DME billing for individual mask parts...

My insurance company has authorized a replacement mask (Mirage Quattro) as well as a new replacement mask cushion and head strap. These replacement parts and new mask will give me 2 full masks to switch out between cleaning cycles. These are the first CPAP replacement items I have ordered since new (16 months now). I understand that the silicone does wear out but I haven't had any problems so I have ignored my (previous) DME's nagging suggestions for replacement. Now this new DME is telling me they are charging me/my insurance for each individual item the insurance has authorized for replacement but I will have to pay full retail for the 2nd headgear requested. Additionally, instead of requesting the replacement parts I wanted, the DME sought out insurance authorization for what I believe are unnecessary items like a new reservoir tank, machine filters, CPAP hose, etc... .

So, I have refused to accept or pay for any item I have not specifically requested and further stated that since the insurance company has authorized the additional headgear (the first headgear is included in the full mask replacement) and insurance will pay their 90% coverage for that additional headgear, I will only pay my remaining 10%, not the full $30 retail the DME intends to charge me. Even tho the new mask comes with the headgear included the DME is billing for each item separately thus they infer my request for replacement headgear is actually a 2nd headgear.

The DME says they must follow Medicare's suggested replacement schedule for CPAP equipment and is why I will be charged full retail for the 2nd headgear. They are ignoring the fact that my insurance has authorized and is willing to pay their 90% for the 2nd headgear. I understand the DME is only trying to boost their revenue but they are trying my patience. It is NOT the few dollars they are trying to get away with billing me as much as it is the deceptive billing principle they want me to swallow. Am I correct here? Am I suppose to bend to the DME's own interpretation of what they are allowed to bill me for? It is no wonder so many people hate their DME's. Please post your personal views and experiences on this.

What does your prescription say about replacement frequency (if anything) and why is your DME telling you no, when your insurance company told you yes? Did you get approval in writing by any chance?

My rule is to take everything insurance will pay for and keep it a spares and back ups. PM me and I'll send you a copy of my script so you can see how it works.

The script my doctor gave me just said "replacement CPAP supplies" with no specifics on what. I guess my doc figured I knew what I needed more than he. He is my general MD physician (I forget the acronym used) as the CPAP doctor I went to after titration study was worthless, I no longer use him.

I have no idea why my new DME is ignoring what my insurance says they will pay for BUT they will have to accept what I am willing to pay for. I did not get in writing approval from insurance but they have spoken to the DME and told them the same thing.

I will accept certain replacement parts that I need or will eventually need but I refuse to pay for (even if only 10% of retail) for the replacement parts my DME wants to supply me with just so they can increase their revenue.

Most times when obtaining auth the insurance gives auth for all cpap supplies not just what you need at that time. There is usually a date range on the authorization, for instance a year. This does not mean that you have to order or receive this supplies just because there is an auth on file. Insurances do this 1) to avoid delay in getting auth if you needed something in a pinch..... For example, your water chamber starts leaking or you get a hole in your tubing 2) to avoid getting auth request for a filter on 1.2 then receiving another auth request on 1.10 for a cushion.

The mask parts are billed as follows: on a complete mask sealed in bag: the frame and headgear are billed separately. The cushion attached to the frame is included in the frame. Anytime a frame comes with a cushion attached, the cushion is included in the frame cost. Cushions packaged alone are billed individually. The exception is when a co pack is delivered; complete mask with an additional cushion of the same size in the same bag. With the co packs. A headgear, frame and only 1 cushion would be billed.

Most insurances cover 1 headgear every 6 months. A few cover headgear every 3 months. Even if insurance authorizes supplies, it does not mean that you can order any quantity you want, as there are allowables put forth by the insurance as to when they will pay. Additional supplies above the insurance company allowables are patient responsibility at the retail cost. Your best bet would be to call your insurance company and ask what the allowables are for the hcpcs codes for supplies. A7027, a7028, a7029, a7030, a7031, a7032, a7033, a7034, a7035, a7036, a7037, a7038, a7039, a4604, a7046.

Headgear is a7035.

After going back and reading your post, your insurance has authorized a frame (with cushion attached), 1 headgear and an additional cushion. So you would have 1 complete mask with an additional cushion.

I think billing separate parts is the proper procedure. Medicare allows that. I have always been charged separately for mask, and headgear. I think most insurance follows medicare standards. Your insurance only will pay the previously agreed amount regardless of what is charged.

I wanted a new mask. Because I still had a deductible to meet my DME wanted to charge me $350 for the mask. I didn't get the mask from them I bought it online from directhomemedical.com. The retail price for the whole bagged mask including head gear and cushion was $77. I submitted the bill to my insurance company and because it was out of network (I knew that) they paid 65% or $50.05 leaving me $26.50 OOP.

Since I can deduct my OOP medical expenses I really wouldn't have had to pay the $350 but I could not bring myself to to go with the outrageous DME charge.

bill-e wrote:I wanted a new mask. Because I still had a deductible to meet my DME wanted to charge me $350 for the mask. I didn't get the mask from them I bought it online from directhomemedical.com. The retail price for the whole bagged mask including head gear and cushion was $77. I submitted the bill to my insurance company and because it was out of network (I knew that) they paid 65% or $50.05 leaving me $26.50 OOP.

Since I can deduct my OOP medical expenses I really wouldn't have had to pay the $350 but I could not bring myself to to go with the outrageous DME charge.

perhaps if more people saw sense like you did, DMEs would stop raping peoples wallets.

LSAT wrote:I think billing separate parts is the proper procedure. Medicare allows that. I have always been charged separately for mask, and headgear. I think most insurance follows medicare standards. Your insurance only will pay the previously agreed amount regardless of what is charged.

It seems to me that there were numerous discussions some years ago about DMEs billing for complete masks by billing for the separate parts. Reading this thread jogged my memory that I hadn't noticed much of those discussions in recent times. Maybe nobody has been questioning it.

Never having gone through any local DMEs, I haven't had to think about it.


Den

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Sometimes when they itemize stuff, they separate parts that would have to be destroyed to come apart.
Makes little sense, but they are allowed.

chunkyfrog wrote:Sometimes when they itemize stuff, they separate parts that would have to be destroyed to come apart.
Makes little sense, but they are allowed.

I dunno, a little plastic epoxy goes a long way... I just epoxied the hooky arm of a quattro air frame back together today.... it's all nice and pretty and swoopy and light and .... fragile. *grumble*