DME question

[nocreek1]

My doctor wrote a prescription for a new style mask (Full Life) FF. She sent said prescription to my DME and they called me to tell me that I could have the mask, but I was not due for a new headgear until November. I am a Medicare patient. Now my question is don't the masks come with the headgear, especially if you are getting an totally new type of mask? The mask I fear would not work with any headgear, but only the one designed for it.
Was I being given the usual run around or was she correct? She did mention that I could pay $49 for the headgear if I wanted the mask this month. I elected to wait until November.



ResMed S8 EScape System
Hunid Aire 3i
Quattra FF mask
11 pressure

[cflame1]

A Brick and Mortar DME will charge you for every little piece... that way they can say that you're not eligible for the headgear even when it's a new mask... plus it allows them to inflate the cost by charging for every little piece.

[6PtStar]

SOME masks can be bought without the headgear but the DME's generally won't buy them that way because they have to have more inventory and they cost them more that way. Medicare allows them to bill each piece seperately and they have a seperate code for each. The replacement schedule also lists them seperately. If I remember right I thing you are elegible for a new mask every 3 months but the headgear is allowed to be replaced only every 6 months. My DME would not sell them seperately (but they did bill medicare and my insurance co. seperately) so it basically limited me to a mask (with headgear) once every 6 months. From what I understand this is SOP.

I suspect with this new model mask the headgear won't interchange.

Jerry

[DannyPh]

Hello. I have the Full Life Mask on order and the mask comes complete with Headgear for one set Price. I also ordered the Fit pack so I would have all three size pillows to determine what size fit me best. Seemes to me that your DME is out to make extra bucks off you. I would make them aware that you are aware that the Mask is sold complete with Head gear and see what their response to that is ? Good Luck

[nocreek1]

Thanks to all that have replied. I do believe that I will contact the DME and mention that the mask and head gear are a matched set of one. May not make any difference, but should be interesting to hear what they have to say.

[Lou Cypher]

I think what they are trying to tell you is :

Medicare will only pay for a new mask every 90 days, no matter what the prescription says.

So if you wait until 90 days from your last mask, it will be paid for .... if Not , you can get it right away but YOU have to pay for it..

As to the headgear ( and please someone correct me if I am wrong) the head gear goes with the mask and in your case here I believe the DME was using the words mask and headgear as one and the same thing....

I believe the point she was trying to make was the payment policy....

[6PtStar]

I think what they are trying to tell you is :

Medicare will only pay for a new mask every 90 days, no matter what the prescription says.

So if you wait until 90 days from your last mask, it will be paid for .... if Not , you can get it right away but YOU have to pay for it..

As to the headgear ( and please someone correct me if I am wrong) the head gear goes with the mask and in your case here I believe the DME was using the words mask and headgear as one and the same thing....

I believe the point she was trying to make was the payment policy....

Not according to Medicare. Medicare code for a full face mask (without headgear) is A7030NU replaceable at 90 days. Code for a nasal mask (without headgear) is A7034NU replacable at 90 days. Medicare code for a headgear is A7035NU and is replaceable at 180 days. If your DME won't sell one without the other total replacement (mask and headgear) can only be replaced every 180 days. Sorry our goverment at work.

Jerry

[mattman]

It's just another of those stupidly irritating things that Medicare/Insurance does. Most DME providers would be thrilled beyond belief if they changed it and in fact regularly beg for to just be a single code with a single replacement schedule.

[jdm2857]

I'm just glad DMEs don't sell cars.

They'd charge separately for each part and then for assembly labor. A Ford Taurus would probably run about $150,000.

And there would be no owner's manual in the glove compartment.

[mattman]

Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.

[cinco777]

mattman wrote

Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.

Actually, the manufacturers decide.

When my DME separately charged my insurance company ($305) for the Card Reading unit included as STANDARD in my Respironics M-Series auto, I was curious on why they did this (other than Greed and WE are the only ones contracted with your Insurance Company). I did some research on the Internet and, after working through layers and layers of the http://www.cms.hhs.gov website, discovered that Respironics, in a 2005 Public DME-related Hearing (of course, only attended by the Manufacturers) requested a separate billing code for their new SmartCard reading unit that they were marketing as a feature. The CMS folks obliged (who are they to disagree). I found many other cases of this "Ask and Ye Shall Receive" for other separate codes requested by Respironics and others. If you feel up to it, go peruse the DME-related Public Hearings on the CMS website - I am sure you will come away more informed (and very possibly upset with the process that led to all these separate billing codes). Someone with "street smarts" might actually believe that the Brick & Mortar DMEs asked their good Manufacturing buddies to request the separate codes so they could bill (or is it called "gouge") for them separately. What do you think?

