You know you are getting the run around when your DME claims that it is necessary for your physician to approve your request for replacement, yes, replacement pillows and cushions. As if our doctors don't have enough to do!
Grrrrr At least my husband is on Medicare and we can switch to cpap for seniors. I'll have to see what it will take for my insurance (Tricare Prime) to cover cpap purchases.
Thanks for the space to vent. I almost feel better already.
Grrrrrrrr
Susan
You know you are getting the run around when
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Perchancetodream
- Posts: 434
- Joined: Mon Aug 13, 2007 7:41 pm
- Location: 29 Palms, CA
You know you are getting the run around when
"If space is really a vacuum, who changes the bag?" George Carlin
Hopefully you already have a copy of the script, in hand!!
I assume this is not a national DME?
I assume this is not a national DME?
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I have no doubt, how I sleep affects every waking moment.
I am making progress-NOW I remember that I can't remember
If this isn’t rocket science why are there so many spaceshots?
Be your own healthcare advocate!
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Perchancetodream
- Posts: 434
- Joined: Mon Aug 13, 2007 7:41 pm
- Location: 29 Palms, CA
Unfortunately, it is one of the new national chains: SleepMed.
They fought me over replacement cushions in November and I mistakenly thought they had gotten their act straightened out. But apparently not, since they are now requiring approval in addition to the original Rx.
They flat out turned me down the first time I requested new pillows in Oct so I ordered mine directly from cpap.com and paid out of my own pocket. I think I will submit a claim and see what my carrier will pay for those. It would certainly be less aggravating, even if it is more expensive.
Susan
They fought me over replacement cushions in November and I mistakenly thought they had gotten their act straightened out. But apparently not, since they are now requiring approval in addition to the original Rx.
They flat out turned me down the first time I requested new pillows in Oct so I ordered mine directly from cpap.com and paid out of my own pocket. I think I will submit a claim and see what my carrier will pay for those. It would certainly be less aggravating, even if it is more expensive.
Susan
"If space is really a vacuum, who changes the bag?" George Carlin
Perchance, get a letter (or email) from your insurance company to the effect that replacement items, e.g., masks, cushions, hoses, filters, etc., do not require a prescription. Mail a copy of that wih a letter, return receipt requested, to your DME. Or bring it in. Have a manager/supervisor _sign_ an additional copy that you bring with you. If/when the DME pulls that trick again, write a complaint to your insurance company with a copy of the DME's signed acceptance.
Then there's the whole issue of replacement _period_. Most insurance companies just use Medicare guidelines for all their plans, even non-Medicare. Here they are:
A7030 full face mask 1/3 months
A7031 replacement cushion for FF mask 1/1 month
A7034 nasal mask 1/3 months
A7032 replacement cushion for nasal mask 2/1 month
A7035 headgear 1/6 months
A7036 chinstrap 1/6 months
A7037 tubing 1/3 months
A7038 disposable filter (cotton) 2/1 month
A7039 non-disposable filter (foam) 1/6 months
A7046 replacement water chamber for humidifier 1/6 months
etc.
Don't expect a DME to volunteer that you're eligible for anything. Unless you're on a plan where you pay for everything.
Then there's the whole issue of replacement _period_. Most insurance companies just use Medicare guidelines for all their plans, even non-Medicare. Here they are:
A7030 full face mask 1/3 months
A7031 replacement cushion for FF mask 1/1 month
A7034 nasal mask 1/3 months
A7032 replacement cushion for nasal mask 2/1 month
A7035 headgear 1/6 months
A7036 chinstrap 1/6 months
A7037 tubing 1/3 months
A7038 disposable filter (cotton) 2/1 month
A7039 non-disposable filter (foam) 1/6 months
A7046 replacement water chamber for humidifier 1/6 months
etc.
Don't expect a DME to volunteer that you're eligible for anything. Unless you're on a plan where you pay for everything.
Suggest you research first. The issue may be with the DME distributor, or it may be with the insurer. Some insurers do require prescription - or at least certification - by the prescribing physician, before they will reimburse the DME for ordinary replacement equipment.
My DME was very helpful in telling me precisely what items, and on what frequency, my insurer (BCBS) would cover. When I called the insurer, they would give me virtually no specific information at all - only that everything was dependent on a certification of "medical necessity" from my doctor.
Blaming the DME is usually easiest (and often justified), but differing insurance rules often tie their hands, too.
My DME was very helpful in telling me precisely what items, and on what frequency, my insurer (BCBS) would cover. When I called the insurer, they would give me virtually no specific information at all - only that everything was dependent on a certification of "medical necessity" from my doctor.
