How do Medical Suppliers work

Hey everyone umm I was wondering what the process is for having my insurance cover medical supplies like nasal pillows, masks, machines, etc. I have been paying out of pocket the whole time.

You need to ask your insurance what they cover/pay for. All insurances are different.

1. Find out from your insurance what durable medical suppliers (DME) they cover in your area. And get a replacement schedule from your insurance.
2. If you got your machine from a DME that your insurance covered, then they can also supply you other supplies and bill insurance so talk with them.

There is "IN" network and "OUT OF NETWORK" and they are covered at different rates depending on your specific policy.
Your "cost" will be lower if you bought from an in network provider. Only your insurance can decide who is in or out and they have a list.

Anything ordered from an in network provider with get the order preapproved by your insurance before they ship the order. If they make a mistake in this process, they will look to you to pay for it.

If you order out of network you can contact your insurance and see if it's approved and at what rate, or just buy it and then try and get reimbursed (check sent to you). You have to submit a claim with receipts to your insurance company.

Never assume that something is covered if you cannot afford to just pay for it your self. I don't know how old an order would have to be before they would tell you that they will no longer pay for it

sleepinow wrote:Hey everyone umm I was wondering what the process is for having my insurance cover medical supplies like nasal pillows, masks, machines, etc. I have been paying out of pocket the whole time.

The advice to check with your insurance company is correct. But I also wanted to add that once you start dealing with DMEs, you may run into what I and others on this board had to deal with. Many companies in my network seemed to have a million unnecessary requirements for getting established as a patient.

Thanks to this board's support, I put my foot down with one company and insisted that all they needed was the prescription for a mask from my doctor so I could get a new one. They relented and to make a long short, they have been good to do business with after the initial snafu. Hopefully, it will last.

Anyway, my point is if you feel one DME is being unreasonable, you can try another one as they are all different.

Best of luck.

49er

You might still have to pay out of pocket due to your deductible. Do check on that when you call the insurance company. Durable Medical Equipment sometimes has zero deductible, which would help you a lot.

If you are using Medicare, however, you have to jump a few hoops which includes a copy of your original sleep study, office notes from your doctor that indicates the need for cpap and supplies, and the script. They have to have this stuff on hand in case of audit.

SewTired wrote:You might still have to pay out of pocket due to your deductible. Do check on that when you call the insurance company. Durable Medical Equipment sometimes has zero deductible, which would help you a lot.

If you are using Medicare, however, you have to jump a few hoops which includes a copy of your original sleep study, office notes from your doctor that indicates the need for cpap and supplies, and the script. They have to have this stuff on hand in case of audit.

Does the original sleep study have to be the one that was under my insurance? I have had 3, 2 of which were not by my insurance.

And thanks all of you for the info

Your question can't be truthfully answered here. There are 100's to 1,000's, of medical insurers and providers they will work with, all with varied and different plans. Even then their people don't have consistent answers as far as the rules.

You must deal with the people, at these places. If they can't or won't provide the answers you need, keep pestering them or move on if there are other options. Many of us purchase out of pocket online from reliable dealers like our sponsor CPAP dot COM. Jim

sleepinow wrote: Does the original sleep study have to be the one that was under my insurance? I have had 3, 2 of which were not by my insurance.
And thanks all of you for the info

Like everybody else has said, everything is up to your insurance company. If your doctor writes a prescription for something that you want your Insurance Company to pay for, the Insurance Company may ask for justification from your Doctor. That justification could be a sleep study they find acceptable, regardless of who paid for it.

In my case, I have gotten almost everything paid for by Carefirst (the first 4 years) and Medicare (the last year). I had to switch DMEs when I went from Carefirst to Medicare. The new DME said that they needed the original sleep study, compliance data from the first 90 days I was on CPAP, a recent dr. note saying I needed CPAP and that it was working for me, and a CPAP prescription, in order to get Medicare to pay for the supplies. They did not require copies of any subsequent sleep studies and said I did not need to get a new sleep study (even though I had one) before getting a new machine after the original CPAP machine was 5 years old.

My initial DME has the sleep studies, compliance data and original CPAP prescription on file and emailed them as attachments to provide to the new DME.

After I provided everything to the new DME, it took approximately a month to get a new mask, which I desperately needed. I got my new (current) CPAP machine a year later, when the old one was 5.5 years old and worn out.

As previously mentioned, every insurer is different. My DMEs have been happy to see I am 100% compliant with CPAP and said they wished everybody was, so they didn't have so many problems with insurance and Medicare.

You should keep a copy of your initial sleep study (no matter how old) and your CPAP prescription for as long as you need CPAP. These may be needed if you change DMEs, want to buy online, travel, etc. Also, sleep labs sometimes go out of business, as my initial sleep lab has, so if the DME didn't keep the sleep studies on file, I wouldn't have been able to change to a new DME and get Medicare coverage because I would not not been able to get a copy of my initial sleep study from 6 years ago.

Thank you for the information. I hope not to run into any DME problems. It seems like there are many not so good DME so I have to keep searching until I find one that is somewhat good