Insurance Payment for Masks

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Insurance usually pays the same for any CPAP machine. Does anyone know how they reimburse for masks? Does the DME usually get paid the same for any mask, or do they get paid differently for different models, brands, or types of mask? For instance, does insurance pay more for FFMs than nasal masks?

I'm wondering why so many people end up getting a bad choice of mask from DMEs.

[chunkyfrog]

BCBSNE has a set price for each HCPCS code--at least for our plan.
This means that full-face payout/credit/reimbursement would be the same for any item with the same code.
In my case, Any full face mask with headgear runs $220; headgear being a bit under $40.
DME's pocket the difference if they can scam you a cheapie.
The numbers for a nasal mask are lower.

[idamtnboy]

Insurance usually pays the same for any CPAP machine. Does anyone know how they reimburse for masks? Does the DME usually get paid the same for any mask, or do they get paid differently for different models, brands, or types of mask? For instance, does insurance pay more for FFMs than nasal masks?

I'm wondering why so many people end up getting a bad choice of mask from DMEs.

Here are the different HCPC codes for masks and parts. They differ according to mask style. This is from a link from a couple of days ago asking about Medicare compliance requirements.

E0601 CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE
ACCESSORIES:
A4604 TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE
A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, EACH
A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH
A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR
A7030 FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH
A7031 FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH
A7032 CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH
A7033 PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR
A7034 NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSURE DEVICE, WITH OR WITHOUT HEAD STRAP
A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE
A7036 CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE
A7037 TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE
A7038 FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
A7039 FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
A7044 ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH
A7045 EXHALATION PORT WITH OR WITHOUT SWIVEL USED WITH ACCESSORIES FOR POSITIVE AIRWAY DEVICES, REPLACEMENT ONLY
A7046 WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, REPLACEMENT, EACH
E0561 HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
E0562 HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE

[diekatzepap]

Idamtnboy thanks for that list of HCPCS codes it should be a link at the top of the forum for all to refer to. I copied it for my own personal use. From my experience with working with the provider office billing side of things, insurances don't differentiate between brands it's all based on the code billed and the contract the provider has with each particular insurance company. Medicare is diferent in that the government has a set fee schedule and guidelines which could be different by each state. I've found that most insurance plans tend to follow the Medicare standard, but not always. Education is the key. That's what make this forum so great.