Full face mask a "luxury item"??

[tonycog]

Hi
A friend of mine is on CPAP for the first night tonight. (I've sent him here to study-up, but I don't know if he's been here yet.)

He got his machine today at a local DME provider. They have already determined that he mouth-breaths and needs a full-face mask, so they sent him home with a UMFF. But the RT told him that his insurance (BC/BS) considers a full-face mask as a "luxury item" and he must pay the difference - $190. Has anyone here dealt with this? Is this true? How could a mask that is needed by mouth-breathers be considered a "luxury"?

He's already getting ripped to the tune of $2K. I don't want him to get hammered again for another $200 if he shouldn't.

Thanks,
Tony

[montana]

tell friend to try cpapauction.com

http://www.cpapauction.com/listingPage. ... ngId=89086

[tonycog]

I've already sent him there for back-up equipment. I just hate to see him ripped-off for nearly $200 for his first equipment. It seems like DME nonsense to me. I am curious if this has come up for any one else.

Thanks,
Tony

[Wulfman]

Hi
A friend of mine is on CPAP for the first night tonight. (I've sent him here to study-up, but I don't know if he's been here yet.)

He got his machine today at a local DME provider. They have already determined that he mouth-breaths and needs a full-face mask, so they sent him home with a UMFF. But the RT told him that his insurance (BC/BS) considers a full-face mask as a "luxury item" and he must pay the difference - $190. Has anyone here dealt with this? Is this true? How could a mask that is needed by mouth-breathers be considered a "luxury"?

He's already getting ripped to the tune of $2K. I don't want him to get hammered again for another $200 if he shouldn't.

Thanks,
Tony

The RT lied to him in that statement, so it's hard telling what else they told him that wasn't true.
It's really unfortunate that so many people don't do their homework before they go into these places or sign the documents.

Here are the insurance billing codes for the equipment. The full face mask is a standard item.

* E0601 RR is CPAP rental.
* E0601 NU is CPAP purchase.
* A7034 is CPAP nasal mask, including all nasal masks, Nasal Aire, Breeze, Spiritus.
* A7032 is CPAP nasal mask cushion.
* A7030 is CPAP Full Face mask.
* A7031 is CPAP Full Face mask cushion.
* A7044 is CPAP Full Oral Interface.
* A7046 is CPAP Humidifier Chamber.
* A7037 is CPAP tubing, long and short hoses.
* A7038 is CPAP disposable filter.
* A7039 is CPAP gross particle (foam) filter.
* A7035 is CPAP headgear.
* A7033 is CPAP nasal pillows.
* A7036 is CPAP chinstrap.
* E0561 NU is CPAP Passover Humidifier
* E0562 NU is CPAP Heated Humidifier
* E0470 RR is BiPAP rental.
* E0470 NU is BiPAP purchase.
* E0471 RR is BiPAP-ST rental.
* E0471 NU is BiPAP-ST purchase.
Other CPAP items are listed under E1399, which is miscellaneous.


Den

[newhosehead]

As Den said, yes, it is a LIE. A FFM mask is NOT a luxury item. I wish I found this statement (the DME's statement) unbelievable; unfortunately I do not. I have dealt with some of the same crap.

Jeanette

[Rick B]

I'm finding out myself that the coverage is different depending on the insurance. As far as your friend goes, I would tell him to buy on here (less expensive). He can probably get the mask for a lesser price and them submit to the insurance for what hey will reimburse him. That's what my insurance told me. Either way, he'll save money in the long run and save money for the insurance company as well. My insurance company told me they don't care where i get stuff. It just makes a difference in my co-pay.

I figured it out on the machine the DME got me. They billed the insurance $6,000 of which the insurance will pay 70% of what they contracted for. I make the co-pay for my 30% which is going to end up being around $1,300-$1,400, they told me. Hmmmmm....same machine online is $1,800 at most. My co-pay would have been 50% ($900) for using a non-provider through my insurance. Do the math. I would have saved and the insurance company would have saved.

Tell him to talk to his insurance company. They are the best advisors in a matter such as this

[kteague]

A medical necessity is not a luxury. Shame on them.

[cpapernewbie]

this kind of situation make me wonder

1) is there no code of ethics among the RT profession?
2) is there no business ethics in the DME industry?
3) who really monitor DME industry and RT profession?

[fisamo]

Has your friend already purchased the equipment? If not, tell him to check around with other DMEs. If he has, tell him to call his insurance company and get his Explanation of Benefits. If that EOB, which indicates patient out-of-pocket responsibility, differs from what the DME charged him, get a refund from the DME. (The DME should have provided a receipt for any payment--you'll need that too, of course.) If the DME gives any hassle about refunding the money, file a complaint with the insurance company. Submit a COPY OF the receipt from the DME (keep the original), and highlight the disputed charge(s). Do not add any marks to the original receipt.

If the DME is breaching their contract with the insurance company (for billing you outside what the insurance company allows), the insurance company will intervene on your behalf, and it probably won't be pretty for the DME.

[Madalot]

As Den said, yes, it is a LIE. A FFM mask is NOT a luxury item. I wish I found this statement (the DME's statement) unbelievable; unfortunately I do not. I have dealt with some of the same crap.

I'm with you Jeanette! I know I complained about my RT and DME at times, but I have to say they have never tried to pull some of the nonsense I've seen described here! It was my RT who said that I probably needed a full face mask after a couple days and brought one to my house. Every machine I've had (cpap, bipap, ventilator) has been fully data capable right from the start.

It really gives me a bit of a reality check when I read some of the stuff that others deal with -- it makes me see that my DME isn't so bad after all!!

[unadog]

If he is already going to be $2k out of pocket with his insurance and the DME, he may want to but online without using insurance. He can buy new, stare of the art setup for under $1.5k total. Depending on what he needs.

He really needs to check with his insurance ASAP on what they will cover, whre, and what his copay is. He also needs to understand what his copay applies to - what the real cost basis is that insure allows and his copay is figured on.

My insurance will pay 100% with certain DMEs, 0% out of network! So it is critical to understand the rules.

Good news is, he has a 3 day weekend to figure this put before he talks to the DME. Bad news is, he better get busy - not much of a holiday weekend!

Has he used the equipt? Do you have comparable equip that you could loan him, and are you qualified to set it up correctly? He may want to just dump it all back on the DME.

Good luck!
Michael

[ozij]

I purchased all of my initial stuff from CPAP.COM......THEN, billed my insurance provider (with an invoice from me as the billing party and them as the party being billed) and they reimbursed me for 80%......because, they considered ME to be "in-network". It works the same for other out-of-pocket expenses......and can be listed on a form and submitted for reimbursement or applied to the deductible.

I discussed these options and procedures with them beforehand (which I believe is important for anyone wanting to use this option).
By the way, I don't have BC/BS, but quite a few others on the forum who have BC/BS have done the same thing with success.

Den

Meanwhile, before your friend slams the door on those liers have him tell the RT that he would very much appreciate to have that info about the full face mask in writing. That may change her tune -- or get her kicked out of the healthcare business (hopefully)

O.

[TheTwinsMom1]

I have BCBS PPO and they covered my FFM with no questions and it was not considered a luxury item.

[JohnBFisher]

I have BCBS PPO and they covered my FFM with no questions and it was not considered a luxury item.

Ditto. It certainly was not considered a luxury item. It was considered a medical necessity.