DME extra charge for mask upgrade

[belrad]

Is it common practice to be charged for mask upgrade? I just started my CPAP (5 days so far) and now want to try different mask.

I called DME and mentioned that I want to try out specific mask and if they have it. I was told I can do it, but I need to pay $60 for upgrade (I can keep my old mask ). The reason (from DME explanations) I need to pay for upgrade - my insurance covers only basic masks.

I believe I have relatively good insurance, so should I try to find another DME or it's simpler just go ahead and pay $60? (at this point I already got my CPAP machine from them, I got what I wanted but also paid additional money for CPAP machine upgrade).

[GumbyCT]

Is it common practice to be charged for mask upgrade? I just started my CPAP (5 days so far) and now want to try different mask.

I called DME and mentioned that I want to try out specific mask and if they have it. I was told I can do it, but I need to pay $60 for upgrade (I can keep my old mask ). The reason (from DME explanations) I need to pay for upgrade - my insurance covers only basic masks.

I believe I have relatively good insurance, so should I try to find another DME or it's simpler just go ahead and pay $60? (at this point I already got my CPAP machine from them, I got what I wanted but also paid additional money for CPAP machine upgrade).

I would contact your insurance to ask if they have other DME's which are in network or if you can purchase online.

Upgrade for machine or mask - this DME sounds like a complete money machine. If your Ins allows you to deal with other DME's - run don't walk, away from this bandit. Once informed by your Ins. you will realize there is one billing code and the profit is what you are paying for.

Even if you cannot go to another DME - I would bluff this one and say look this mask isn;t working for me, if you won't provide another mask at NO Charge then come pick-up this machine bc I can't use it then. Oh btw - it will be out on the porch in the shopping bag.

If you haven't read or searched the forum please do so. The post at the top "Where a newbie should start" is a good place - to start.

Good Luck and post back with updates.

[Snorebert]

Oh btw - it will be out on the porch in the shopping bag.

And tell them to watch out for the dog.

[Paul56]

Hmm interesting... I never thought there were "basic" masks.

What exactly IS a basic mask?

On the other hand if the only fee they will charge is $60 for a new mask... that is pretty cheap. Masks are more expensive than that.

[mattman]

This could be a charge for a couple of different things, and I would ask a few more questions just to be clear.

First thing - an insurance company only pays for 1 mask usually every 6 months. Some are only once a year and some are every 3 months but they are very rare and certainly not the norm. Regardless though, it makes things very difficult when just starting out. There is no way around the fact that the DME company basically can't provide another mask when the first doesn't work out. It's POSSIBLE to file a claim for a 2nd mask and have it sent for review but that process takes literally hours of work on the part of the DME and by the time you're done even if it's approved it's cost more to go through that process than it's worth.

SO - that leaves 2 choices - the DME foots the bill or you do. So to me, the 60 bucks is a nice compromise. That may be what they are calling an 'upgrade' fee.

There are insurance companies that have such low reimbursement that the more expensive masks cause the DME to lose money on the deal. I have seen cases where a patients insurance reiumbursed around $50.00 for a mask and if they wanted something like a Soyala they had to pay a portion of the cost themselves. It's a fair deal all the way around in those cases. This also may be why there is an 'upgrade' charge.

So yeah, I'd again just suggest talking to them and finding out a little more. It sounds like they are really trying to be reasonable and help you and if that's the case it's definately worth keeping them around and working with them!

mattman

[belrad]

> What exactly IS a basic mask?

Have no idea. Probably just a way to charge more based on some random classification.

Currently I got form them: "Profile Lite Nasal" (https://www.cpap.com/productpage/profil ... onics.html)
I want to try this one: "Mirage Activa LT" (https://www.cpap.com/productpage/resmed ... dgear.html)

On cpap.com price wise they seem almost identical.

I hate to pay for something when it should be provided as a part of the service. I was told that I should be able to exchange mask without any problem in 30 days, but i wasn't wise enough to ask about if they have different mask categories like basic vs advanced .

But then I don't mind get another mask for $60 and keep current one in case it works better for me. I just started and originally had some problem with noise from the mask, but now I am getting used to it ( still hear noise, just don't pay too much attention to it). But would hate to realize that my original mask was better and go back again to ask first mask back.


Anybody can recommend good DME providers in San Francisco/San Jose area? Not sure I want to change DME at this moment, hate to start over again, I'd rather focus on my treatment, but in case if I would run into more problem it would be good to know some good DME companies around.

[GumbyCT]

> What exactly IS a basic mask?
Anybody can recommend good DME providers in San Francisco/San Jose area? Not sure I want to change DME at this moment, hate to start over again, I'd rather focus on my treatment, but in case if I would run into more problem it would be good to know some good DME companies around.

