Hello Guest, Welcome to Apnea Board !
As a guest, you are limited to certain areas of the board and there are some features you can't use.
To post a message, you must create a free account using a valid email address.

or Create an Account


New Posts   Today's Posts

[Equipment] Does your provider unbundle your mask kit?
#1
So something that I noticed when I re-upped my supplies for my CPAP:

My mask comes as a kit with a small, medium, and large nose-pillow. My insurance allows me 6 nose pillows per 3 months, so I get another five along with it.

I realize that my supplier is removing the small and large pillows from the kit (obviously so they can sell them to someone else).

But this seems wrong as:
1) When I got my kit the first time, they gave me all three in the kit as well as the 5 extras .
2) They are invoicing my insurance company (and me) for the full kit based on the manufacturer's item number.

Like I said, this seems wrong to me (and possibly fraudulent).

When I asked my sales rep, she claims that they are required to remove the small and large pillows as otherwise I would be getting 8 pillows and my insurance wouldn't allowed that (but again, they left them in the first time, and they are still invoicing for the full kit).

Is this a standard practice? Should I switch providers? Should I contact my insurer?
Post Reply Post Reply
#2
Hi vpescado,
WELCOME! to the forum.!
You might call your insurer and tell them what is going on. This happens quite a bit where the DME takes out some of the stuff in the mask kits.
Much success to you with your CPAP therapy and hang in there for more suggestions.
trish6hundred
Post Reply Post Reply
#3
Depends on your insurance company billing. For Medicare, the different parts of the mask are billed separately even if they come together in a kit. So, a kit for a nasal pillow mask AND your monthly nasal pillows are billed as:
A7033 Nasal Pillows
A7034 Nasal Interface
A7035 Headgear
A7029 Replacement Nasal Pillows (2 per month)

They may only provide the 3 sizes for when you buy the mask for the first time in order to determine your correct size and they eat less profit for it. Yes, some provide all 3 sizes in every kit, but I honestly don't think that is the norm.

So, contact your insurance company and ask them how this works for what they have contracted for. I pay 20% of everything, so I made sure I understood how this stuff works for Medicare. It may work differently if you have an HMO as well. Remember, you only pay based on what the allowed amount is, not what is billed.
Post Reply Post Reply


#4
vpescado,
I believe it depends on your insurance company and your DME or supplier.
In my case, I've had 3 "complete" mask sets. Each set included all three size pillows.
At one point I asked my DME if they could exchange one of the large sizes for a small and they told me that they would not be allowed to do that mostly for hygiene purposes. They are not allowed to remove any mask parts, or exchange. So I end up with two pillows that I can't use.

I've heard folk on this forum saying that their DME has exchanged pillows sizes, but I really don't know if there is a standard policy.

OpalRose
Apnea Board Moderator
www.ApneaBoard.com

How to Organize and Post ScreenShots

http://sleep.tnet.com/resources/sleepyhead/shorganize
https://sleep.tnet.com/reference/tips/imgur

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




Post Reply Post Reply
#5
(09-08-2015, 01:47 PM)vpescado Wrote: I realize that my supplier is removing the small and large pillows from the kit (obviously so they can sell them to someone else).
I believe, its illegal to tamper with sealed items
Once the sealed item been tampered with, no longer new, get contaminated and unhygienic

Post Reply Post Reply
#6
Take a look at your bill. If the item number is the same as what is on the box itself, then that is insurance fraud. If, however, it is all itemized (mask, pillows, headgear, etc), then all is well. They can usually get more money by piecing it out rather than selling it whole anyway.
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




Post Reply Post Reply


#7
(09-08-2015, 09:09 PM)PaulaO2 Wrote: Take a look at your bill. If the item number is the same as what is on the box itself, then that is insurance fraud.

They are definitely invoicing it as the part number for the full kit.

Any advice on how to handle it? Gentle hints to the DME provider isn't doing the trick.

Post Reply Post Reply
#8
If it is bothersome to you, switch providers. Not worth the angst.
Post Reply Post Reply
#9
My DME just shipped me 5 replacement cushions, and a new headgear and frame, in a sealed package, with you guessed it - ONE cusion of the correct size. Gotta believe they get them made like this since it was clearly a factory seal. At 3 months, I was entitled to a frame and headgear, and cushions, per my insurance. Be interesting to see at 6 months, when I am entitled to a complete mask if I get cushions in sizes I cannot use.

I've stopped trying to figure this mess out, and just go with the flow, as long as I have what I need. So far, so good, on that score. Carecentrix for me, since I am on CIGNA. As of Jan 1 looks like we will be with Apria, however, as CIGNA is being bought by Anthem Blue Cross.

Post Reply Post Reply


#10
(09-09-2015, 07:52 PM)parkerdt Wrote: My DME just shipped me 5 replacement cushions, and a new headgear and frame, in a sealed package, with you guessed it - ONE cusion of the correct size. Gotta believe they get them made like this since it was clearly a factory seal. At 3 months, I was entitled to a frame and headgear, and cushions, per my insurance. Be interesting to see at 6 months, when I am entitled to a complete mask if I get cushions in sizes I cannot use.

I've stopped trying to figure this mess out, and just go with the flow, as long as I have what I need. So far, so good, on that score. Carecentrix for me, since I am on CIGNA. As of Jan 1 looks like we will be with Apria, however, as CIGNA is being bought by Anthem Blue Cross.


^^^THIS^^^

Post Reply Post Reply


Possibly Related Threads...
Thread Author Replies Views Last Post
  [Equipment] Best DME Provider In Seattle jdana24 9 596 04-25-2017, 02:11 PM
Last Post: Ephraimh
  Does dreamstation need a provider for dreamapper data to sync? Axxel6307 5 488 02-02-2017, 08:19 PM
Last Post: Jimsp1
  Can home care provider make our machine unusable? LPN2012 10 702 12-01-2016, 05:22 AM
Last Post: LPN2012
  [CPAP] Local Provider vs. Online CPAP BigDaddySnooze 15 1,328 07-10-2016, 05:06 AM
Last Post: kwhenrykerr
  Problems Getting Into Provider Settings [DreamStation] Hopefullady 5 1,513 12-16-2015, 09:31 AM
Last Post: Hopefullady
  Dealing with a dishonest Healthcare provider kfujioka 39 7,268 06-11-2015, 11:56 AM
Last Post: Adoniscmj
  Provider manual for philips respironics BiPAP autoSV Advanced System One racprops 0 2,781 10-30-2014, 04:05 PM
Last Post: racprops

Forum Jump:

New Posts   Today's Posts




About Apnea Board

Apnea Board is an educational web site designed to empower Sleep Apnea patients.

For any more information, please use our contact form.