Blaming the DME is usually easiest (and often justified), but differing insurance rules often tie their hands, too.
Velbor wrote:
> Some insurers do require prescription - or at least
> certification - by the prescribing physician, before they will
> reimburse the DME for ordinary _replacement_ equipment.
Some will -- if they can pull it off.
It is difficult to believe that any DME or insurer can _demand_ a prescription to order a cotton air filter, 2/month, EVERY MONTH! I don't believe it.
> When I called the _insurer_, they would give me virtually no
> specific information at all
Then clearly you got a poor Customer Service rep.
So you can't believe a word they said.
> only that everything was dependent on a certification
> of "medical necessity" from my doctor.
Not believeable for _replacement_ items like cotton air filters. What doctor wants to take the time EVERY MONTH for _every OSA patient_ to write a prescription for a 99 cent cotton air filter?
Call that customer service rep back. Say "Show me where it says what you told me in print in my contract?" Here's the clue: if they can't show that to you in writing in your contract, then it's not a rule! It could be a belief. Or an opinion. Rules that affect eligibility for services or products need to be printed.
You yourself said "they [insurer] would give me virtually no specific information at all." So why would you believe them when they tell you that you need a prescription for a 99 cent filter?
Do you work for a capitated DME?
More believeable is that the CS rep you got doesn't know _anything_ about DME and was reading the "medical necessity" clause out of the DME section of the contract as it pertains to _big ticket items_ like a machine or a sleep study. You can bet _that's_ in writing! Just ask them to send it to you in writing where it says a prescription every month for every replacement item (filter, cushion, hose, whatever).
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CPAPopedia Keywords Contained In This Post (Click For Definition): hose, DME, Prescription
> Some insurers do require prescription - or at least
> certification - by the prescribing physician, before they will
> reimburse the DME for ordinary _replacement_ equipment.
Some will -- if they can pull it off.
It is difficult to believe that any DME or insurer can _demand_ a prescription to order a cotton air filter, 2/month, EVERY MONTH! I don't believe it.
> When I called the _insurer_, they would give me virtually no
> specific information at all
Then clearly you got a poor Customer Service rep.
So you can't believe a word they said.
> only that everything was dependent on a certification
> of "medical necessity" from my doctor.
Not believeable for _replacement_ items like cotton air filters. What doctor wants to take the time EVERY MONTH for _every OSA patient_ to write a prescription for a 99 cent cotton air filter?
Call that customer service rep back. Say "Show me where it says what you told me in print in my contract?" Here's the clue: if they can't show that to you in writing in your contract, then it's not a rule! It could be a belief. Or an opinion. Rules that affect eligibility for services or products need to be printed.
You yourself said "they [insurer] would give me virtually no specific information at all." So why would you believe them when they tell you that you need a prescription for a 99 cent filter?
Do you work for a capitated DME?
More believeable is that the CS rep you got doesn't know _anything_ about DME and was reading the "medical necessity" clause out of the DME section of the contract as it pertains to _big ticket items_ like a machine or a sleep study. You can bet _that's_ in writing! Just ask them to send it to you in writing where it says a prescription every month for every replacement item (filter, cushion, hose, whatever).
_________________
CPAPopedia Keywords Contained In This Post (Click For Definition): hose, DME, Prescription
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Perchancetodream
- Posts: 434
- Joined: Mon Aug 13, 2007 7:41 pm
- Location: 29 Palms, CA
I know that my insurer will pay for whatever is medically necessary and that the original Rx included a little box for replaceable items that was checked and signed by my physician.
This is the same DME that I had to refer to the Medicare website for codes and max replacement (my husband is on Medicare). They swore that cushions & pillows were only replaceable every six months.
I suspect that what is going on is that this DME wants to be able to keep the costs low so that they will become a Medicare provider when Medicare starts to contract exclusively with a couple of national firms. The easiest way to keep costs down is to drag their feet on filling replacement requests.
Unfortunately for me, the only other DME in the area is Apria and from what I have read here, that may mean going from the frying pan into the fire.
cpap.com is not a network provider, so they will only reimburse 75% and I don't think the supplemental policy will pay anything. Currently, between the two coverages, 100% is paid. But it still might be worth using just to avoid the heartburn.
Susan
This is the same DME that I had to refer to the Medicare website for codes and max replacement (my husband is on Medicare). They swore that cushions & pillows were only replaceable every six months.
I suspect that what is going on is that this DME wants to be able to keep the costs low so that they will become a Medicare provider when Medicare starts to contract exclusively with a couple of national firms. The easiest way to keep costs down is to drag their feet on filling replacement requests.
