DME Bill

[atab]

Got my insurance statement for the equipment billed by DME.
It has:
Billed Allowed
E0601 CPAP Device 115.66 95.22
E0562 Humidifier, Heated 340.75 281.10

Why is Airsense 10 Auto only $95.22, whereas humidifier charge seems normal?

[LSAT]

This is my guess.....If your insurance requires a rental period before you own the machine, the $95 is what they are billing for the rental. If the Insurance allowable is less you will be responsible for a co-pay 20%(?) of their allowable amount. It is common for the Humidifier to be fully billed up front. If the DME billed $281 for the humidifier, the insurance allowable amount may be much less and you are responsible for a co-pay of 20%(?). Wait for your statement from the insurance company to see how much they paid and how much you are responsible for.

[Guest]

Got my insurance statement for the equipment billed by DME.
It has:
Billed Allowed
E0601 CPAP Device 115.66 95.22
E0562 Humidifier, Heated 340.75 281.10

Why is Airsense 10 Auto only $95.22, whereas humidifier charge seems normal?

W/o knowing who your insurance is or if they use a 13 month rental for the cpap here are some numbers.
95.22 * 13 = 1237.86
and the humidifier a one time paid in full 281.10
no mask no hose no filters
total = 1518.96 Does that make you feel better?

Give your insurance a call to see if they are using a rental period and if you have a co-pay to add to that total.

[JimW159]

Why is Airsense 10 Auto only $95.22, whereas humidifier charge seems normal?

What strikes me as abnormal is the fact that you cannot buy an AirSense 10 WITHOUT a humidifier. Are they using a separate coding for the APAP and humidifier to jack up the total cost to about double the cost from cpap.com?

[Janknitz]

What strikes me as abnormal is the fact that you cannot buy an AirSense 10 WITHOUT a humidifier. Are they using a separate coding for the APAP and humidifier to jack up the total cost to about double the cost from cpap.com?

Yep.

[Hopeful50]

The way it worked with my insurance (Medicare & a Medigap policy) was the "humidifier" billing was actually for the removable/replaceable (every 6 months) humidifier tank.

[JimW159]

The way it worked with my insurance (Medicare & a Medigap policy) was the "humidifier" billing was actually for the removable/replaceable (every 6 months) humidifier tank.

If your replacement tub was costing Medicare and your Medigap plan nearly $300 every six months for a part that retails for about $30 at the most, I would be screaming "Medicare fraud" at the top of my lungs. If they were to bill with the same E0562 Humidifier code each time a new tub was provided, that would be an unconscionable overbilling.

[Pugsy]

For years humidifiers have always been separate devices that are billed for separately. That's why there is a separate HCPCS billing code for the heated humidifier. ResMed AirSense/AirCurve devices now have the humidifier built in but there's no HCPCS billing code available for a xpap machine that has the humidifier built in so DMEs still separate the charges.
Most of the other machines still offer the humidifier separately...like the Respironics new DreamStation.
Until there is a separate HCPCS billing code for a xpap machine that has the humidifier built in DMEs are well within their "rights" to bill the humidifier part separately. It's just the way it is and nothing we can do about it.

Puts a whole new twist on things when someone fails compliance and has to return the machine that they have already paid a separate fee for the humidifier up front during the first month. They own the humidifier...at least technically...but there's no way of keeping the humidifier if they are forced to return the blower since it is built in.

Got my insurance statement for the equipment billed by DME.

What is your insurance plan? Do you have a deductible? If you do have a new deductible after Jan 1 then it is very possible that you will have to pay the full allowed amount through any "rent to own" months.
Have you checked with your insurance company to find out how they handle cpap machine purchases?
If it is "rent to own" you need to find out how many months before this monthly fee ends. If you have Medicare it's 13 months and there is a small deductible after the first of the year before Medicare starts paying their 80%. If it's not Medicare there could be any number of scenarios so you need to find out from your insurance company what their policy might be.

[SewTired]

Puts a whole new twist on things when someone fails compliance and has to return the machine that they have already paid a separate fee for the humidifier up front during the first month. They own the humidifier...at least technically...but there's no way of keeping the humidifier if they are forced to return the blower since it is built in.

FWIW, when I bought my machine through Medicare, Lincare charged me $10 for the humidifier. So, that matches with the earlier poster who said they may just charge you for a 'bin.' Not sure if all DMEs follow that plan. One thing though, unlike regular insurance plans, you don't get stuck ponying up for the deductible for your machine in January if your rental goes past it (as it would at 13 months). I vaguely remember someone pointing out that durable medical equipment is not subject to the annual deductible.

[JimW159]

For years humidifiers have always been separate devices that are billed for separately. That's why there is a separate HCPCS billing code for the heated humidifier. ResMed AirSense/AirCurve devices now have the humidifier built in but there's no HCPCS billing code available for a xpap machine that has the humidifier built in so DMEs still separate the charges.

ResMed has published guidance to their DME customer base that deals specifically with integrated systems under Medicare. http://www.resmed.com/us/dam/documents/ ... gories.pdf
The unfortunate situation is that they don't seem to address how to ethically deal with this circumstance. As it stands, it seems each DME MAC (Durable Medical Equipment Medicare Administrative Contractor) must interpret it according to their own policies. One thing that could contribute to abuse in using separate codes is in the payment category related to E0562 Heated Humidifier: "Inexpensive and Routinely Purchased." For one who is passing judgement on thousands of payment claims, this alone might push the charge forward without challenge or pause.

