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Insurance woes: Who has my "compliance" and "post pap" documentation?
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luminous Offline

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Post: #1
Insurance woes: Who has my "compliance" and "post pap" documentation?
I had to switch insurance a few months ago. MY DME didn't accept the new insurance, but they referred me to one who did. I have spent the past two and a half months trying to get the equipment I was due for three months ago, running in circles between DMEs and the doctor's office. But the new DME always said they still needed "compliance" and "post pap" documentation. My doctor sent over every scrap of apnea-related info on me they had, and it still wasn't enough. It was incredibly frustrating and I was eventually reduced to calling my insurance company and the doctor's office to beg them to advocate for me to figure out what was going on. No dice.

Eventually, for an unrelated reason, I switched to an insurance my old DME accepted, so it seems for now there is a solution in that they told me they can still provide my equipment.

But I know that if I ever have to go anywhere else I'll run into this problem again. (I had also tried a few other local DMEs too; they also all wanted paperwork that didn't exist.)

They told me "post pap" was my follow up visit with the sleep doctor. They had no help when I pointed out that I've never seen a sleep doctor in my life, or any doctor related the sleep study other than my primary care.

"Compliance" was supposedly the data showing I'm using the machine. I offered to bring in my SD card, but that was apparently too confusing.

How do I get a hold of this, and all the other, paperwork I need to prove to a supplier that I am eligible for equipment?
12-14-2015 11:46 AM
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Crimson Nape Offline

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Machine: ResMed S9 Autoset
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Post: #2
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
Hi Luminous, Welcome to the forum!

Depending on the DME you will need either ResScan or SleepyHead to produce the Compliance printout. A lot of the DME's won't accept the SleepyHead printout because of its disclaimer and it's not "certified". ResScan has a Compliance Report option that you can print and provide to your DME. The compliance report that the DME and insurance company is looking for will show that you used the CPAP for at least 77% of the time during the last 30 days. Qualifying usage is defined as its operation at or over 4 hours each night. The biggest problem that occurs with this type of therapy is its non-use.

Here is the link to obtain a copy of it:
http://www.apneaboard.com/forums/Thread-...397#pid397

Good Luck!

Statistics prove that people who have more birthdays live longer.
12-14-2015 12:42 PM
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PoolQ Offline

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Post: #3
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
Okay lets see if we can clear some things up for you.
"post pap" is a follow-up visit with whoever ordered the sleep study, "usually" this will be a sleep doctor so this is what everyone talks about. The follow-up visit will generate a "medical necessity" form signed by your doctor. This is what they are looking for.

"compliance" can indeed be achieved from the data on your SD card IF they know what to do with it. Here's my path. DME provides the cpap machine and "logs" into their ResMed site to enter the serial number and patient name. ResMed starts getting compliance data directly from the machine (cellnet modem is in the machine). The DME can again access this information through their ResMed portal (or from reading the SD card).

I am pretty sure that my insurance company could also directly access my compliance data, call yours and see if it's there. If they don't have it, explain your concern about the DME "registering you machine correctly" and see it they will contact them directly (have the DME phone number handy)
12-14-2015 12:52 PM
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OpalRose Offline

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Post: #4
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
It's ok if all you've seen is your primary care doc. It doesn't have to be a sleep doc.

What insurance wants, besides compliance is proof that you had a "face to face" visit with your doctor before the first 90 day period of Cpap use was up.

OpalRose
12-14-2015 01:30 PM
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trish6hundred Offline

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Sex: Female
Location: Missouri, USA

Post: #5
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
Hi luminous,
WELCOME! to the forum.!
I wish you much success with your CPAP therapy and getting your insurance woes straightened out.
Hang in there for more responses to your post.

trish6hundred
12-14-2015 09:30 PM
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Mosquitobait Offline

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Machine: Resmed AirSense 10 For Her
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Humidifier: integrated, Climate line tube
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CPAP Software: ResScan SleepyHead

Other Comments: RLS and Bradycardia

Sex: Female
Location: Minneapolis

Post: #6
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
Yup, the face-to-face is what they are looking for regarding the followup. That was what was required of my brother whose machine was scripted by his primary. As far as getting the compliance information, your DME is INCOMPETANT. Getting the compliance information from your machine that they sold TO YOU is their basic function and they can't do it? Be thankful they are not your oxygen supplier!
12-15-2015 12:47 AM
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JenJen Offline

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Post: #7
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
I think you can go to http://www.u-sleep.umbian.com and set up an account that links to your resmed machine. I can pull my stats and compliance information within 20 min of machine use in the morning. Just part of the program my dme uses to monitor compliance.

Jen JenThanks
08-14-2016 09:22 PM
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Ghost1958 Offline

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Other Comments: Moderate to Severe SA Obstructive. Rapid O2 desat off the machine.

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Post: #8
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
You need compliance data from your machine.
A thirty day face to face visit with you doc
A ninety day face to face visit wit doc.
An annual recertification letter from your doc saying your using and need the equopment.
08-14-2016 09:34 PM
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SaldusMiegas Offline

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Post: #9
RE: Insurance woes: Who has my "compliance" and "post pap" documentation?
Hi luminous,

It's curious to note that you are a member since 2014, so I apologize if this post rehashes stuff you already know. Also wondering if maybe this is a replacement machine you are going after? That might make a difference in the compliance requirement, which you may have already met long ago with your old machine? Or are you just talking about reordering supplies and getting snagged in all this compliance BS because of the new DME? I'm confused about what you are asking about.

