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[Equipment] Does your provider unbundle your mask kit?
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vpescado Offline

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Post: #1
Does your provider unbundle your mask kit?
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?
09-08-2015 01:47 PM
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trish6hundred Offline

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Post: #2
RE: Does your provider unbundle your mask kit?
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
09-08-2015 02:39 PM
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Mosquitobait Offline

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Other Comments: RLS and Bradycardia

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Post: #3
RE: Does your provider unbundle your mask kit?
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.
(This post was last modified: 09-08-2015 03:36 PM by Mosquitobait.)
09-08-2015 03:09 PM
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OpalRose Offline

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Post: #4
RE: Does your provider unbundle your mask kit?
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
09-08-2015 07:53 PM
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zonk Offline

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Post: #5
RE: Does your provider unbundle your mask kit?
(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
09-08-2015 08:07 PM
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PaulaO2 Offline
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Post: #6
RE: Does your provider unbundle your mask kit?
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
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09-08-2015 09:09 PM
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vpescado Offline

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Machine: Resmed AirSense 10 Autosense
Mask Type: Nasal pillows
Mask Make & Model: Resmed Swift FX
Humidifier: Resmed Airsense 10 Autosense
CPAP Pressure: 14.0-18.0
CPAP Software: SleepyHead

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Sex: Male
Location:

Post: #7
RE: Does your provider unbundle your mask kit?
(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.
09-09-2015 12:38 AM
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Mosquitobait Offline

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Machine: Resmed AirSense 10 For Her
Mask Type: Nasal pillows
Mask Make & Model: Airfit P10
Humidifier: integrated, Climate line tube
CPAP Pressure: 9-12
CPAP Software: ResScan SleepyHead

Other Comments: RLS and Bradycardia

Sex: Female
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Post: #8
RE: Does your provider unbundle your mask kit?
If it is bothersome to you, switch providers. Not worth the angst.
09-09-2015 08:38 AM
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parkerdt Offline

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Post: #9
RE: Does your provider unbundle your mask kit?
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 was last modified: 09-09-2015 07:53 PM by parkerdt.)
09-09-2015 07:52 PM
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ginzo Offline

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Post: #10
RE: Does your provider unbundle your mask kit?
(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^^^
09-13-2015 05:36 PM
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