MASK ARRAYED

This is part 1 of what I hope to be a series:  “I’ve just been diagnosed with apnea–now what????”

Sometimes you have your titration study (test with a CPAP mask to determine how much pressure you need to keep your airway open) on the same night as the sleep study (a “split-study”) or sometimes you have the tiration study on a second night in the sleep lab.  In either case, once you have had your titraiton study and the sleep specialist has determined the type of machine and pressure you will need, a prescription will be sent to a “DME” (CPAP supplier). 

DME stands for Durable Medical Equipment, and the term “DME” is sometimes used to describe the equipment (CPAP machines and masks, as in “I have 80% coverage from my insurance company for DME”) or the supplier (the company that provides the CPAP machine, as in “Valley Oxygen is my DME”).  Sometimes, “DME” is even used to describe the person who owns or works at the DME company, as in “my DME said . . . “

A DME (company) is supposed to receive your prescription, help you find the best machine to meet your needs, help you find the mask that you are most comfortable in, educate you about these, and provide the machine and equipment.  DME’s are supposed to understand how your insurance works and have Respiratory Therapists (RT’s) who can help you have a good experience with the CPAP so you can be successful in your therapy. 

SUPPOSED TO. 

And in the real world . . .

Some DME’s actually work that way.

Most do not. . .

That’s the first bit of information you need to know before you meet your DME.  This is ‘Merica, folks, land of free enterprise and capitalism.  Every company must make a profit and their goal is to make the most profit they can.  If, in doing so, they can serve your needs, that’s great.  But your needs are not their main concern, except to the extent that meeting your needs furthers the DME’s profit.  It’s the American way.  And sometimes, it stinks!

If this sounds cynnical, it is.  Some people are lucky to stumble on to a great DME supplier that has a knowledgeable and caring staff who really make it their goal to make sure you are comfortable with your equipment  and that it’s working as well as possible for you.  Unfortunately, this is the exception rather than the rule.  Most DME’s simply want to sell you the equipment at maximum profit, document your compliance so they can get paid, and they hope never to hear from you again except when it’s time to place your order for replacement supplies.   And DME’s (staff) have been known to lie or be totally ignorant of the facts, just to make sure that they maximize their profits and get you the heck out of their hair.  So YOU must be armed with knowledge BEFORE you ever set foot in a DME’s storefront or sign anything on the dotted line.

Your first step will be to determine what insurance coverage you have for DME if any.  If you don’t have insurance coverage, RUN, don’t walk, to an online supplier unless you like paying 2 or 3 times more for equipment and supplies (a rare few DME’s will match online prices for the uninsured).  DME suppliers claim that they give better service than online providers, so it’s worth the extra money, but in almost every case that is simply not true.  So if you don’t have insurance, skip the DME entirely and order your equipment online from a reputable online supplier. 

Now, if your insurance is Medicare, you need to know whether you have traditional Medicare Parts A and B with a supplement/Medigap policy, or if you have Medicare Part C, also known as Medicare Advantage.  What I’m about to say about Medicare applies to traditional Medicare with a supplemental policy, NOT to a Part C Advantage Plan.  Those differ a lot, and you’ll have to figure out the ins and outs of your particular Medicare Advantage plan to learn what your DME coverage is yourself. 

Most (but not all)  private insurerance plans (purchased through an employer  or privately through a broker) follow Medicare guidelines, so I’ll talk about Medicare first. 

Medicare (traditional) pays 80% of the cost of a machine and all the supplies.  There are a few things you need to know:

1.  Medicare sets the price of the machine and then pays 80% of that, regardless of how much the DME wants to charge. 

     a.  Example:  DME charges $2500 for the top of the line machine.  Medicare does NOT pay 80% of $2500.  Medicare decides a reasonable price is $1200 and pays 80% of $1200. 

     b.  Medicare pays by HCPC codes.  These are billing codes, and the HCPC code for a CPAP machine is E0601.  You can look up how much Medicare pays for an E0601 machine in your state on the Medicare Website.  (It’s hard to find and I will post a link one of these days). 

    c. ANY CPAP or APAP machine (but not a bilevel or ASV machine) is E0601, from the dumbest brick of a machine without data capability or EPR to the top of the line machine with all the bells and whistles you could wish for.  Medicare pays one price regardless of which machine you get within the E0601 HCPCs code.  So the only one who really cares (besides you) about what machine you get is the DME.  If you get the bottom of the line brick, the DME makes a lot of money.  If you get the top of the line bells and whistles machine, the DME makes very little.  Guess which one the DME wants you to get? 

2.  Your co-pay is the remaining 20%.  Your supplemental/Medigap policy may pay all or part of that 20%.  Some supplemental policies pay more if you use a “preferred provider”.

3.  Medicare does not actually “buy” the machine, though it buys the humidifier, hose, filters and mask (all by different HCPCs codes).  Medicare requires the machine to be purchased on a “capped rental” basis.  This means that Medicare rents the machine for a period of 13 months.  At the end of the 13 months, the machine is YOURS. 

