Insurance company can't tell me replacement schedule?

[pam933]

I just called my insurance company to find out their replacement schedule for masks, tubing, etc. and they told me that their policy on replacing equipment is that they'll replace it when it's medically necessary - there's no schedule that they have written, like they replace masks every 6 months. They said that I should go by the schedule that the DME gave me for replacing equipment and that I don't need to call them and the DME calls them and checks to make sure that whatever I'm replacing is covered. I don't understand- I'm sure that they have a schedule that they go by - that's got to be what the DME bases her information on. I was calling them because I thought that the first DME I saw said I could get a new mask every 3 months and the one that I'm using now said every 6 months so I wanted to check. But there's no way for me to check because they have no written policy other than "as medically necessary" - I guess that gives them wiggle room to deny or accept claims as they see fit, but that seems odd to me. I'll never understand the health insurance business. I know in the scheme of things this is pretty minor and I shouldn't worry about it. But I find it odd that I can't call them up and say "Do you replace masks every 3 months or every 6 months?" and they can't/won't answer me.

[6PtStar]

My DME gave me a printed copy of the schedule they use but I am not positive it is correct for all insurances. The thing on the mask was that the mask could be replaced once every 3 months but the headgear could only replaced every 6 months. Since they would not sell the mask without the headgear you were stuck with a mask every 6 months. Hoses used to be every month but they changet to one every 3 months now. Fine filters are 2 per month with the non disposable filters are one every 6 months. They did tell me that the month you got the non disposable filter you could not get the 2 fine filters that month. Nasal Pillows were 2 sets per month and mask cushions were one per month IF they sell them seperately.

Jerry

[Janknitz]

If the insurance company's policy is vague to give them "wiggle room" don't forget it also give YOU wiggle room. Find out the manufacturer's recommendations for replacements which are usually pretty liberal (the more they sell . . . ). Then, if your insurance denies a replacement, you can whip out the manufacturer's recommendations as evidence of medical necessity.

Kaiser goes by Medicare guidelines, and they seem to be fairly standardized. 2 fine filters a month (and I don't see anything that says you don't get the fine filters the same month as a regular filter), 1 regular filter every 6 months, one mask AND headgear every 3 months, one hose every 3 months.

[Wulfman]

I never could get a replacement schedule from my insurance provider, either.......so, since I never met my deductible in any of the ensuing years (since 2005), I just bought my supplies out-of-pocket and saved alot of money. I'm still using all of my original stuff (five years old) and all my spare stuff (masks, seals, hoses, filters, etc.) is still in their packages waiting for the day they're needed. I should be "good to go" for about 30 years or so.


Den

[LSAT]

THe Medicare replacement schedule is on several sites on the internet...many insurance companies follow it. It says that mask replacement can be 3 months, but masks usually last much longer.
Most masks last a long time....replacing the cushion may be necessary at 1-3 month intervals.

[bearded_two]

The medically necessary requirement for CPAP equipment also means that if the doctor writes a prescription for a different type of mask, such as full face when you had been using a nasal mask; insurance will cover the different type of mask without any sort of time interval requirement.

[GumbyCT]

I think that it is the mask seals 3 mos. and mask w/headgear 6 mos. I think if you have the doc write a script for another mask they will prob cover it. Esp. IF you are having mask leaks. So be sure to let your DME know when you are having leak problems. ::hint, hint::

Most DME's will provide another mask if you notify them within 30 days the mask you have is not working for you. This policy is from the mask manufacturer, which they ALL do, and not DME specific.

If you start getting billed for things the Ins. won't cover - I would write a letter to the DME (certified mail) requesting they not send anything that the Ins. won't cover.

[SteinyD]

I joined this website when I first started CPAP therapy (6 months ago) but haven't been a participant. As such, I haven't had time as yet to catch up with all threads. This thread caught my attention as it is one of the reasons I was coming here today. Since being diagnosed with apnea, I purchased my CPAP machine and all subsequent supplies from the supplier setup by my doctor. However, I've grown tired of being part of the problem which is causing our health insurance costs in the U.S. to cost us more every year. After doing a bit of searching, I've realized that the same products sold by the supplier and prices allowed by my insurance company are at about 3-4 times the price I can find on the open (e-tailer) market. So what if I have to fill out some paper work and potentially pay out of network. The cost to me, to my insurer and to the rest of us will be greatly reduced.

