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Compliance, Masks, & Medicare
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sir_sleeps_alot Offline

Preferred Members-2

Posts: 58
Joined: Oct 2013

Machine: ResMed S9 Autoset
Mask Type: Nasal mask
Mask Make & Model: Mirage FX
Humidifier: Hi5
CPAP Pressure: 14 cm h2o
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: New England

Post: #1
Compliance, Masks, & Medicare
I've done a lot of reading in the forums and I am trying to figure out if A. I'm reading old outdated info, B. My DME company is making things up, or C. Both.

When I met with the respiratory therapist from the DME company, she said that I had to have 30 consecutive days of 5+hours of cpap usage in order for Medicare to agree to purchase (after 13 monthly payments) the machine. I believe I read in the forum that Medicare requires 4 hours of use for a certain percentage (70%?) of 30 days.

Clarification?

The other question/issue is about masks. I think I read something somewhere (maybe not in this forum, or maybe so--can't remember, stupid sleep apnea!) that during the first 30 days of cpap treatment, the patient could try on multiple masks and that the DME would be able to return them and be reimbursed for ones not purchased. When I met with the respiratory therapist the second time, when I realized the mask I'd been given wasn't going to work, she said that I was allowed to try (and reject/return) two masks on each mask replacement period (which was either ever 30 or 60 days).

The confusing part is that after I tried on and failed my second mask, she went and got a third one and then sent me home with all three saying they were just going to be thrown away.

Again, can anyone clarify?

Thanks,
SSA
11-24-2013 04:36 AM
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zonk Offline

Advisory Members

Posts: 7,908
Joined: Feb 2012

Machine: A10 AutoSet
Mask Type: Nasal mask
Mask Make & Model: Activa LT
Humidifier: Integrated /ClimateLineAir
CPAP Pressure: 9/13
CPAP Software: ResScan

Other Comments: CPAP since Nov 2010

Sex: Male
Location: Australia

Post: #2
RE: Compliance, Masks, & Medicare
My understanding the DME get refunded for the mask from the manufacturer but need to fill the paper works

They,re telling you fibs about Medicare guidelines.
1- Determining patient compliance with the S9
The ResMed S9 displayed information meets Medicare criteria for visual inspection of adherence demonstrating the patient is using the device for four or more hours per night for 70% of nights in a consecutive 30-day period http://www.resmed.com/us/assets/document...liance.pdf

2- Physician review of objective evidence of adherence (defined as use of PAP ≥4 hours per night on 70% of nights during a consecutive 30-day period) via direct download or visual inspection of usage data http://www.resmed.com/us/documents/10134...ilevel.pdf

Replacement allowance (page 6)
http://www.healthcare.philips.com/pwc_hc..._Hints.pdf

Edit: the link to Medicare gone kaput or maybe not allowing me in, as being an outsider Sleep-well
(This post was last modified: 11-24-2013 05:42 AM by zonk.)
11-24-2013 05:25 AM
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Shastzi Offline

Advisory Members

Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #3
RE: Compliance, Masks, & Medicare
just curious: How much are the 13 monthly payments? Smile

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
11-24-2013 06:57 AM
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cbramsey Offline

Advisory Members

Posts: 900
Joined: Mar 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage FX
Humidifier: ResMed H5i with ClimateLine
CPAP Pressure: 6 - 12
CPAP Software: ResScan

Other Comments: Supreme Overlord of Web Darkness

Sex: Male
Location: NC, USA

Post: #4
RE: Compliance, Masks, & Medicare
My opinion is your DME is making stuff up.

With regard to the masks, there is nothing I am aware of in the Medicare documentation that the DME has to take the mask back. Dont-know

Sleep-well

@Shastzi

With regard to your question as to costs, it depends on what type of machine you have (a standard CPAP should be cheaper than an APAP which should be cheaper than a VPAP), and if you have any type of Medicare Advantage or Medicare Supplement policy in addition to Medicare or not.

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.
(This post was last modified: 11-24-2013 09:14 AM by cbramsey.)
11-24-2013 09:11 AM
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Donna Offline

Preferred Members

Posts: 28
Joined: Nov 2013

Machine: REMstar Pro C-Flex+ Auto IQ
Mask Type: Nasal mask
Mask Make & Model: Respironics Wisp
Humidifier: System One Heated
CPAP Pressure: 10
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Tennessee USA

Post: #5
RE: Compliance, Masks, & Medicare
Interesting information, Zonk. You have been so helpful to me. I've learned more from you in a matter of a few days than from my physician and DME provider over the past two years.

