Replies to This Discussion

Permalink Reply by Daniel on July 7, 2009 at 4:34pm

Ahh, the Catch-22 of the Durable Medical Equipment Providers...

Since there is no insurance code for the forehead support cushion, there is no way for a DME to get paid by an insurance company for the part. Therefore, they generally do not stock the part, even though it can be ordered from the manufacturer.

There are only three items associated with a traditional nasal mask that are recognized by the insurance industry - the Mask Assembly, the Nasal Cushion, and the Headgear. If your provider gives you any other mask part, they are supposed to bill code E1399 - miscellaneous DME supplies. It's kind of pointless though, since the insurance will pay $0 when they receive a miscellaneous item claim.

The solution is absurd. The forehead support cushion is considered to be part of the Mask Assembly. Therefore, if the cushion is worn out, it's time for a new mask. Hopefully, the mask is more than three months old, which would qualify you to get a replacement mask. If it isn't, then your provider could theoretically return the mask to the manufacturer for a warranty replacement. Most manufacturers will warrant their masks for 90 days.

Daniel

• ▶ Reply

Permalink Reply by Mike on July 7, 2009 at 5:55pm

great insight, Daniel, thanks -- ballpark range, about how much are the items if bought by the DME from the manufacturer? maybe a user in need can just pay cash to their DME to order the part on their behalf if not too expensive.

Daniel said:

Ahh, the Catch-22 of the Durable Medical Equipment Providers...

Since there is no insurance code for the forehead support cushion, there is no way for a DME to get paid by an insurance company for the part. Therefore, they generally do not stock the part, even though it can be ordered from the manufacturer.

There are only three items associated with a traditional nasal mask that are recognized by the insurance industry - the Mask Assembly, the Nasal Cushion, and the Headgear. If your provider gives you any other mask part, they are supposed to bill code E1399 - miscellaneous DME supplies. It's kind of pointless though, since the insurance will pay $0 when they receive a miscellaneous item claim.

The solution is absurd. The forehead support cushion is considered to be part of the Mask Assembly. Therefore, if the cushion is worn out, it's time for a new mask. Hopefully, the mask is more than three months old, which would qualify you to get a replacement mask. If it isn't, then your provider could theoretically return the mask to the manufacturer for a warranty replacement. Most manufacturers will warrant their masks for 90 days.

Daniel

• ▶ Reply

Permalink Reply by sleepycarol on July 7, 2009 at 7:12pm

Okay, I see your point Daniel -- one question though.

When I get a mask from the DME (a whole new mask and not just the seal) I only receive one of the cushions and not all cushions that come with the mask, nor do I get the handy little carrying bag many of the companies include. Those are whisked away before one even has a chance to ask about them. What happens to those parts? Do the DME's send them back? Although the DME bills each item individually (seal, headgear, frame, etc.) it seems pointless not to give the patient the whole setup since insurance is paying a pretty penny for the items given to the patient.

• ▶ Reply

Permalink Reply by Daniel on July 7, 2009 at 10:08pm

While it is possible to order the parts, there is little motivation for the DME to do so. They'd rather sell you an entire new mask. Let's say the DME's cost for a mask part is $15. Added to that is the freight costs the DME must pay to the manufacturer. Not to mention the overhead to take the time to order the part, receive, inventory it, and call the patient to him that it has arrived. I would imagine you are looking at $25 at that point, not to mention that since it is not a prescription item, sales tax should be charged.

Compare that to a theoretical 20% co-insurance for a new mask, and it is actually cheaper for the patient to get a new mask.

Daniel

Mike said:

great insight, Daniel, thanks -- ballpark range, about how much are the items if bought by the DME from the manufacturer? maybe a user in need can just pay cash to their DME to order the part on their behalf if not too expensive.

Daniel said:

Ahh, the Catch-22 of the Durable Medical Equipment Providers...

Since there is no insurance code for the forehead support cushion, there is no way for a DME to get paid by an insurance company for the part. Therefore, they generally do not stock the part, even though it can be ordered from the manufacturer.

