DME Automatic Replacement of supplies ??

[lovescuba]

Just got a letter from my DME, only had my CPAP 3 weeks. They want me to sign up for a automatic replacement of supplies, of whitch they say "MOST insurance companies pay for". I have not called BCBS yet, as it is the weekend. However the schedule seems excessive, and don't feel any insurance would cover.

Tubing, mask and filter replaced every 3 months.....I have resmed climate line !
Headgear and humidifier chamber replaced every 6 months

I would like to hear from some of the experienced pros here....... Does this sound right ??

THANKS

[Cotay]

I am not a seasoned vet here, but I'm already on my second DME due to some insurance issues.

The schedule may indeed be excessive depending upon your environment, but the schedule is designed to maximize the insurance company's savings while still protecting them from lawsuits due to health risks from dirty/damaged equipment. If you live in a particularly dusty or humid environment or have kids/pets, the equipment can be damaged quickly.

Some people have hoses that last for years...some need regular replacements. Seals on humidifier chambers can go bad causing loss of pressure. Filters get dirty and headgear gets crusty from head cheese.

BCBS will allow these charges...just watch your deductibles and co-insurance premiums and make sure you understand the ramifications of whether the DME is "in-network or out-of-network".

I have BCBSTX...they generally follow the schedule you've posted as do most insurance plans.

[lovescuba]

wow, I just can't imagine a new mask and hose every 3 months. Most post on here talk about once a year.

Any other thoughts...

[LSAT]

DMEs love to do this...they usually know what your insurance will pay for and they take advantage of it. Usually you pay a co-pay or you have a deductable. You can say NO to the auto replenishment and order whenever you need something. It is a good idea to keep a back up on items in case you have a problem on a week end.

[RocketGirl]

My insurance is BC/BS federal and they will cover a new mask, hose, humidifier chamber every 6 months; new nasal pillows every 3 months. My doctor says these things often last much longer than the replacement schedule suggests, but she strongly recommended that I get everything my insurance will cover for at least the first time or two, to ensure that I have replacements right on hand in case anything breaks or goes missing during travel.

I use nasal pillows, so she also recommended that I get at least one full-face mask at some point in case I need one for use during a cold.

I don't think I'd be comfortable with an automatic replacement program, but that's just me.

[lovescuba]

Yes, may be a good idea to "stock up" this year, as my deductible is met with the sleep study and CPAP. So I will only have the copay for the rest of the year. Will call BCBS Monday to see what the copay will be.

[archangle]

Get a spare or two of everything as your insurance will pay for it. It's good to have a backup and it makes it easier to keep it clean. Figure out how often you need to replace things and what it costs you and adjust your ordering schedule to match.

I wouldn't go for auto replacement, but it might be easier at the start.

[DocWeezy]

wow, I just can't imagine a new mask and hose every 3 months. Most post on here talk about once a year.

Any other thoughts...

It's not always about things wearing out. I discovered the hard way that at about 3 to 4 months, I HAVE to replace my tank, climateline, and mask hose (Swift LT) because something happens and I develop a chronic cough that simply will not go away. Cleaning or not cleaning seems to make no difference in how long I can go. It's like some sort of mold or bug takes root and won't be disinfected out (I use RespCare soak) so my only choice is to replace them. When I do, the cough disappears within a day.

So it is good to have some spares just in case, especially until you know how you will react over time. But even though I need frequent replacements, I would not do an automatic schedule....something about that bothers me. I just send an email to my DME when I start coughing and she sends out the new stuff. Yes, my DME really is wonderful; I'm one of the lucky ones.

Weezy

[RUFFSTUFF]

My DME provides a new mask (complete with the headgear and all accessories), a new hose and new filters every 3 months. After 11 months, I still have the original machine and humidifier.

[DreamDiver]

DMEs love to do this...they usually know what your insurance will pay for and they take advantage of it. Usually you pay a co-pay or you have a deductable. You can say NO to the auto replenishment and order whenever you need something. It is a good idea to keep a back up on items in case you have a problem on a week end.

I concur with LSAT. This is more about milking your insurance to their maximum benefit.

[Randyp1234]

Just the other day I got a letter from Lincare thanking me for my interest in setting up automatic supply deliveries and that all I needed to do was "sign here" on this letter. The only time I've talked to them was to tell them to stop calling me.

