME is confused (nice way of saying lying).

You should be able to get a new, different mask at least every 6 months. Some insurance companies are every 3 months.

I would be interested to see what "code" they use for just a cushion, which would be A0732 for a nasal mask. Codes for full face cushions and masks are different.

A new complete new nasal interface would be coded A7034, and alot more money would be reimbursed.

Hopefully they are not trying to pull a fast one and accidentally use the wrong billing code.

Definitely call your insurance company and ask the replacement schedule.

ces44 · Post by **ces44** » Mon Mar 05, 2007 5:52 pm

If you have BCBS of Oklahoma, good luck getting an answer for cpap stuff. I keep getting "medical necessity" My DME gave the same answer.
ces44

TGregg · Post by **TGregg** » Mon Mar 05, 2007 9:42 pm

Linda3032 wrote:I would be interested to see what "code" they use for just a cushion, which would be A0732 for a nasal mask. Codes for full face cushions and masks are different.

A new complete new nasal interface would be coded A7034, and alot more money would be reimbursed.

Hopefully they are not trying to pull a fast one and accidentally use the wrong billing code.

Oooo, use the codes, good idea. Thanks a bunch, Linda! Man, I love this board. I bet crooked DMEs hate this forum.

TGregg · Post by **TGregg** » Mon Mar 05, 2007 9:43 pm

ces44 wrote:If you have BCBS of Oklahoma, good luck getting an answer for cpap stuff. I keep getting "medical necessity" My DME gave the same answer.
ces44

Fortunately Aetna has been pretty helpful so far. We'll see when I call them about this.

Guest · Post by **Guest** » Mon Mar 05, 2007 10:13 pm

I am throughly confused about insurance, DMEs, schedules of replacement and who make what decisions about all this...

1. My insurance tells me that I have a $3,000 cap for what I can spend this year on DME supplies and equipment, with no schedule in place for when I can get what.

2. The DME says that I can get a new mask in 3 months. The charged me when I had to get a new cushion for my UMFF (they had given me the small shallow and I needed the regular) Then later I read somewhere that the schedule for getting a replacement cushion was one month.

3. I am almost at the end of my rental for my CPAP machine (3 months) after which I can't exchange it for another one. (I want to trade out my PB 420 for an APAP - haven;t started that process with them yet. The RT said the owner does not let them order anyone an APAP because they lose money.)

4. BillMyInsurance (through cpap.com) has refused my request for insurance for my APAP order because they lose the rental payments of the 3 months and that won't cover the cost of the APAP.(-a catch 22, since the DME that I have rented the CPAP from for 3 months is not allowed to purchase APAPS....aaargh) I do have a prescription for an APAP/C-Flex machine.

5. Now that I am approaching the 3 month timefirame for getting a new mask (set by whom? when that is not set by my insurance?_I re-applied to BillMyInsurance for a new mask (Hybrid) now that I am nearing my 3 months. (I also notified them that my insurance has no such timeline, and will cover anything up to my cap)

I was refused coverage from BillMyInsurance again, this time with the reason that since I am having so much trouble finding a mask that fit, I needed to work with the DME I already had a relationship with (I have been using a friend's Hybrid and it is the only mask I have been able to sleep with more than a couple of hours - so I am not having mask fitting problems - I know the one that works) (Besides cpap.com has given me more correct information about mask fitting than my DME!)

6. I have been told by my doctor's nurse, the head of the sleep center, and one of the doctors that I can change my DME. (One said that I could change as long as my insurance had an agreement with the new one.) The nurse even put in a request for a different DME to call me.

So what's up? Who calls the shots about who pays what and when I can get what new/replacement equipment - the insurance plan I am on or the DME? Who determines that I can change DMEs (besides checking to see that my insurance company works with the new DME) - does this have to be on doctor's "orders" or what.

Anyone got ideas how to sort out all this?

[/i]

TGregg · Post by **TGregg** » Tue Mar 06, 2007 7:51 am

Anonymous wrote:Who determines that I can change DMEs (besides checking to see that my insurance company works with the new DME) - does this have to be on doctor's "orders" or what.

In my case, I know I can switch DMEs if I want. I've got a list of a dozen or so that have agreements with my insurance company.

First thing is to read any agreements you signed with your current DME to make sure you haven't agreed to stick with them. If not, check your insurance company to see if you can switch, and to whom. There are national companies that are DMEs for most insurance companies (Apria springs to mind), as well as local outfits. IIRC, some insurance companies will allow you to use anybody, but most have a limited list.

Slinky · Post by **Slinky** » Tue Mar 06, 2007 12:53 pm

Also check all the paperwork you signed for that DME supplier as most will have a clause that you will be personally responsible for all costs not reimbursable by your insurance. Thus, while, yes, you probably CAN change DMEs you MOST LIKELY will be responsible for self-pay all costs incurred to date w/this DME supplier.

izzyb · Post by **izzyb** » Tue Mar 06, 2007 1:02 pm

I thought my mask was too big so when I went for my second sleep test they let me use a smaller one and it fit better. But when my DME rep came in to replace my CPAP for a BiPAP machine she said my insurance wouldn't cover another mask until 6 months. It didn't seem to matter that it was her fault I had the wrong size. Anyway, when I went for my follow-up at the doctor's office and I told her about it, she said to contact my DME because something should have been done. I talked to my rep and they said to get a prescription from the doc and my insurance would cover it. So I did. I won't get into how my rep should have taken care of the problem that morning after my sleep test. But I have the new mask now. The bottom line is that your insurance may cover it if you have a new prescription from your doctor.

Wulfman · Post by **Wulfman** » Tue Mar 06, 2007 1:06 pm

DO THE MATH!

Deductibles, co-pays, out-of-pocket vs. insurance, the whole works.

If you haven't met your deductible this year and considering going through a B & M DME, you're going to pay a premium price compared to online.

How often do you REALLY NEED to replace some of that stuff?

Den

onecoknower · Post by **onecoknower** » Tue Mar 06, 2007 2:54 pm

Insurance coverage is as individual as a good mask fit (and as hard to figure out). Keeping that in mind, and because misery loves company - here's my coverage:

-2006 plan covered 80%, my first sleep study was Dec '06. Total out of pocket $600
- 2007 insurance has $3000.00 deductible, after that 100% coverage IN NETWORK, according to payment schedule. So second sleep study maxed my deducible - total out of pocket the full $3000.00. Therefore, cpap machine and first mask free (paid 100% by insurance over 12 mos).
- NO coverage for replacement masks/hoses for one year
- ONE service call for repair of the machine only
- all extras (filters, bells and whistles etc) completely out of pocket.

My saving grace? I head the flex benefits department at my work (also my insurer) and know how to get medical expenses covered by my HRA account. So until it runs out, all my out of pocket is picked up by the employer. After it runs out, I'll quit buying extras...

Donna[/u]

gster · Post by **gster** » Tue Mar 06, 2007 7:01 pm

i am lucky. i have a dme of 1500 per year. i looked at the dme policy and it says all cpap items are covered. but nowhere does it state that i can only get a mask every so many months. i can get one every week if i wanted to. but when the dme reaches 1500 per year, that's it. i am 100% positive about this. i am grateful to have good medical insurance no matter what it cost per year.

a side note: if your employer has medical care reimbursement program where you set aside pretax dollars, it is a good thing.