DME wants to know why I want a new mask every 4 months

buckeyered · Post by **buckeyered** » Mon Nov 27, 2006 6:05 pm

I called to see if I could get one more mask before my insurance cancels on Dec 31st and they asked why I want a new mask every four months? They said they have people who use the same mask for years. I had to scratch my head on this one since they make their money off me getting the equipment from them or is it that they would make more by repairing masks and parts?
Anyway I told them that my insurance was going to end and I wanted to try and get an oracle before it does but she said not till January, so I will order it from cpap.com

mattman · Post by **mattman** » Mon Nov 27, 2006 6:11 pm

If it's prior to the expected utilization for your particular insurance and plan then when the claim is submitted to the insurance company the provider has submit extra documentation to explain why the over-utilization is needed.

mattman

buckeyered · Post by **buckeyered** » Mon Nov 27, 2006 6:16 pm

my current insurance pays for about half of a new mask every 4 months, not much of a bargain for me since they jack the price up but it does save me a little, all my other masks I have tried I paid for out of my pocket.

whatrdreamsmadeof · Post by **whatrdreamsmadeof** » Mon Nov 27, 2006 6:44 pm

You deal with them every 4 months because you have a need to be harassed.........that's what i told my DMe they are useless. Sorry your in the same DME boat "Titanic"

buckeyered · Post by **buckeyered** » Mon Nov 27, 2006 6:51 pm

If I do get medical coverage next year I am cleaning the slate and starting over with a new sleep Dr. and a new DME, my ENT has washed his hands of me since I refuse anymore surgeries.

whatrdreamsmadeof · Post by **whatrdreamsmadeof** » Mon Nov 27, 2006 6:55 pm

I've been to two specialist and the DME, I washed my hands of all three, get my info, here and buy my equipment from cpap.com........less stress is better........good luck

gecko1977a · Post by **gecko1977a** » Tue Nov 28, 2006 7:57 am

unfortunatly my insurance will pay 100% if i go through apria, so I will go through their horrid service.

They made a bad mistake the other week - they sent me a customer survey...... oh did i write some comments.

Julie · Post by **Julie** » Tue Nov 28, 2006 10:08 am

Hi, just wondering if there isn't confusion about getting a new mask every 4 mos. (which does seem excessive to me!) vs replacing the silicone - which does make sense.

buckeyered · Post by **buckeyered** » Tue Nov 28, 2006 10:15 am

I have purchased more masks out of my pocket than the insurance has paid for. My DME does not allow me to try out a mask and then hand it back so when I get my 1 mask every four months from them I am stuck with it even if it doesn't work for me so I don't feel bad about getting a mask every four months from them.

yardbird · Post by **yardbird** » Tue Nov 28, 2006 10:39 am

Most insurance providers follow teh Medicare guidelines for equipment replacement. Medicare's allowable replacement frequency for masks is one every 90 days. Yup...

A7034NU Mask 1 every 90 days

Here are a bunch of others...

Code: Select all

A7032NU  	Mask Cushion  	2 every 30 days
A7044NU 	Oracle 	        1 every 90 days
A7033NU 	Nasal Pillows 	 2 pairs every 30 days
A7035NU 	Headgear 	      1 every 180 days
A7036NU 	Chinstrap 	     1 every 180 days
A7037NU 	Tubing 	       1 every 30 days
A7039NU 	Non-Disposable Filters 	1 every 180 days
A7038NU 	Disposable Filters 	2 every 30 days

WindFlyer · Post by **WindFlyer** » Tue Nov 28, 2006 10:53 am

What I don't understand is why my DME insists on pricing my mask and headstraps separately. When I buy a mask online it's all one price that includes straps. When I buy from DME, mask alone would be cheaper, but with the $80 headstraps it brings it up to the same price I would pay online. That's after insurance. If I buy online and then submit a claim, I wind up paying less than I would through DME.

mattman · Post by **mattman** » Tue Nov 28, 2006 11:42 am

WindFlyer wrote:What I don't understand is why my DME insists on pricing my mask and headstraps separately.

It's because the insurance companies require them to be listed seperately.

mattman

yardbird · Post by **yardbird** » Tue Nov 28, 2006 11:51 am

WindFlyer,
I just recently got a ComfortLite2 from a local DME. I have 50% co-pay using a local DME. Tehy did bill 2 codes for the mask. Basically they are billing a mask code and a headgear code and in teh MANUFACTURER'S LITERATURE it shows them that when you sell this mask, you bill these 2 codes. I'm not sure why there is no MASK COMPLETE single code, but.... be that as it may. I could have bought my mask from cpap.com where I normally shop, but wanted to give this DME a try. I found out SO much...

Know what is ALLOWABLE for a xPAP machine? I'm talking ALLOWABLE now... they can BILL whatever they want, but what is allowable is what they'll get paid.

ONE THOUSAND THREE HUNDRED EIGHTY FIVE DOLLARS AND FIFTEEN CENTS !!!

That's right... $1385.15. My copay on that would be $692.58

On the other hand, I can buy a new machine from cpap.com for... oh let's say $703.90 (REMStar auto with cflex and heated humidifier)

Now... I bill my insurance based on the new machine code. I bill them for $1,385.15. They'll only pay half of that (50% co-pay...remember?) so they send me a check for $692.58. Now $703.90 - 692.58 is $11.32. That's my out of pocket instead of paying the DME $692.58. Quite a difference.

DME wants to know why I want a new mask every 4 months

DME wants to know why I want a new mask every 4 months

tell them

no use

Mask

Additional Comments: 16 cm x 14 cm

Mask

Additional Comments: 16 cm x 14 cm

Mask

Additional Comments: 16 cm x 14 cm

Mask	Humidifier