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Have compliance criteria for Medicare reimbursement changed?
#1
Have compliance criteria for Medicare reimbursement changed?
I enrolled in CPAP therapy as a Medicare patient on September 21 and am plugging away at achieving compliance.
I have received an information note from my DME (LinCare) in which they cite compliance criteria for insurance coverage as "Use therapy for 4 hours each night for 30 consecutive days between days 31 & day 90 (of receipt of CPAP machine)"

This is more stringent than the criterion quoted elsewhere, e.g. ResMed, "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,.." 
 
I sure hope that the more relaxed criterion prevails!
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#2
RE: Have compliance criteria for Medicare reimbursement changed?
I am not aware of any changes in Medicare compliance requirements, which are as you quoted from ResMed.
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#3
RE: Have compliance criteria for Medicare reimbursement changed?
Since my primary is Medicare starting this past May, and my new pulmonary doc just ordered a new ASV (long story and not pertinent), I am about to find out the Medicare way on compliance. I'm not waiting for it to slap me in the face though. I'll be digging in on details about this Monday. I will report the findings. If others dig up the info, please update us.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Have compliance criteria for Medicare reimbursement changed?
I just got a new ResMed after 5 years on a PR machine. No compliance whatsoever except from my sleep doc--3 months. That is his request, not Medicare I think. He's a great guy and I go willingly. I originally had the 4 hr per night, 70% in 30days. It is possible to actually talk to someone at Medicare--just be prepared to be on hold for awhile.
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#5
RE: Have compliance criteria for Medicare reimbursement changed?
Copied on my side, thanks.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Have compliance criteria for Medicare reimbursement changed?
I have a Medicare Advantage plan and received this information:  

Compliance:
Medicare requires that a patient use CPAP for more than 4 hours per night on 70% of nights (21 nights) during a 30-day consecutive period any time in the first three months of use.

Patient must also have a face to face appointment with their doctor any time after the first 30 days, but before the 90 days expires.


I have no information that this has changed, but doesn't mean it hasn't.

Note: If your skip the second part about having a face to face with your doctor, they can deny coverage.

And I wouldn't count on Lincare or any other DME to give you accurate information. I had to take it as far as to have a three way phone call between myself, Lincare and Humana, where my Humana Medicare representative took great pains to get it right with Lincare.
OpalRose
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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.
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#7
RE: Have compliance criteria for Medicare reimbursement changed?
I have had 5 machines through Medicare since dx. This last replacement was hard. My doctor was in another state. I went to see him, he ordered the vauto and told me I had to come back this time for a face to face after 30 days but before 90. Unfortunately Covid hit and I couldn’t go back to him. My family doc took over my rx’s and put a f2f note in our virtual visit notes. I have had zero issues with Medicare. First time a replacement needed that f2f so some things have changed a little. I was able to finally have a televisit with the other doctor. Another post. Good luck. And record any conversations with the Medicare csrs. They will tell you outright that their information could be wrong and they won’t pay.
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#8
RE: Have compliance criteria for Medicare reimbursement changed?
Elgee1, your comment about seeing the doctor by 3 months make sense--apparently Medicare does require that even on a replacement machine, thus my 90 day appointment.
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#9
RE: Have compliance criteria for Medicare reimbursement changed?
Thanks, to all of you, for your advice. I'll tell you how it all works out after the 0 day period .. I do have a tele-face-to-face scheduled with the prescriber.
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#10
RE: Have compliance criteria for Medicare reimbursement changed?
I hope it goes well. I ended up with Aerocare after my Mom n pop dme got bought out by Verus. Very few medicare dmes after their failed bidding program, ehich I think is on hold. Aerocare is not perfect by any means, but way better than the service from Verus and Lincare and Apria.
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