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Confusing call from sleep doc's office today
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JJJ Offline

Advisory Members

Posts: 751
Joined: Apr 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal mask
Mask Make & Model: Most recent: Wisp, Pilairo, Mirage Vista
Humidifier: ResMed S9 Autoset
CPAP Pressure: 17-20
CPAP Software: SleepyHead

Other Comments:

Sex: Male
Location: USA 97217

Post: #1
Confusing call from sleep doc's office today
First some background: I had a sleep study in late March and was diagnosed with severe sleep apnea. The doc (very nice lady) wrote a prescription for a PRS1 with settings of 5-15 cm H2O and sent it to a local DME. I picked up the machine from the DME on April 3. I was assured by everyone that Medicare would pay for everything, minus my copay, and they have done so.

However, I muddied the insurance waters by purchasing my own PRS1 in late April on the local Craigslist for $300. Subsequently I returned the PRS1 to the DME. Since I did so without authorization from the doc they filled out an "AMA" form (against medical advice). I signed this form, else they would not have taken the machine back.

A few weeks later I went to the sleep doctor's office and obtained a copy of the prescription and results of the sleep study from her assistant. With prescription in hand I went to a different local DME and bought a Swift LT. Since it had not been three months I knew Medicare would not pay for the mask, so I just paid for it out of pocket.

The Swift LT was not satisfactory, so a couple weeks later I sent the prescription to Supplier #1 and bought a Mirage Vista from them. Again, it had not been three months, so I just paid for it out of pocket.

But a few weeks later the Pilairo finally became available and my new DME had them in stock. And now it was past three months, so theoretically Medicare would pay for it. I went to see the respiratory therapist at the new DME and ended up buying the Pilairo. They just charged me the Medicare copay ($22 and change) and assured me that according to my paperwork Medicare would pay for the rest. They also offered me a new hose and filters, all on Medicare's tab, but I declined them as I did not need them.

OK, now for the confusing phone call. I was in the back yard building a fence and suddenly my pocket started ringing. I quickly divined that it was the phone in my pocket that was ringing, not the pocket itself. I can figure these things out so much more quickly now that I am getting better sleep. I have the sleep doc in my contact list, so when I went to answer it I saw that it was from her office. It turned out to be a lovely sounding lady secretary calling me to tell me that I was past due for an appointment.

Trying to sound intelligent I responded "huh?" She explained further that if I did not let the doc see my data for compliance every 90 days Medicare would stop paying for the machine. I pointed out that I had my own machine, so to heck with Medicare. She insisted that Medicare still required an appointment every 90 days. We went back and forth for a bit until she finally concluded that if I had my own machine the 90 day compliance requirement was not necessary. We decided that she would leave a message for the doc explaining that my AHIs were under 5, that all was cool with me, and I didn't see the need for an appointment. If the doc thought that there was still some reason she needed to see me the secretary would call back.

What confuses me is whether the compliance information is necessary for Medicare to pay for supplies and new masks, which I do want them to do. And some day one of our manufacturers will come out with a new killer machine guaranteed to turn my body clock back to age 18. It will probably cost a lot, so I'll want Medicate to pick up the tab. I tried to read the Medicare information, but it was written in a mixture of two obscure dialects: Federalese and Medicalese, neither of which I ken. For that matter, as far as I know, the speakers of those dialects do not understand them either.

Does anyone think I ought to go see the doc, even though I don't need to? Any insights and observations welcome. Thanks
08-09-2012 11:12 PM
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PaulaO2 Offline
Wiki Editor
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: #2
RE: Confusing call from sleep doc's office today
I have Medicare and Medicaid. I have never been asked to show compliance data.

Way way back when I first started, I was asked to bring the machine in once a year to make sure it was still putting out the right pressure. Easy two minute test. It was also when we discussed masks. This was before CPAP DME staff had to be RTs. (he knew more about stuff than the RT does; I miss him) Anyway, the only "compliance data" I have heard from my DME was when the guy joked about how rough my CPAP headgear looked. Back then, they replaced the headgear just once a year. He laughed and said it was obvious I wore it every night. Part of it was held together with duct tape.

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.
08-10-2012 12:10 AM
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Schnauzers 5 Offline

Preferred Members-2

Posts: 184
Joined: Mar 2012

Machine: Respironics Rem Star A Flex
Mask Type: Nasal pillows
Mask Make & Model: LT swift for her
Humidifier: Respironics, I guess
CPAP Pressure: 9-14
CPAP Software: Not using software

Other Comments:

Sex: Female
Location:

Post: #3
RE: Confusing call from sleep doc's office today
Once I became 65 I was required to see the doc every six months to prove my compliance too. I paid out of pocket for my first machine and when I was 65+ I figured they owed me a new one. I now have the medicare one and the one I paid for and I like having a backup. I still have to prove compliance and it is paid for now too. ?????? Who can figure out their rules? So I go see the doc and we have the same conversation each time. I am doing as well as I can and my AHI too is under 5, very low 1.6 or so.
08-10-2012 01:57 AM
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zimlich Offline

Preferred Members-2

Posts: 392
Joined: Feb 2012

Machine: Respironics PR System One BiPap Auto SV Advanced
Mask Type: Nasal mask
Mask Make & Model: ResMed gel Nasal Mask
Humidifier: System One
CPAP Pressure: 8-20 ASV, 8 EPAP,PS 12
CPAP Software: Not using software

Other Comments: I use the Quattro FFM when necessary

Sex: Female
Location: Norfolk, VA

Post: #4
RE: Confusing call from sleep doc's office today
Why are you changing machines so often? No wonder things are confused.
08-14-2012 07:56 AM
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