As a previous Clinical Compliance Auditor, I know that most all insurances follow Medicare Guidelines pretty closely. I have Tricare insurance, which is also a Government payor for retired military personnel. My DME provider told me that if a mask doesn't work for me, I only have one exchange option. I was told the mask I return is "sent back to the company and refurbished for resale". I only get replacement items every six months. DME companies would benefit from selling replacement items as often as possible, so why would they lie about how often people can get accessories? Strange.... Looks like I need to check out my insurance regs related to CPAP. It is disgusting that people have to research every thing they are told since the truth is so elusive now days!
11-24-2013 09:45 AM
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Sleepster Offline
Wiki Editor
Moderators

Posts: 4,988
Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #6
RE: Compliance, Masks, & Medicare
Doctors and DME providers have two reasons for not filling you in completely. First, they may want to maximize their profits. Second, they may have learned from experience that it's not a good idea to overwhelm patients with more information than they need.

Medicare and insurance company guidelines are changing.

Equipment providers have their own policies, too, and it's hard to sort out which guidelines are being made up by them and which are imposed on them by insurance companies and government agencies like Medicare.

Sleepster
Apnea Board Moderator
www.ApneaBoard.com


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.
11-24-2013 10:02 AM
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PaulaO2 Offline
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Moderators

Posts: 8,065
Joined: Feb 2012

Machine: S9 Autoset
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: H5i
CPAP Pressure: 14-20
CPAP Software: SleepyHead

Other Comments: Ehlers-Danlos Syndrome, Hypermobility Type; chronic sarcasm

Sex: Undisclosed
Location: western NC, USA

Post: #7
RE: Compliance, Masks, & Medicare
I am on Medicare and Medicaid. Medicare is what pays for my CPAP stuff. With my S9 Escape, which I have had for over 3 yrs (although I use the Autoset now) no one has ever asked about compliance information.

Before the S9, I had the S7. I was called once a year to bring it in to have the pressure tested. He never checked the hours (or if he did, he memorized them because he never wrote anything down). Once the state made the switch and only RTs or nurses could touch the machines or see the "patients", no one asked me to bring in the machine to make sure it still worked right.

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.
11-24-2013 11:05 AM
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justMongo Offline

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Posts: 3,840
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #8
RE: Compliance, Masks, & Medicare
Medicare is not uniform throughout the US.
They set new standards in large metro areas to see if they can save money (of course the process itself actually costs Medicare more.)

I got my S8 in 2009 on a 13 month rental under Medicare. No one checked my compliance other than to ask me.
I do not recall what the monthly reimbursement rental was.
My DME gave me a refurbished S8 to maximize their profit.

<RANT> The government was happy to tax the baby boom generation to pay for Social Security and Medicare -- now that the Baby Boomers are on the receiving end, they change the goal line; change the method for calculating CPI for the annual COLA; and lower physician reimbursement. </RANT>

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.
11-24-2013 01:09 PM
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Homerec130 Offline

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Posts: 444
Joined: Mar 2012

Machine: Philips/Resperonics BiPAP auto SV Advanced System One (950P)
Mask Type: Full face mask
Mask Make & Model: ResMed Quatro FX
Humidifier: Philips Respironics System 1
CPAP Pressure: 6-16
CPAP Software: SleepyHead

Other Comments: But it is a dry heat.

Sex: Male
Location: Tucson, AZ

Post: #9
RE: Compliance, Masks, & Medicare
(11-24-2013 09:45 AM)Donna Wrote:  Interesting information, Zonk. You have been so helpful to me. I've learned more from you in a matter of a few days than from my physician and DME provider over the past two years.

As a previous Clinical Compliance Auditor, I know that most all insurances follow Medicare Guidelines pretty closely. I have Tricare insurance, which is also a Government payor for retired military personnel. My DME provider told me that if a mask doesn't work for me, I only have one exchange option. I was told the mask I return is "sent back to the company and refurbished for resale". I only get replacement items every six months. DME companies would benefit from selling replacement items as often as possible, so why would they lie about how often people can get accessories? Strange.... Looks like I need to check out my insurance regs related to CPAP. It is disgusting that people have to research every thing they are told since the truth is so elusive now days!

Interesting. I am also on Tricare and get a new mask and assembly, hose, and filter every three months (whether I need it or not) and a new water tank every six months.

Paul
11-24-2013 02:27 PM
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me50 Offline

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Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA

Post: #10
RE: Compliance, Masks, & Medicare
I can get the water chamber and headgear every six months.

A new mask assembly and hose every three months.

The cushion and 2 filters every month.
(This post was last modified: 11-24-2013 03:12 PM by me50.)
11-24-2013 03:08 PM
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