Unfortunately for me, the only other DME in the area is Apria and from what I have read here, that may mean going from the frying pan into the fire.
cpap.com is not a network provider, so they will only reimburse 75% and I don't think the supplemental policy will pay anything. Currently, between the two coverages, 100% is paid. But it still might be worth using just to avoid the heartburn.
Susan
"If space is really a vacuum, who changes the bag?" George Carlin
Apria tells me that they will only bill Medicare every six months for mask replacements, filters, hoses etc. And Medicare only allows a one month spply of pillos or filters to be sent at one time. Then the guy starts some song and dance about assignment of benefits. When I buy out of pocket from Apria (and pay Apria prices), they "help" me bill Medicare. They are not a participating Medicare provider. Medicare will pay for supplies monthly.
My secondary will pay for supplies monthly after Medicare pays their part.
Apria is the fly in this ointment.
My secondary will pay for supplies monthly after Medicare pays their part.
Apria is the fly in this ointment.
Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof.....Galbraith's Law
krosseau, you are saying that you have medicare, correct?
See the replacement period schedule that I posted above. That is what medicare allows. It is very important to know that schedule. DMEs will _often_ give you the wrong information about replacement periods.
Many/most insurance companies use that schedule even for their non-medicare customers, simply because it is so common.
> When I buy out of pocket from Apria (and pay Apria prices)
1. Don't buy out of pocket unless you absolutely have to.
2. If you have to, buy from the least expensive place, which is usually the internet.
> Apria tells me that they will only bill Medicare every six
> months for mask replacements, filters, hoses etc.
OK.
> And Medicare only allows a one month spply of pillows or
> filters to be sent at one time.
That's true. I'm just not sure how those two points relate. Is the bottom line that Apria will only get you one month's supply and that you are paying out of pocket for the other five months?
> Apria is the fly in this ointment.
You'e being too kind. Are there other DMEs in your area? I don't have medicare. Any medicare people here who can suggest alternates for krousseau? I see your ID says "Calif motherlode", so you're in the foothills?
See the replacement period schedule that I posted above. That is what medicare allows. It is very important to know that schedule. DMEs will _often_ give you the wrong information about replacement periods.
Many/most insurance companies use that schedule even for their non-medicare customers, simply because it is so common.
> When I buy out of pocket from Apria (and pay Apria prices)
1. Don't buy out of pocket unless you absolutely have to.
2. If you have to, buy from the least expensive place, which is usually the internet.
> Apria tells me that they will only bill Medicare every six
> months for mask replacements, filters, hoses etc.
OK.
> And Medicare only allows a one month spply of pillows or
> filters to be sent at one time.
That's true. I'm just not sure how those two points relate. Is the bottom line that Apria will only get you one month's supply and that you are paying out of pocket for the other five months?
> Apria is the fly in this ointment.
You'e being too kind. Are there other DMEs in your area? I don't have medicare. Any medicare people here who can suggest alternates for krousseau? I see your ID says "Calif motherlode", so you're in the foothills?
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Perchancetodream
- Posts: 434
- Joined: Mon Aug 13, 2007 7:41 pm
- Location: 29 Palms, CA
If you are on Medicare, why not use the Bill My Insurance service of cpap.com (or is it cpap for seniors)? They will bill medicare for you and not argue with you if your needs don't exceed the max allowable.
Susan
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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, medicare
Susan
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CPAPopedia Keywords Contained In This Post (Click For Definition): cpap.com, medicare
"If space is really a vacuum, who changes the bag?" George Carlin
Yes the comments about what Medicare allows and what Apria policy is means that you can't get monthly replacements from Apria without purchasing out of pocket.
I do buy elsewhere and do not order replacement pillows unless absolutely needed.
When I called cpapforseniors, the person I spoke to stated that they would not start sending replacements/billing Medicare until I had not received any supplies from other sources (that billed Medicare) for six months. My last Medicare billing for CPAP supplies was in late November. I recently ordered what I need to finish the six month "waiting period". I do intend to try sending that claim to my secondary-but it isn't clear that they pay until Medicare has paid-and Medicare can't be billed.
I do buy elsewhere and do not order replacement pillows unless absolutely needed.
When I called cpapforseniors, the person I spoke to stated that they would not start sending replacements/billing Medicare until I had not received any supplies from other sources (that billed Medicare) for six months. My last Medicare billing for CPAP supplies was in late November. I recently ordered what I need to finish the six month "waiting period". I do intend to try sending that claim to my secondary-but it isn't clear that they pay until Medicare has paid-and Medicare can't be billed.
Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof.....Galbraith's Law
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