Mask question

[Jaylee]

My mask is $176 at Cpap.com Does anyone know how much they usually run when you get them from your DME? My insurance will pay for 50%, so I am assuming that 50% of the DME price is cheaper than $176, but you never know!

My info is all filled out down there.

[cflame1]

the last time that I bought a FFM from my DME... came to about $400. They part out every little piece of it.

[Jaylee]

I am going to call them on Tuesday, but I am impatient.

[cflame1]

I can understand that one.

[Pugsy]

Also just because DME initially bills a huge amount doesn't mean they get it. There is usually a disallowed amount and your portion would be 50% of the allowed amount, not what was first billed.

[Jaylee]

I've only had to get one mask from them, the initial one. My insurance isn't great so normally it is cheaper to order off of the internet. I am eager to see how much they charge for one.

[Madalot]

Hi Jaylee,

In my experience, with my insurance, it is cheaper for me to go through that. My insurance allows me a mask every 3 months and my co-pay on it was usually around $25. But I found in my situation, I sometimes didn't owe anything. The DME was billing close to $250 for a $99 mask through cpap.com.

I would definitely check your insurance/co-pay and see what the best deal is.

[DreamOn]

Hi, Jaylee! What normally happens is the DME sends a bill to the insurance company for an outrageous amount. The insurance company has a standard "allowable amount" for each billing code, which is usually quite a bit less than the DME bills them. The billing code for a full-face mask is A7030. The DME may bill for the headgear separately (even though mask and headgear are packaged together). The headgear billing code is A7035. The percentage you pay is usually based on the "allowable amount," not on the amount the DME billed, but you need to confirm that with your DME.

Here's how it worked out when I purchased a Quattro full-face mask from my DME:

Billing Code A7030 - Full-face mask (Quattro):
DME billed insurance $330.12
Insurance allowable amount = $136.58
My share of cost (20% of allowable amount) = $27.31

Billing Code A7035 - Headgear:
DME billed insurance $50.00
Insurance allowable amount = $28.78
My share of cost (20% of allowable amount) = $5.75

My insurance pays for a mask every 3 months. They pay for headgear only once every 6 months. If I buy a new mask every 3 months, my DME includes headgear at no charge every other time, meaning that they bill insurance and charge me for headgear only once every six months. Your DME may handle that differently though.

You need to contact your insurance company and find out how it works with them. Ask them what their "allowable amounts" are for those two billing codes. I strongly suggest that you discuss this with the DME before purchase, so you know exactly what you will be paying. Then you can compare your share of cost with the option of buying online. Make sure your DME will be "writing off" any difference between the billed and insurance-allowable amounts. This is called "accepting assignment," which means that they won't bill you for the difference. If your DME doesn't accept assignment, you could get stuck paying the difference plus your percentage-based amount.

I hope that helps you know what questions to ask of your insurance company and DME.

[bayourest]

It's also worth checking with your insurance company for "out of network" charges. I have a high deductible yet if I were to buy a mask online, it would qualify as "out of network" and I would probably have to pay MORE than if I go through DME

[Jaylee]

My insurance isn't very good. They let me have a mask every 6 months but I have to pay 50% of whatever the DME charges. Thanks for the information.

[Madalot]

My insurance isn't very good. They let me have a mask every 6 months but I have to pay 50% of whatever the DME charges. Thanks for the information.

Your insurance doesn't have an "allowable charge" that the DME contracts to accept? Wow. That stinks in a major way. I am so sorry.

With me, my DME charges an amount (usually outrageous). The insurance company comes back and says "nope -- you can only charge THIS much" and because the DME accepts the insurance, they have to accept that amount. I pay my co-pay based on the allowable charge, not the outrageous prices the DME tries to charge.

[archangle]

My insurance isn't very good. They let me have a mask every 6 months but I have to pay 50% of whatever the DME charges. Thanks for the information.

Jaylee, check and see if your insurance provider has "in network" or "preferred" providers. If so, they have to accept the insurance rate, which is often much less.

DME "list" prices are very squirrely and fictional. You might try calling a few local DME's, including your own and price shopping. Be sure and get a written price when you pick up the mask. Don't accept the "we'll bill your insurance and tell you your copay later" scam.

[LSAT]

The Quattro mask itself shouldn't wear out....it's plastic.. Can you get along with a new headgear and a new silicone cushion?

[Jaylee]

Madalot- I am sure they do have an allowable amount, I am sorry I didn't mean to be confusing. I just meant that instead of a copay I pay 50% of whatever the insurance is billed.

The clips wont stay in the mask. They fly off several times at night. Maybe I can just replace those. The headgear and plastic part seem fine. Can you get new plastic clips? They aren't bent or anything, they just wont stay in the holder anymore. My nasal mask came with extras but this one did not.

[Janknitz]

Take a look on CPAP.com and you should be able to but just the clips. Be sure to count the cost of postage.