[bwexler]

It is important to understand your insurance companies policy on renting or owning your CPAP.
When I got my PRS1 960 my insurance required 10 months of rental than I owned it. They had an interesting twist, any items under $500 had no copayment. The monthly rental was around $440 so I got my machine with zero copayments.
My current insurance is perpetuall rent. You never own DME. It doesn't take long for just the copayments to equal the price at CPAP dot com.

[atab]

Yes, now I remember they were saying about a rental. When asked to bill the purchase price, they said the insurance won't allow that. By the way the total bill, with headgear, additional pillows, service etc. is about $800.

My insurance is little complicated. DME services has $1500 or so deductible. Then there is another insurance (HRA) which pays deductible. HRA doesn't care whether it is coming from DME or something else. They pay up to $3000. However, main insurance deductible goes up to $5000. So, there is a doughnut hole of $2000, which I have to pay. When I called HRA, they said about $350 is left before they stop paying. So, half of this and all remaining rental will be out of my pocket.

atab

[Pugsy]

For years humidifiers have always been separate devices that are billed for separately. That's why there is a separate HCPCS billing code for the heated humidifier. ResMed AirSense/AirCurve devices now have the humidifier built in but there's no HCPCS billing code available for a xpap machine that has the humidifier built in so DMEs still separate the charges.

ResMed has published guidance to their DME customer base that deals specifically with integrated systems under Medicare. http://www.resmed.com/us/dam/documents/ ... gories.pdf
The unfortunate situation is that they don't seem to address how to ethically deal with this circumstance. As it stands, it seems each DME MAC (Durable Medical Equipment Medicare Administrative Contractor) must interpret it according to their own policies. One thing that could contribute to abuse in using separate codes is in the payment category related to E0562 Heated Humidifier: "Inexpensive and Routinely Purchased." For one who is passing judgement on thousands of payment claims, this alone might push the charge forward without challenge or pause.

I think that is the same humidifier HCPCS code that has been used for years and years and years by everyone and isn't limited to ResMed and their "integrated" humidifier.
It's the same code that is used by DMEs whether they are supply ResMed, Respironics, F & P, DeVilbiss or whatever machine...which all have separate humidifiers available as a separate entity.

I don't see Medicare (or anyone else) coming up with a new machine billing code that includes humidifier anytime in the foreseeable future. Maybe when every brand has the humidifier built in like ResMed....maybe then it will happen.
Until then it is what it is and not much we can do about it.

[JimW159]

For years humidifiers have always been separate devices that are billed for separately. That's why there is a separate HCPCS billing code for the heated humidifier. ResMed AirSense/AirCurve devices now have the humidifier built in but there's no HCPCS billing code available for a xpap machine that has the humidifier built in so DMEs still separate the charges.

ResMed has published guidance to their DME customer base that deals specifically with integrated systems under Medicare. http://www.resmed.com/us/dam/documents/ ... gories.pdf
The unfortunate situation is that they don't seem to address how to ethically deal with this circumstance. As it stands, it seems each DME MAC (Durable Medical Equipment Medicare Administrative Contractor) must interpret it according to their own policies. One thing that could contribute to abuse in using separate codes is in the payment category related to E0562 Heated Humidifier: "Inexpensive and Routinely Purchased." For one who is passing judgement on thousands of payment claims, this alone might push the charge forward without challenge or pause.

I think that is the same humidifier HCPCS code that has been used for years and years and years by everyone and isn't limited to ResMed and their "integrated" humidifier.
It's the same code that is used by DMEs whether they are supply ResMed, Respironics, F & P, DeVilbiss or whatever machine...which all have separate humidifiers available as a separate entity.

I don't see Medicare (or anyone else) coming up with a new machine billing code that includes humidifier anytime in the foreseeable future. Maybe when every brand has the humidifier built in like ResMed....maybe then it will happen.
Until then it is what it is and not much we can do about it.

As you say, "...not much we can do about it." My point was the opportunity for the unscrupulous out there to take advantage and blatantly overbill. In which case, I would suggest observing and reporting if seen; cry foul if a foul it is. There is simply no reason for these same sellers to gain obscene profits through chinks in the system. This is especially true with Medicare, it is already under enormous attack as it is.

[atab]

What is your insurance plan? Do you have a deductible? If you do have a new deductible after Jan 1 then it is very possible that you will have to pay the full allowed amount through any "rent to own" months.
Have you checked with your insurance company to find out how they handle cpap machine purchases?
If it is "rent to own" you need to find out how many months before this monthly fee ends. If you have Medicare it's 13 months and there is a small deductible after the first of the year before Medicare starts paying their 80%. If it's not Medicare there could be any number of scenarios so you need to find out from your insurance company what their policy might be.

Pugsy, sorry I couldn't respond to this. I did not think about these and just followed the easy path. Not a good way to do that. My insurance details were given in my earlier post. I am not on Medicare. Since a portion of this is paid by my HRA, I think I will break-even with buying this independently.

I always find it a lot of hassle to buy stuff myself. Cpap.com needs a prescription. In my case the doctor sends the prescription directly to DME. I know, I can ask for the prescription. But I work about 35 miles away from my home (40 miles from Dr's office), I find these things are hard to do. Dr is really good, lets me adjust pressures and so on, but her staff is useless. Most of the time they don't pick the phone. I remember the DME saying that my insurance pay for rental, I thought they said 12 months, but it could be 13 months. I forgot that when I saw the bill and did the original post.

atab