You need to ask your Insurance Co. who else they do business with, NOT people who have NO idea which Ins. Co you are dealing with. Don't get the cart before the horse.

Start with your Insurance Co. first then people can recommend when you have the list of DME's you CAN use.

Of course, if you are willing to pay out of pocket then use cpap.com

[GumbyCT]

oh what was the fee to 'upgrade machines'? Be sure to let your Ins. know how much you have been charged already. This could be a violation of their agreement.

[jules]

HMO?

[builta]

This could be a charge for a couple of different things, and I would ask a few more questions just to be clear.

First thing - an insurance company only pays for 1 mask usually every 6 months. Some are only once a year and some are every 3 months but they are very rare and certainly not the norm. Regardless though, it makes things very difficult when just starting out. There is no way around the fact that the DME company basically can't provide another mask when the first doesn't work out. It's POSSIBLE to file a claim for a 2nd mask and have it sent for review but that process takes literally hours of work on the part of the DME and by the time you're done even if it's approved it's cost more to go through that process than it's worth.

SO - that leaves 2 choices - the DME foots the bill or you do. So to me, the 60 bucks is a nice compromise. That may be what they are calling an 'upgrade' fee.

There are insurance companies that have such low reimbursement that the more expensive masks cause the DME to lose money on the deal. I have seen cases where a patients insurance reiumbursed around $50.00 for a mask and if they wanted something like a Soyala they had to pay a portion of the cost themselves. It's a fair deal all the way around in those cases. This also may be why there is an 'upgrade' charge.

So yeah, I'd again just suggest talking to them and finding out a little more. It sounds like they are really trying to be reasonable and help you and if that's the case it's definately worth keeping them around and working with them!

mattman

Oh give me a break. A successful DME knows the routine. Charge for the mask, charge for the "interface membrane" and charge for the head gear, the filters and the holy grail --"the hose". By the time all these are paid for they have made more then enough to pay the "actual cost" of the product that they "sell to us." It is a dance and and DMEs knows all the steps!

It is much less expensive to purchase the mask directly from an on line e-tailer (like cpap.com), or find a deal on cpapauction.com. The advantage that the local DME (i.e. brick and mortar retailer) offers us is the ability to "trial" different masks offering the 30 day manufacturer's "grace period." They get their money back!

[belrad]

> HMO?
PPO

>what was the fee to 'upgrade machine'?
$150

[jules]

> HMO?
PPO

>what was the fee to 'upgrade machine'?
$150

sounds like you need a heart to heart talk with insurance on this --- contact the people where you get the insurance for a start and ask about durable medical goods coverage - get the pamphlet and read it too

[mattman]

Oh give me a break. A successful DME knows the routine. Charge for the mask, charge for the "interface membrane" and charge for the head gear, the filters and the holy grail --"the hose". By the time all these are paid for they have made more then enough to pay the "actual cost" of the product that they "sell to us." It is a dance and and DMEs knows all the steps!

It is much less expensive to purchase the mask directly from an on line e-tailer (like cpap.com), or find a deal on cpapauction.com. The advantage that the local DME (i.e. brick and mortar retailer) offers us is the ability to "trial" different masks offering the 30 day manufacturer's "grace period." They get their money back!

I know this is a very touchy issue. I also know that when we are talking about our own health it can also be difficult to be objective and try to see someone else's point of view.

I don't deny that in many cases things look like a ripoff. Hell, I won't even argue that sometimes they aren't!

The thing that's really important to understand here though is that DME providers do not set the prices.. End of story. They do not.

It's also crucially important to try and understand just how much money gets spent to provide that mask or that machine.

There is no comparison to getting a mask from a brick and mortar DME provider and buying one online. It's just not an appropriate comparison. The closest analogy I can think of is the difference in cost between buying a pack of tomato seeds and growing your own tomatos versus going down to Publix and buying one. The cost won't even compare.

When you buy a mask online you are getting the mask. The supplier has next to zero overhead. He/She gets paid right away. The cost is basically bandwidth. A lot of the time they aren't even stocking the equipment - it's being done through a supply house that packs and ships with their name on the label. They charge you right away, they get paid right away. No insurance company setting the price, they are free to do what they want.

When you buy from a DME provider everything changes. They do not set their prices, Insurance Companies and Medicare do. They don't get paid right away. They may get paid 2 months later, they may get paid 12 months later. They may never get paid.

FYI - if they don't get paid, most of the time they are NOT allowed to recover payment from anyone else. In the case of Medicare it is considered Medicare fraud and people can and do go to jail for it. So the doctor never signs the appropriate paperwork? Too bad, no payments. The patient decides they don't want to use the CPAP? Too bad, no payments. Ever. Think it doesn't happen all the time? Go work for a DME provider for 6 months. You can't imagine the paperwork that the provider has to go get from hospitals, labs, doctors, ALF's, everywhere. One place I worked, it was so bad we had a full time employee who did nothing but drive around town getting paperwork from all the different places we needed it simply because we weren't getting it when we'd call and ask for it.