I contacted my insurance company which is very likly the same one the person who started this thread was referring to. Why do I think that? When I spoke to them yesterday, they couldn't answer my questions a regarding their policy of coverage for disposable components of the CPAP equipment. They had to call me back today. And when they did, they told me they, "don't have such a policy". They told me that as long as what I need to acquire is 'medically necessary', they will cover it. I indicated to them that my current supplier - and supplier for the past 6 months - has been emphatic about not sending me more than what is allowed by 'medicare' policies and adopted by all medical plans. I told them that the supplier suggested that if they shipped me more than allowed it wouldn't be covered. My insurance company wasn't sure what I was talking about and couldn't back that up at all. I had been previously told that hoses and masks were replaceable every 6 months, filters and nose pilows / cushions could be purchased 2 at a time every 30 days (or something like this). Something in the industry must have recently changed.

The other reason I came to the forum today is to find out who the reliable suppliers are on the web, and which will provide the proper invoicing with insurance codes required for submission to insurance companies. I do not want to derail the original topic so please don't respond to this here. I will seek this information elsewhere in the forum.

[BrettAnd]

I my self was stunned by the variances. I'll expand. The RT at my DME showed me that different insurance companies maintain different ideas about costs. Some say it's a part that should last for several mos. and some say it's a part exposed to bodily fluids and should be replaced every use. The insurance companies and the doctors that they employ are, as we speak, hoping to find a middle ground between screwing us literaly to death, and/or keeping us alive longer so that we can keep paying a reduced price. It's a win win for them, confusion for us. Xpap use is rapidly rising to a point even the medical community branches are starting to backbite each other as to who should be doing what. Ack!, sorry to start a rambling vent episode. The short answer is that many insurance companies simply dont know because the trend is hitting them like a tidal wave and they look at the local RT at the DME to set a baseline. Brett

[Wulfman]

I joined this website when I first started CPAP therapy (6 months ago) but haven't been a participant. As such, I haven't had time as yet to catch up with all threads. This thread caught my attention as it is one of the reasons I was coming here today. Since being diagnosed with apnea, I purchased my CPAP machine and all subsequent supplies from the supplier setup by my doctor. However, I've grown tired of being part of the problem which is causing our health insurance costs in the U.S. to cost us more every year. After doing a bit of searching, I've realized that the same products sold by the supplier and prices allowed by my insurance company are at about 3-4 times the price I can find on the open (e-tailer) market. So what if I have to fill out some paper work and potentially pay out of network. The cost to me, to my insurer and to the rest of us will be greatly reduced.

I contacted my insurance company which is very likly the same one the person who started this thread was referring to. Why do I think that? When I spoke to them yesterday, they couldn't answer my questions a regarding their policy of coverage for disposable components of the CPAP equipment. They had to call me back today. And when they did, they told me they, "don't have such a policy". They told me that as long as what I need to acquire is 'medically necessary', they will cover it. I indicated to them that my current supplier - and supplier for the past 6 months - has been emphatic about not sending me more than what is allowed by 'medicare' policies and adopted by all medical plans. I told them that the supplier suggested that if they shipped me more than allowed it wouldn't be covered. My insurance company wasn't sure what I was talking about and couldn't back that up at all. I had been previously told that hoses and masks were replaceable every 6 months, filters and nose pilows / cushions could be purchased 2 at a time every 30 days (or something like this). Something in the industry must have recently changed.

The other reason I came to the forum today is to find out who the reliable suppliers are on the web, and which will provide the proper invoicing with insurance codes required for submission to insurance companies. I do not want to derail the original topic so please don't respond to this here. I will seek this information elsewhere in the forum.

This one for sure.

https://www.cpap.com/


Den

[DoriC]

viewtopic/p473694/viewtopic.php?f=1&t=4 ... le#p455304

This may help.

[hose head]

My insurance plan is replacement when medically needed. I just got a Swift FX four months after getting an Activa. My face sweats a lot with Activa and it was getting hard to wear all night long. The DME billed $149 for FX and insurance paid $88. I have 100% coverage on DME.

m

[DreamOn]

My impression is that most (but not all) insurance companies go by the Medicare supply replacement guidelines (link cited by DoriC earlier in this thread).