There are only three items associated with a traditional nasal mask that are recognized by the insurance industry - the Mask Assembly, the Nasal Cushion, and the Headgear. If your provider gives you any other mask part, they are supposed to bill code E1399 - miscellaneous DME supplies. It's kind of pointless though, since the insurance will pay $0 when they receive a miscellaneous item claim.

The solution is absurd. The forehead support cushion is considered to be part of the Mask Assembly. Therefore, if the cushion is worn out, it's time for a new mask. Hopefully, the mask is more than three months old, which would qualify you to get a replacement mask. If it isn't, then your provider could theoretically return the mask to the manufacturer for a warranty replacement. Most manufacturers will warrant their masks for 90 days.

Daniel

• ▶ Reply

Permalink Reply by Daniel on July 7, 2009 at 10:37pm

Some masks are packaged with more than one size cushion or pillows. This is done for a variety of reasons, almost all of which are to cater to the DME, not the patient.

Some DMEs want to drop-ship a CPAP and mask to a patient with no mask fitting. Masks can be ordered in a "fit-pack" with more than one size, so that the patient can figure out what fits best. This is to make it easier for the DME, not to offer the patient more choice.

Some DMEs order masks in a "Duo-Pack," with two cushions that are the same size. This is so that they can charge the patient and the insurance company for a mask, a headgear, and a replacement cushion. When a mask only has one cushion or one set of nasal pillows, the DME is not supposed to charge for the cushion/pillows. They are part of the original mask (A7034). If there is a second cushion, they are allowed to charge for a replacement cushion/pillows (A7032 or A7033). If a DME is taking out extra cushions and still charging for a replacement, they are committing fraud.

Somtimes masks are packaged with multiple sizes so that the DME can minimize its inventory. I'd rather order 5 masks, each packaged with three sized cushions, than take up the shelf space (and tie up my cash) to order 15 masks - five of each size.

What happens to the spare cushions/pillows that aren't the size that particular patient needs? They are sold to other patients as replacement supplies, of course. I have a very large supply of Swift LT small nasal pillows and I have never had to order them as seperate parts, but I constantly have to order extra supplies of the Mediums. Is that unethical? I don't think so. I'm not doing anything in secret. If a patient wants the other sizes, I'll give them to the patient, especially if s/he is on the cusp between two sizes. But if you are between a small and a medium, what are you going to do with the Large? I'll offer to replace the Large with an additional Small or Medium, but then I would charge for two replacement cushions/pillows, in addition to the mask and headgear, because that is what the patient is receiving.

As for the bag, I can only imagine one reason why a DME wouldn't give it to you, Manufacturers give out free samples, usually to sleep labs in order to encourage them to use a particular mask. Sometimes these sample masks make their way to the DME. The samples are marked "Not for Resale," or "Lab Use Only," and they are not packaged with any handy carry bags. Perhaps an unscrupulous DME is selling a lab mask, or perhaps they are taking a bag from a legitimate mask so they can repackage a lab mask as a complete mask. By the way, on ResMed Masks that have a forehead adjusting dial (Activa LT, Micro, and Quattro), if the adjustment dial is gray rather than clear, you have been given a lab mask that the provider got for free.

To someone who buys a mask on the internet and expects it to be packaged with all sizes, this must seem absolutely crazy. However, running a DME is very difficult, and one must look for ways to cut costs whenever possible. I do not regard removing and reselling unneeded sizes as unethical in any way, but I realize that it may seem so to internet buyers.

Daniel

sleepycarol said:

Okay, I see your point Daniel -- one question though.

When I get a mask from the DME (a whole new mask and not just the seal) I only receive one of the cushions and not all cushions that come with the mask, nor do I get the handy little carrying bag many of the companies include. Those are whisked away before one even has a chance to ask about them. What happens to those parts? Do the DME's send them back? Although the DME bills each item individually (seal, headgear, frame, etc.) it seems pointless not to give the patient the whole setup since insurance is paying a pretty penny for the items given to the patient.

• ▶ Reply

▶ Reply to Discussion