The DME provider also has to go get all new paperwork at 1 month, 3 months and 10 months for anything rental. Then every 6 months after. Forever. Oh and don't forget that they also have to keep fully cross-referenced paperwork on the doctor (including when and where he got his certification), the equipment (including where it was purchased, when, and all service records), the DME itself, the employee who provided the machine to the patient (including all training and certification AS WELL AS the training on the person who certified the employee) and finally the patients prescription. This all has to be maintained and kept up to date for a minimum of 7 years. Think THAT isn't a freaking nightmare? Again, go work for a DME for 6 months.

Don't forget also the fact that you have to be accessible 24 hours a day, 7 days a week and 365 days a year. When I was taking after hours duty I would average 6 calls a night, with 2 being calls that someone actually had to go to a patients house. Sometimes at 2am. Sometimes at 6:30pm. But it doesn't matter. If someone has a piece of equipment that has failed you go out. It doesn't matter if you just sat down to dinner, if your kid just broke his leg falling out of a tree. Tough. You go. Oh, and it's not billable either. It's all considered by payors to be part of the cost of doing business. This is the honest truth - about 5 years ago I had call on Christmas Day. I ended up with just under 30 calls that day. I worked from 8:30am until 8:00pm that night. Sucked to be me but it had to be done. Try and figure out how much that cost.

There's more as well, but the fact remains that it's simply not a fair comparison and it's not accurate to paint all DME companies as money grubbing scum, or as cheats or as people trying to screw anyone over. Are there some that are? You're damn right there are. However - I'd be willing to wager that 90%+ of them are genuinely trying to help patient as best they can in a system that's screwed up thanks to Lawyers and Insurance companies.

NOW - the kicker to all this. I'd also wager that 75% of the people who visit this site absolutely do not need this kind of handholding. To those that don't - it's a riddiculous cost to have to bear. If you don't need someone coming out to your house at midnight, if you don't need a company to go get all the paperwork for you then it's INSANE to have to pay the same price as someone who does.

However, just as important is the fact that those same 75% here make up maybe 5% of the typical patient a DME company sees. The vast overwhelming majority of patients I saw absolutely needed that kind of handholding and reassurance. A lot of times our service calls were just to go out and let someone know they were okay. Seriously. Every single day I'd see at least 2 or 3 people that I'm fairly certain the only reason they called up with a "problem" is that they were afraid of doing something wrong and hurting themselves or worse.

This is also not to say that a DME company doesn't make a profit. They do. And there's nothing wrong with it. I'm willing to bet though that once you really balance the books and boil down the real profits and real losses, the average DME makes about as much profit or even less than your typical online retailer.

Sorry to have gone on like this. I know it's way too long and many will not read this because of it but it's obviously something I'm serious and passionate about.

Plus I just really don't like seeing someone pounded on when all their side of the story isn't represented, no matter what or who it is!

Sincerely -

mattman

[mattman]

lol!

I just saw my post as it looks on the forum page.

Holy crap that's a long post!

[Pugsy]

Holy crap that's a long post!

Yep, looks like one of my novels.

I had to order a new nasal pillow for my Swift LT for Her. DME didn't have any in stock in my size. I only get supplies from them because I bought my machine privately. DME is about 14 miles away. No big deal, no rush, call me and I will find a reason to go to that town (Lowe's is a good reason, I always need something from Lowe's). A week later I get a phone call and I am not home telling me they are delivering my nasal pillow. Huh?? One little pillow. I said oops I am not at home (it is nearly 6 PM) but will be home in about 15 minutes. Okay the guy says, I have a couple of other stops and I can do yours last. At 6:30 PM he shows up and delivers the pillow. I tell him, no need to make a special trip. He says, no problem, "I live in this town (where I live) and I do this all the time". Guess who gets to be their delivery person..

They charge $35 for that nasal pillow. I just got the EOB on that pillow. Insurance paid $20.57, they have to write off 9.29 and I get to pay $5.14. Insurance company will allow me to do this every 2 weeks. They won't let me order 2 at one time. I have only bought one individual pillow in 60 days from DME. Got a couple of spares in my size by trading sizes. I am set for a little while.

I do have a DME question for you though. I get a piece of paper that says I can get a "new mask" every 90 days and new headgear and mask every 180 days. How can I get a new "mask" without new head gear? Are they talking about just the mask interface minus the Swift LT for her blue headgear?? I am assuming at 6 months I can get a new mask of my choice, completely different if I wish. Just wondering what the 90 "mask" is? Not that I need or want to abuse things, I was just wondering... My insurance follows Medicare guidelines to the tee.