BTW, I purchased my backup unit (same model#) from an online DME vendor and THEY didn't bill me separately for the Card Reading unit included as standard in my Respironics model. In fact, their total price for my unit ($526 including free shipping) was less than 1/2 of the cost ($1180) that the DME billed my insurance company. My copay was 20% so I paid $236 for my DME provided AutoCPAP unit. Boy did I get a Deal! Until, of course, you step back and realize that if my Insurance Company did not have a single source agreement with the B&M DME, my copay could have been 20% of $526 or $105, saving me $131 and my Insurance Company even more (if you are naive enough to believe that my insurance company really paid $1180 to the DME).

[mattman]

Well, the mfr can decide but it still boils down to what the Insurance company decides.

Basically the way it works is:

Ins company tells the DME: You will bill us for the following items - Item 1, Item 2 and Item 3. You will bill 'x' amount (The submitted amount) and we will pay you 'y' amount (The allowable) for each of those items.

DME company doesn't get a lot of choice in the matter. If they agree to take patients who have that insurance, they have to bill exactly the way the insurance company has set it up.

Online provider who is charging cash doesn't have to abide by those restrictions since they are going the cash route. It's a wonderful thing.

[jules]

Yep, a DME dealing with insurance bills by the piece not the package.

When I got a swift from a major DME my insurance got billed for the headgear, the mask and a nasal pillow and refused to give me all 3 sizes without my money to pay for the other two sizes because they could sell them to other patients for replacements.

[Wulfman]

Well, the mfr can decide but it still boils down to what the Insurance company decides.

Basically the way it works is:

Ins company tells the DME: You will bill us for the following items - Item 1, Item 2 and Item 3. You will bill 'x' amount (The submitted amount) and we will pay you 'y' amount (The allowable) for each of those items.

DME company doesn't get a lot of choice in the matter. If they agree to take patients who have that insurance, they have to bill exactly the way the insurance company has set it up.

Online provider who is charging cash doesn't have to abide by those restrictions since they are going the cash route. It's a wonderful thing.

Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.
Again, it's how Medicare has set it up.

Medicare (And other insurance companies) decided that items should be billed seperately.

Which one is it? Medicare or the insurance companies?
Do the insurance companies go by what is established by Medicare/CMS? I suspect that's the way it is, but I'd like a clarification on this. It would help explain why things are so screwed up.


Den

[cinco777]

mattman wrote

Well, the mfr can decide but it still boils down to what the Insurance company decides.

Basically the way it works is:

Ins company tells the DME: You will bill us for the following items - Item 1, Item 2 and Item 3. You will bill 'x' amount (The submitted amount) and we will pay you 'y' amount (The allowable) for each of those items.

DME company doesn't get a lot of choice in the matter. If they agree to take patients who have that insurance, they have to bill exactly the way the insurance company has set it up.

Online provider who is charging cash doesn't have to abide by those restrictions since they are going the cash route. It's a wonderful thing.

Let's see if I fully understand what you are claiming. My Insurance Company tells its DME (it only contracted with one) to Bill it (the Insurance Company) for my AutoCPAP machine at $875 and my machine's STANDARD feature, a Card Reading module, at $305, for a total of $1180, as these are the numbers on the invoice that I receive from my DME, along with my 20% copay amount of $236. However, you state that my Insurance Company has previously told its DME (in a hidden agreement/contract that we the insured never see) that it will only pay the DME a smaller "allowable" 'y' amount. For math purposes, let's say this "allowable" 'y' amount totals $260. So, as the insured, I may think (if I am naive) that I am getting a really great deal since I am only paying $236 for a machine that costs my Insurance Company $1180.

However, since the Insurance Company is only paying the contracted (hidden) "allowable" amount 'y' of $260, it is really a great deal for them as they only pay $24 to the DME for the machine and I pay $236, 10x as much. Since you are an ex-DME with insider expertise, please correct any "bad" assumptions, including math, that I have made in my example.. Thanks. I'm so so glad that my online vendor didn't have these bothersome "consipiratorial" restrictions.