Under Medicare guidelines, nasal masks can be replaced every 3 months, but the headgear replacement interval is every 6 months. My DME bills separately for the mask and headgear, as there are different insurance billing codes for each component. The way my local DME handles this is that I can get a complete mask (including headgear) every 3 months, but they only bill my insurance for the headgear part every 6 months. So, in essence, I'm getting the headgear "free" every other time.

[DoriC]

Yes, our DME works with Medicare the same way. They don't sell masks separately so when we were getting a new mask every 3months we got the headgear too but they only billed Medicare for the mask at that time. We haven't replaced our mask in about 6months now as we always have a problem with the new "break-in period".

[mattman]

This is one of the more interesting areas of Healthcare Insurance in my opinion. It also (again in my opinion) really starts to show how good our insurance system is, but at the same time how terrible and for the same reasons. It's really unique and complicated and goes to the core of why I say I've no idea how to fix it.

Note that this is all from my perspective as both a user of healthcare (a diabetic CPAP patient) AND as a DME provider for close to 15 years.

In a nutshell, we want our supplies - in this case CPAP masks. There are 2 ways an insurance company can come at this:
1) Setup a schedule for replacement supplies that balances comfort/cleanliness with cost effectiveness
2) Don't set a schedule, replace as needed. However, there has to be SOME sort of check/balance in place to control costs.

In theory, either of those practices work and both have limitations. The 2nd choice is (at least to me) the obviously better choice since it's more freeform.

Replacement Schedule thoughts:

• Easy to manage. If an item is replaced every 3 months you simply check the last date that HCPC Code was billed, if it's 90 days ago or longer, it's covered. If it's 89 days or sooner, it's not covered. Pretty cut and dry.
• Easy to understand for the same reason as above.
• Easy to convey to suppliers and members - just print up a list and post it on website and/or mail it to suppliers and members

--

• Somewhat difficult to implement - who decides what and when and how do they do it? This isn't automatically a really big deal but it can be. Certainly there is a cost to starting this and then having it reviewed every so often. For masks and/or filters it's not a big deal but remember, this has to be done individually on EVERY disposable medical product that can be billed. Not just CPAPs but EVERY product. That means it's a continuous full time job for a lot of people. That cost really does add up.
• How to handle exceptions? It's great if you know your Swift can be replaced every 3 months like clockwork, but what happens if, after a month, you get in an auto accident and break your nose? This is usually handled by a review board. In theory, this is great since it adds in the flexibility to handle any situation. In practice though, it's almost not worth it. It takes months and it's not as flexible as you'd think. I've seen review cases literally take almost 2 years to resolve. In most cases it takes months. For many things the need has already come and gone by the time reviews can be completed.

For the "No Schedule, replace as Medically Necessary" program:
Great for flexibility. Pretty much anything whenever it's needed.
--

• Difficult to understand for many people; "What does Medically Necessary actually mean?"
• Requires a lot more paperwork - DME will have to contact Dr, Dr will have to document reasons and send back to DME, often this will have to go back and forth multiple times
• Usually will require patient to see Doctor more often (How does Doc know something isn't working unless he/she sees you?)
• VERY difficult to quickly determine if a given product is covered for a patient at any given time
• For certain items, supplier will have to obtain authorization prior to providing the item in question which can dramatically delay treatment. Easiest example is certain specialty beds for patients with serious bed sores require extensive prior auth which can take weeks. Obviously those patients really really need these though. It's a catch-22.
• Allows for a lot more fraud (Both intentional and unintentional), especially by doctors who think they are doing someone a favor by signing off on anything. This is the most often (at least that I've seen) situation where you hear about doctors billing for hundreds of thousands of dollars for patients not seen or treated. Also the area where the most unintentional fraud takes place where you hear about suppliers getting hit for items that were later determined to not be Medically Necessary even though the doctor they contacted signed off on them.

Again, both solutions have great intentions - easily get products to the people who need them. Both have some form of flexibility built-in but that very same flexibility becomes a liability when it's applied to millions of people.

I honestly don't know a better solution though, that meets all the criteria that I think a system should have:
-Flexibility first and foremost
-Cost Control First and foremost (Yes that's a contradiction already!)
-Ease of use by BOTH a patient AND a supplier (online or brick and mortar)
-Involves patient, doctor and supplier in the equipment process

So again I come back to, this highlights both the great things our Health System can do and also the massive drawbacks and faults.

mattman