4.  Medicare requires the DME to prove “compliance”–that you are using the machine for at least 4 hours 70% of the time within a 30 day period.  For that reason, the DME will want to review your data card sometime within the first 30 to 90 days to confirm that you are using the machine.  If you do not meet the compliance requirements, Medicare will not pay.  For that reason, EVERY machine has compliance data capability.  So if you ask a DME for a “data capable” machine, be specific.  Make sure it has “efficacy data” as well as compliance data.  Another way to say this is to insist that there is access to AHI (apnea hypopnea index scores) and leak data. 

5.  Even though it is MUCH less expensive, Medicare will not pay for you to obtain a machine from an online supplier (except for the very few that are Medicare Certified).  Medicare pays only for certified DME’s, because Medicare has requirements (i.e. patient instruction, documentation of compliance, etc.) that DME’s must meet.  Medicare doesn’t have a way to regulate most online suppliers.  So you are stuck with a brick and mortar DME if you want Medicare to help pay.

6.  If you are having trouble figuring out how Medicare and your supplemental policy will work for CPAP equipment and supplies, you can get free Medicare assistance from your states SHIP (State Health Insurance Program in most states)  or HICAP (Health Insurance Counseling and Advocacy  Program in California)  program–the number for these agencies is on the back of your 2011 Medicare and You booklet, or you can find it on the www.medicare.gov website, or by calling 1-800-MEDICARE. 

Most private insurers work a lot like Medicare, but there can be infinite variations.  Therefore, if you are not on Medicare, it’s extremely important that you call YOUR insurer and ask the following questions:

A.  Does the insurer pay by HCPC code, or are only certain machines covered?  If only certain machines, does it pay more for some than others?  If the insurer covers only part of the DME’s cost, are you required to pay the difference between the insurer’s allowable cost and what the insurer pays, or between what the insurer pays and the DME’s retail price?

B.  Does the insurer purchase the machine outright, or require a rental period?

C.  What are your co-pays and deductibles?  This is important!  If a rental period spans more than one calendar year, your out of pocket expenses for co-pays and annual deductibles could easily cost more than buying the machine yourself online.  Or, if you will be changing insurers, you could lose the “credit” for co-pays and deductibles already made or have to change machines.  Make sure you understand all of this before you sign on the dotted line with a DME. 

D.  Does the Insurer cover only certain masks or all masks from the DME?  Again, does the insurer cover supplies (hose, filters, masks, cushions and nasal pillows) by HCPC’s codes or have a limited “formulary” for supplies? 

E.  Does the insurer require you to use only certain DME providers, or will it pay for any DME company?  Do you get better coverage if you go to a “preferred provider”? 

F.  What is the insurer’s schedule for replacement of supplies?  Many, but not all,  follow Medicare guidelines (2 nasal pillows or one mask cushion every 30 days, 2 paper filters every month. 2 foam filters every 6 months, 1 hose every 6 months, one new mask and headgear every 3 months). 

Now, if you have an HMO, all bets are off.  Often (but not always), HMO’s limit the type of machine you can get, the DME provider you use, and may have a limited “formulary” of masks and other supplies.  Medicare Advantage (Part C) plans often work this way as well. 

Why is all this important?  Because you want to walk into the DME armed with this knowledge so they can’t pull “stupid customer” tricks on you like this:

 You want a ResMed Auto S9 (the APAP with the most bells and whistles and the highest price of all the current machines).  The DME says:

     A.  “Your insurance doesn’t cover that machine.”  But you know that your insurer pays by HCPC’s codes and doesn’t care what machine you get as long as it’s under the E0601 HCPC’s code, and the S9 is. 

     B.  “Your prescription has to specify that machine.”  Actually, it does not.  Any prescription for a CPAP machine will allow you to get this machine, but this battle is often never ending with a reluctant DME.  The best defense is to have your doctor specify this machine and write “dispense as written” on the prescription. 

   C.  “You will have to pay $XXX dollars more if you want that machine.”  This is often untrue.  If your insurance covers any E0601 machine and sets an allowable fee, most likely this is NOT true.  But some insurance contracts allow the DME to charge over and above the allowable fee.  So you should know this in advance, AND ALWAYS CHECK WITH YOUR INSURER BEFORE agreeing to pay the extra fee (some people have saved hundreds of dollars they would otherwise have willingly paid by taking this advice!)

    D.  “Your HMO doesn’t cover that machine.”  In most cases, this IS true of HMO’s, but be sure you know if it is true or not before believing the DME on this one. 

For a list of data capable machines, see http://maskarrayed.wordpress.com/2011/09/19/data-capable-machines/ .   You should decide what machine or machines you want and are willing to accept before walking into the DME as well.  Armed with this knowledge, you won’t be a sucker, and you can’t be taken advantage of by your DME.