[UPDATED] Since you mention that your old DME who accepts your new insurance says they can supply your equipment, then I would go get a copy of whatever they have in their files which establishes your compliance and allows them to sell you stuff, plus get a copy of the original CPAP prescription they used to order the machine you have now. That stuff will be golden and may answer the entire question for you. Get copies and keep a copy in a safe place. Then you will have it handy if you ever change DMEs again. Maybe that's all you are asking about, and if so then hopefully it's that easy to resolve for future reference.

I think all the discussion above, and my original response below are all based on the idea that you are trying to establish compliance, not that you already had established compliance with the original DME. So at least for my part I may have originally missed the mark, but since I spent a lot of time composing it, here goes:

I would call your current insurance company to clarify the situation and ask them IF and WHAT they require for compliance. The DME is a vendor who provides you with equipment and bills the insurance company. The DME requires compliance data only if the insurance company requires it of them, but they might be working on the assumption that compliance data is always required.

DMEs are not like doctors and other medical providers in the sense that your doctor chooses which insurance companies they will accept. But in the case of DMEs, it is your insurance company who accepts the DME. DMEs compete and bid aggressively to win contracts from insurance companies to be their providers. So the dynamic is a little different. You might think it doesn't make any practical difference but the decision maker for medical equipment is your insurance company and not your DME. So when you need to get clear about policy, talk to insurance not the DME.

It is common for insurance companies to follow Medicare guidelines (see link below), which require the stuff the others mentioned above. I believe one fine point about the Medicare requirements might be that it's the doctor who reviews the compliance data and makes a determination / recommendation that the therapy is effective and beneficial for you. That is documented in the face-to-face followup meeting. This closes the loop on the requirements. And this may be why the DME was confused about demonstrating compliance to them. Check me on that one, but I suspect the doctor followup visit is the key to establishing the compliance.

Note that it is also common for private insurance companies to NOT require compliance data and simply buy the equipment outright. That's what my insurance company did. The doc said we needed a CPAP machine, and the doctor's order was good enough for my insurance company. We had the option of whether we desired to rent-to-own or purchase outright. Our DME (who had already prepared a rent-to-own contract which we rejected) was surprised to hear this, but they called the insurance company and verified what I had told them. We left the DME store that day with a machine that was purchased outright and with no requirement to demonstrate compliance. Insurance varies, and not everyone will be as lucky as I was.

While you have the insurance company on the phone, ask them about lease versus purchase. The benefits of your policy will be clear and you may have the option like I did to choose how you want to proceed.

Always, always, always, talk directly to your insurance company. Use your conversation with the DME to confirm what you already know from the insurance company, and if there is ever a conflict then go back to insurance to clarify.

The insurance company calls the shots, and in my experience the insurance company customer service is always happy to explain the benefits to you. Then you are in a position to make decisions and tell the DME what you require from them.

Remember you are the customer and the DME is a vendor who wants your business. You need to be an informed customer. Your constraints are dictated by your insurance company not your DME, so don't get confused and let the DME tell you what their policy is. Yours trumps theirs if they want your business.

People with our condition already feel lousy enough fighting through the fog to deal with all this stuff. Hope this whole discussion thread is useful info that will help you sort through the crap, get your machine, and start feeling better soon.

Saldus Miegas


p.s. here's a link to the medicare policy on CPAP machines which says in a lot more words what the others have said above. I grabbed it from a google search and I think it is actually a health provider quoting the Medicare Policy, but it seems to agree with everything else I have seen written elsewhere about it. For some reason I can't find the authoritative Medicare web page tonight.

http://www.genesishealth.com/care-treatm...-for-cpap/

Medicare Guidelines for CPAP

1) The patient must have a face to face evaluation with a physician of their choice. At this appointment there must be documentation of symptoms of OSA, a completed Epworth Sleepness Scale, BMI (Body Mass Index), neck circumference, and a focused cardiopulmonary and upper airway system evaluation. This appointment with the physician must always proceed the baseline sleep study.

2) If the patient is currently using CPAP and becomes a medicare patient, the first baseline must meet Medicare criteria. It does not matter how long ago this baseline was performed. If the patient did not have enough OSA then the patient must repeat #1 and re-qualify for CPAP. If the prior baseline met Medicare criteria, the first face to face with the physician, after going on Medicare, must include documentation about the patients compliance of CPAP according to Medicare guidelines.

3) After 3 months, if a patient did not prove nightly usage of CPAP, Medicare will not cover the cost. If the patient wants Medicare to cover the CPAP again they must start with a new face to face evaluation prior to the CPAP.

Medicare Coverage of CPAP at Home

After the patient starts CPAP treatment at home there has to be documentation of patient compliance. This is done after 31 days but before 90 days of usage. They must have a download of the CPAP usage and a face to face re-evaluation with their physician. Their physician must document that the patients symptoms have improved. 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 post was last modified: 08-15-2016 12:39 AM by SaldusMiegas.)
08-15-2016 12:09 AM
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