(07-30-2016, 12:17 AM)SuperSleeper Wrote:
Probably a software hiccup. Some server maintenance is ongoing tonight, which could be the cause.
I deleted 0rangebear's duplicate post.
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07-30-2016, 10:32 AM
When I hit preview post yesterday it hung up. I hit the preview post a second time time, no response. I shut my computer down and went to bed thinking it didn't post.
07-30-2016, 11:40 AM
(07-29-2016, 09:40 PM)PaulaO2 Wrote: I am looking for a reliable source that states this. The compliance information for Medicare. All I find is "they say this" from Resmed and other places but no where can I find where Medicare itself says it.
Until you brought this up, I "assumed" that I knew the rules set by Medicare.
Now after searching the Medicare.gov site, I cannot find what I thought to be the Compliance Guideline Rules for Cpap use. All I can find is that they will pay for a 90 day trial, and if a person meets certain requirements, they will continue paying the rental. They don't state what the "certain" requirements are.
Now, thinking back to when I first started therapy, who told me what Medicare requires.....oh yeah, it was my DME! I've never seen actual documentation by Medicare. So now I begin to wonder if the DMEs put this in place in order to get paid.
I also would like to see the actual wording by Medicare on their rules. As I said, couldn't find it on their site. Just very vague wording.
Medicare never asked me for anything, and the only thing DME asks me is the average hours of usage. Why do they ask me this after 17 months? I own the machine, but they try to tell me Medicare won't pay for supplies if I'm not using machine.
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07-30-2016, 12:58 PM
(07-30-2016, 11:40 AM)OpalRose Wrote: [quote='PaulaO2' pid='170702' dateline='1469846436']
(07-30-2016, 11:40 AM)OpalRose Wrote: Medicare never asked me for anything, and the only thing DME asks me is the average hours of usage. Why do they ask me this after 17 months? I own the machine, but they try to tell me Medicare won't pay for supplies if I'm not using machine.
The Medicare rules are very clear in the link to their website I posted earlier in this thread
1) Medicare covers a 3-month trial of CPAP therapy if you’ve been diagnosed with obstructive sleep apnea. (12 week according to the manual in SECTION 240.4
2) Medicare covers it longer if you meet in person with your doctor, and your doctor documents in your medical record that the CPAP therapy is helping you. ( there is no minimum hours of use in this requirement)
3) Medicare pays the DME to rent the machine for the 13 months if you’ve been using it without interruption. (Your doctor has to document this in your medical records, interruption is based on the treatment the doctor has prescribed not a arbitrary formula)
3) After you’ve rented the machine for 13 months, you own it.
You pay 20% of the Medicare-approved amount for rental of the machine and purchase of related supplies (like masks and tubing). The Part B deductible applies.
Medicare pays the supplier to rent the machine for the 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it.
Based on the criteria above the only thing the DME should need is the prescription from your doctor which I believe is good for two years, although I am still looking for confirmation on the two year prescription rule
(07-29-2016, 10:39 PM)Jim Bronson Wrote: .... When I first got the machine, the wireless modem sent usage data to the DME (I think). Anyway, it sent it somewhere, but not to the doctor. I have to take him the chip every time we review my therapy. I always wondered how Medicare found out about the data and what compliance standards they applied.
shows that his doctor understands and is working to the Medicare rule. He has a face to face visit with his doctor who validates the therapy is helping him and documents it in his medical records. His doctor is asking for the chip so he has objective evidence for his records.
My doctor accepts my sleepyhead report. These face to face visits and the associated prescribed therapy from you doctor is all the Medicare requires.
Unfortunately, the modems in the machine typically report to the DME based on a template in the software written by the manufactures of the device that uses a "one size fits all" template that imports the criteria mention in Mosquitobait poste - Yesterday 06:49 PM
"Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage."
This criteria is typically accepted by all major insurance providers in the USA, Medicaid, VA, and various commercial drivers licensing organizations world wide. So it is understandable why people think it is also the Medicare rule.
Nevertheless, Medicare is only looking for documentation from you Doctor that your therapy is helping you and that your prescription is not interrupted.
Maybe your DME uses your hourly report to justify that your therapy has not been interrupted.
07-30-2016, 04:55 PM
I did find on the CMS website a pdf of their '09 Cert. of Medical Necessity. On it is a line with Y/N for stating compliance, using the 4hrs/70% note. That is the only place I could find it in any of CMS website.
I also found this document where they list problems with DMEs filing correctly. No where does it mention compliance numbers.
If we at Apnea Board wish to provide the most accurate information, then we need to have sources for this. And it seems as though it exists, just not officially. I would never consider it a myth, however. It is something DMEs use, something manufacturers expect to be happening (modems), and something even doctors believe should be done. Yet, there is no official request/requirement for it other than the Medical Necessity Form.
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The OMB form you reference is department of health an human service from. It is intended to be a checklist for use by all departments of the US federal government for evaluating health care needs. It would not be logical to interpret the existence of the criteria in the formm as a Medicare requirement. We know that Medicaid has requirements variation in every state and the form would also be used for those evaluations.
Both of these links are tied to forms related to HCPCS Codes E0601 and E0470. See my post in the off topic forum on HCPS codes. I believe that this codes are the source of the confusion. These codes trace back to the American Medical Association not Medicare
It is likely from the regulatory language that I have read. That this was a Medicare requirement at some point in PAP history. Which has been removed. Yet, still remains in many forms though out the industry.
(07-30-2016, 04:55 PM)PaulaO2 Wrote: I did find on the CMS website a pdf of their '09 Cert. of Medical Necessity. On it is a line with Y/N for stating compliance, using the 4hrs/70% note. That is the only place I could find it in any of CMS website.
it'll take more than a doctor to prescribe a remedy
Observations and recommendations communicated here are the perceptions of the writer and should not be misconstrued as medical advice.
07-30-2016, 11:43 PM
(07-30-2016, 04:55 PM)PaulaO2 Wrote: I also found this document where they list problems with DMEs filing correctly. No where does it mention compliance numbers.
I have a copy of the same document dated ICN 905064 September 2013. On page 5 (page 4 of the Dec 2010 version in your link) it states:
"Objective evidence of adherence to use (defined as use of PAP devices for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device, reviewed by the treating physician.
Noteocumentation of adherence to PAP therapy shall be accomplished through direct download or visual inspection
of usage data with documentation provided in a written report format to be reviewed by the treating physician and included in the patient’s medical record"
The curious thing is when I searched for "ICN 905064 September 2013", the CMS web site identified the document and provided a link to download it BUT the page that comes up says
"Fact Sheet is no longer available. If you want to continue using this product, please contact the MLN at MLN@cms.hhs.gov"
I did not try to pull that string so I don't know whether the info in the document is no longer valid (although telling how to continue using it wouldn't make sense) or whether their competitive bidding system and its requirements (contracts) make the guidance provided less necessary. Hope this sheds some light.
08-02-2016, 07:03 AM
I believe that earlier I did see the 4 hour rule on the medicare site when I first got my machine. And elsewhere I saw the same 4 hours referenced by insurance companies as the Medicare rule that they also follow. Medicare had 2 criteria- one for if you even qualify to use a machine and if it is making a difference and the second to determine if you are using it often enough.
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