What is required for a DME?

sleepinow · Post by **sleepinow** » Fri Aug 11, 2017 10:34 am

Hey I have ACA medicaid United Healthcare Community Plan. I called a DME a while ago but never went through with giving them the required needs. I have since forgot what the DME needs in order to satisfy sending me equipment. Do they need a script from my doctor? Does it have to be my specialist or can it be my regular doctor? Do they need sleep study proof? Does it vary with insurances? Sorry for all the questions.

Edit: Wish I still had their number... or where I placed it

Okie bipap · Post by **Okie bipap** » Fri Aug 11, 2017 10:53 am

A prescription is required for a complete mask. Cushions, head gear, hoses, filters, etc. do not require a prescription. Contact your insurance company and find out which local DMEs are in the network. Going outside of the network normally means more money out of pocket.

sleepinow · Post by **sleepinow** » Fri Aug 11, 2017 11:11 am

Alright thank you

HoseCrusher · Post by **HoseCrusher** » Fri Aug 11, 2017 11:14 am

Another perspective...

I recently purchased and received a complete Brevida mask from Amazon. No prescription needed.

Pugsy · Post by **Pugsy** » Fri Aug 11, 2017 11:18 am

DMEs will need what is required for proof by your insurance so that they get reimbursed if you are wanting insurance to pay anything.
Your insurance may require initial documentation of the need for any cpap stuff. Just a doctor's RX isn't necessarily enough to satisfy insurance requirements. It is enough to satisfy a DME in terms of purchase but the hitch is getting the insurance on board.
What sort of documentation might be needed can vary by insurance...some might want a copy of the sleep study and some might just be happy with office notes supporting whatever diagnosis you might have.
Probably should be contacting the actual insurance carrier and trying to see if they can tell you what they want.

For just mask stuff...probably won't be a huge hurdle...getting them to pay for a new machine (since you use ASV) might be a much bigger hurdle.

Okie bipap · Post by **Okie bipap** » Fri Aug 11, 2017 11:19 am

I have also purchased several masks and cushions on eBay for much less than what the DME charges. If you look at the pictures closely, many times a "mask frame" will be an entire mask. You cannot sell a mask on eBay, but if you sell the mask frame and the other parts just happen to be in the bag, no big deal.

DAYMX5 · Post by **DAYMX5** » Fri Aug 11, 2017 11:51 am

Before my Medicare kicked in I had an insurance co pay of 20% for supplies. The DMEs supplies were so inflated I could find stuff on e-bay for less than my 20% co-pay would be.

Janknitz · Post by **Janknitz** » Fri Aug 11, 2017 2:20 pm

DAYMX5 wrote:Before my Medicare kicked in I had an insurance co pay of 20% for supplies. The DMEs supplies were so inflated I could find stuff on e-bay for less than my 20% co-pay would be.

This may be true, but make sure that you understand that your 20% co-pay is 20% of what the INSURANCE company sets as the reasonable price, not the DME's fantasy price. A DME, for example, can charge $180 for a mask, but the insurer says the reasonable amount is $100 and pays 80% or $80. You only owe $20, which is 20% of $100, not $80 (the difference between the insurance and the retail price) and not even $36 which is 20% of $180. You might be able to find a mask for less than the 20% of the insurance price, but not always.

OTOH, not having to hassle with the DME by buying stuff on your own is priceless!

flightco · Post by **flightco** » Sun Aug 13, 2017 8:03 am

Janknitz wrote:
DAYMX5 wrote:Before my Medicare kicked in I had an insurance co pay of 20% for supplies. The DMEs supplies were so inflated I could find stuff on e-bay for less than my 20% co-pay would be.
This may be true, but make sure that you understand that your 20% co-pay is 20% of what the INSURANCE company sets as the reasonable price, not the DME's fantasy price. A DME, for example, can charge $180 for a mask, but the insurer says the reasonable amount is $100 and pays 80% or $80. You only owe $20, which is 20% of $100, not $80 (the difference between the insurance and the retail price) and not even $36 which is 20% of $180. You might be able to find a mask for less than the 20% of the insurance price, but not always.

OTOH, not having to hassle with the DME by buying stuff on your own is priceless!

Both are excellent points.

LSAT · Post by **LSAT** » Sun Aug 13, 2017 10:59 am

xxyzx wrote:
sleepinow wrote:Hey I have ACA medicaid United Healthcare Community Plan. I called a DME a while ago but never went through with giving them the required needs. I have since forgot what the DME needs in order to satisfy sending me equipment. Do they need a script from my doctor? Does it have to be my specialist or can it be my regular doctor? Do they need sleep study proof? Does it vary with insurances? Sorry for all the questions.

Edit: Wish I still had their number... or where I placed it
=====

you need to get a DME on their current approved list ...Check to see who is in Network

all they need is a complete Rx from any doctor... A doctor will not issue an RX without a Sleep Study

insurance may want a sleep study before honoring the Rx and paying for it...Insurance will approve a Sleep Study if recommended by a doctor...will not approve CPAP without it.

What is required for a DME?

What is required for a DME?

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