What does Medicare pay for cpap masks

[Restless1]

My husband got a new Breeze cpap mask with 3 nasal pillows from Apria, and the sheet says it cost $1,556. My husband has Medicare as primary insurance, and Cigna is his secondary. However, he has a new $300 deductible for Cigna which started 7/1/10 so I am concerned what we will have to pay.

We could get the same mask at cpap.com for $85 plus postage. If we bill Medicare ourselves and would pay the difference, we may be better off than going with Apria.

Apria said that the $1,556 is just the market price, and Medicare will discount it; but how do I find out what they will discount it to?

My husband will not use this new mask until he finds out what it is going to cost us, which could be 2 to 3 weeks waiting for Medicare to process it.

Also, why do people charge so much when they know Medicare isn't going to pay that? Is it so they can write the difference off on their taxes and not pay taxes?

Thank you for any help.

Restless1

[Jaylee]

Wait, $1500 for a mask? Is that a typo?

[Restless1]

That was not a typo. It was $1,556. I called Apria just now, and they said Medicare would allow $168.14; and I would have to pay 20% of that, which would be $33.63, which is less than buying it outright from cpap.com.

I don't understand why they bill Medicare such high prices when they know they won't pay them. It must be so they can write off the difference for tax purposes. Does anyone know?

[Janknitz]

LOL, it cracks me up what DME's put down as the "actual cost" for items. Don't worry, Medicare sets the price and you only have to pay 20% of Medicare's price. Or, if the DME doesn't "accept assignment" the DME can charge you up to 15% above the Medicare allowable.

If you tell me what state you live in, I can look up the exact price Medicare bases its reimbursement on. Medicare allows between $90 and $106.46 for the mask and you are responsible for 20% of that, or if the DME doesn't "accept Medicare assignment" up to 15% above the Medicare allowable. For nasal pillows, the range is $21.85 to $25.71 per pillow--you pay between 20% and an addtional 15% depending on the DME. [Note, these are the January allowables and I haven't checked to see if these were increased in July]

$1,556

Send the bill to your congressman, just for giggles.

What they are doing is trying to establish their "costs" so that when Medicare sets the allowables they go higher. Especially since Medicare is going to try to cut DME CPAP reimbursement.

BUT, pity the poor person without insurance who gets billed that much, then Crapria will give them a good discount of say 25% (Whoopee!!!!!!!!!)

[Restless1]

I live in Illinois. Is there a web site that you look this up on? If so, could you give it to me.

Thanks.

[Janknitz]

I still see the Medicare Allowable as of July 1, 2010 as $25.71 for each nasal pillow and $106 for a nasal mask in Illinois. I'm not sure where your DME is getting the $168.14 figure (maybe 1 mask, 2 extra sets of pillows, and sales tax????). Since they seem to be accepting assignment, I'd wait until they bill Medicare and then pay the 20% indicated on the EOB--though Crapria usually wants your out of pocket share up front. Make them show you where those figures come from--getting a refund if you overpay your share is a PITA.

Yes, there is a website.
Go to: http://www.cms.gov/DMEPOSFeeSched/LSDME ... rPage=2000 then download the format of your choice.

The codes are as follows:
E0601 Continuous airway pressure (CPAP) device (e.g. smart CPAP, auto CPAP, CPAP)
E0561 Humidifier, used with CPAP device
E0562 Heated humidifier, used with CPAP device
A7033 Nasal pillows/seals, replacement for nasal application device, pair
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 Headgear, used with CPAP device
A7036 Chin strap, used with CPAP device
A7037 Tubing, used with CPAP device
A7038 Disposable filter used with CPAP device
A7039 Non-disposable filter used with CPAP device
A7044 Oral interface used with positive airway pressure device
A7046 Humidifier chamber - replacement
E0470 Bilevel
E0471 Bilevel with backup rate
E1399 Miscellaneous durable medical equipment items

[Kevin G.]

I believe they charge these prices because they are engaged in predatory pricing. If the insurance company is smart enought to know what a reasonable price is they accept it and make a small profit. If either the patient does not have insurance or if the insurance company does not have its act together then the DME collects a windfall. If there was a monopoly then this would be illegal.

[LoQ]

I believe they charge these prices because they are engaged in predatory pricing. If the insurance company is smart enought to know what a reasonable price is they accept it and make a small profit. If either the patient does not have insurance or if the insurance company does not have its act together then the DME collects a windfall. If there was a monopoly then this would be illegal.

Sort of seems like gouging. I know that when there is some kind of emergency, like a hurricane that has destroyed the water supply or any other critical supply, people try to sell drinking water at outrageously high prices. I think that kind of price gouging may be illegal, because people have to have water to survive.

I dunno for sure, but it just seems kinda wrong to me. If it's not illegal, it certainly is indecent.

[DreamOn]

I still see the Medicare Allowable as of July 1, 2010 as $25.71 for each nasal pillow and $106 for a nasal mask in Illinois. I'm not sure where your DME is getting the $168.14 figure (maybe 1 mask, 2 extra sets of pillows, and sales tax????).

They are probably billing for the headgear separately too, which is standard procedure for the DMEs:

A7035 Headgear, used with CPAP device

[Wulfman]

I live in Illinois. Is there a web site that you look this up on? If so, could you give it to me.

Thanks.

Here are some "cash money" prices.

https://www.cpap.com/productSearch.php?query=Breeze


Den

[Restless1]

Thank you everyone.

Restless1