Maybe I'm a control freak but I prefer to keep track and call them when it's time to get new supplies rather than have them send stuff. I've already had them tell me my insurance required I do certain things that I knew for a fact was not true so how would I trust them to even know when insurance would pay for more supplies. I read an interesting blog a while back about someone that worked for Lincare's telemarketing CPAP division and the deceptive practices they used to get sales. It was pretty interesting. Here's the link

Randy

[sapphirerose]

My insurance (UHC) will pay for a new mask, hose, and filters every 3 months, new humidifier tank every 6 months, new cushions or pillows every month. They also bought my machine outright instead of renting it, and I can get a new machine in 5 years. So, it is possible that your schedule is correct. However, what your insurance pays for will vary not only by insurance provider but also on which level of plan you or your employer purchased. I have 100% durable medical coverage, which I have come to understand is unusual.

You can't determine your coverage without checking with your insurance provider.

[xm41907]

My DME's policy is that they call to verify it is ok to send out supplies. I was told they will want to replace my Swift FX pillow every 6 weeks. I don't know if this is typical, but I'm at 6 weeks right now, and mine is in great condition. I got a call less than a month in use, and the lady said it was time to refill the supplies and if it was ok. I took that as the opportunity to say I didn't need anything at this time. She didn't seem very happy, but oh well. I don't see the point in replacing the pillow after only using it for about 30 days. Maybe next month I'll say "yes", just to have one for backup.

[Uncle_Bob]

BCBS AL medical policy for the management of OSA states

"Supplier should receive a request for additional supplies and should not automatically deliver supplies/accessories on a predetermined routine basis."

[xyz]

There are two fundamentally different ways that insurance works. And a whole lot of variations on each of those.

The two fundamentally different ways are:
Capitated and Fee For Service (FFS).

Capitated means that the DME is given a _fixed amount_ for each OSA patient. That's important to know and understand.

The reason that it's important for you to know is that many (most?) DMEs will fight you for any little thing that you ask for. Think of it this way (the way that they think of it). Every product or service that they deliver to you cuts into their profit margin! They get X dollars per month for you, and every dollar that they spend on you is a dollar of profit that's lost.

Some will pull every dirty trick in the book:
Different phone number for capitated patients than FFS patients. No live person that answers that number. (Rarely.) Don't call you back promptly (or at all). Say that you're not eligible to order something when you are. Tell you that if you want it anyway (that you're eligible for but don't know it) that you can pay for it. Demand prescriptions for things that don't need prescriptions. Say a new prescription is needed when it isn't. And more, many more.

Now see the difference.

For FFS patients, the DME gets _reimbursed_ for every product or service that they deliver to you. Yes, they'll whine like a little child about the reimbursement rate, but they'll cash the check.

Point: they only make money by giving you something.

The difference is like day and night.

It is _absolutely essential_ that every OSA patient FULLY understand the _details_ of the DME coverage in their insurance plan. And it's not easy. They average Customer Service rep knows little about anything. And it's worse for DME issues because they're a small percentage of the calls that they get. Unfortunately that doesn't stop most of them from giving you a WAG which is almost always wrong. You need to 1) insist on speaking with someone who actually knows those things and 2) ask where it says (what they told you) in writing. "Send me a copy of that page that says what you just told me. No? Then get me a supervisor right now please." Tell them that if it's not in writing, it's not a "policy".

Us geeks read the Dilbert cartoon strip regularly. Here is one from just a couple of days ago that relates to all this.

"Hello, this is tech support. May I close your ticket now?"
"No, you haven't helped me yet. I just called you."
"I'm not evaluated on how helpful I am. I'm evaluated on how many trouble tickets I close."
...
"BTW, if our call gets disconnected I count that as a closed call."

Unfortunately this is very true.

One of the variations that I referred to above is co-pay. If you are fortunate to have little or no co-pay, then get replacement items when you are eligible.

Always "get ahead" with your supplies so that if something breaks (a break in the hose), or if you lose something (that little silicone headpiece on the mask ... in the middle of the night ... and you can't find it), or whatever, you will have a replacement. Go ahead and wash that next cushion, the next mask, the next hose/humidifier/whatever and have it available on your shelf so that when something unexpected happens you'll have it's replacement ready.