When it comes to your insurance and how the CPAP machine reimbursement operates there is a very deep seeded confusion among CPAP patients. The dismay includes new patients to positive pressure therapy and veteran patients alike. Mainly due to the constant changes in the guidelines that insurance has decided to use and the lack of communication available to durable medical equipment (CPAP) patients. In an ever growing Medicare population, this problem is especially evident. So read on if you are looking for what exactly Medicare is wanting from you in regards to your CPAP therapy and supplies.
The first thing to understand about Medicare is the guidelines can be extremely straight forward and very confusing if any form of them is not followed strictly. The rules are meant to complete in a certain way, and if they are, the insurance process will flow much easier for users. So the first key is simple, assure that you are following the process correctly!
The steps of Medicare are very concrete as follows:
1. You must meet with a physician who will then note accurately in your medical chart that you are a qualified candidate for a sleep study due to a possible diagnosis of sleep apnea.
2. You will have your sleep study or sleep studies and complete them diagnosing with a form of sleep apnea.
a. In your sleep study, you must have an “apnea-hypopnea index” (AHI) great than five apnea per hour.
b. You must be placed on the appropriate type of CPAP or Bi-level CPAP unit that corrects the sleep apnea.
3. After your sleep study qualifies you for a CPAP machine, all documentation must be provided to a DME provider of your choice. Sometimes your choice is limited due to your location and the Medicare “competitive bid” process which will limit you to a small amount of DME provider options. However, you will still have options, and they must adhere to the following documentation:
a. A copy of the chart notes from your physician stating a sleep study was suggested and planned to be completed.
b. A prescription stating all of the particular supply descriptions and healthcare common procedure coding system (HCPCS) code listed. It also must have the pressure settings for your new CPAP unit listed or the DME provider will typically not proceed with dispensing the machine.
c. A copy of your completed study proving a diagnosis of sleep apnea. with sleep apnea and that a CPAP or Bi-level unit provided that corrected.
4. Once you have found the DME provider of your choice, you will receive the appropriate CPAP or Bi-level machine. The DME provider must adhere to the following for proper reimbursement:
a.The CPAP will not be your machine initially. It will rent for thirteen months.
b. In the first three months, you must meet compliance; this means you must wear your CPAP machine for at least four hours nightly for thirty consecutive days taken out of the first ninety days of use. So for thirty consecutive days, in any correlation, out of the first ninety days, you must wear the CPAP or Bi-level machine for four hours or greater.
c.You must show that you have met compliance, and a copy of a download of your CPAP machine information proving you are correctly using your device submitted with a claim to Medicare. If you have achieved compliance, the positive pressure device will rent for the remaining months and then become yours pending the last piece of documentation required.
d. Within the first three months, you must also have a follow up with the physician that provided the prescription or certificate of medical necessity (CMN) to the DME provider. It must annotate in your chart that you are using the CPAP machine and receiving benefit. This record must be forwarded to the DME provider also to submit with your compliance information to Medicare.
A few even more complex events that can take place can occur every day. First is that many patients get a sleep study before consulting with a physician properly. If that happens, you will have to re-start the entire process! Yes, you read that correctly. If you go straight to a sleep laboratory, have your studies then go to get your machine you will not be eligible until you have completely re-start and have a second study completed after consulting with a doctor first! So, if you have Medicare do not neglect to have that initial consultation with a physician to chart correctly in your record that you are a candidate for a sleep study and that your doctor is going to order one.
The second is simple; the same “re-start” will have to be done if you do not meet compliance. You have three months to prove, to Medicare, you are compliantly using your therapy! So do not take it lightly. If any troubles arise in your first months of acclimating communicate that with your DME provider, physician or do your research quickly.
Lastly, is that this does not necessarily apply to a follow-up appointment with your doctor. Many patients meet compliance, but never follow-up with the physician that ordered the CPAP unit. If that happens, then a visit to the physician must be done as soon as possible. Once the note is completed, it can be provided, and the DME provider can resume the reimbursement process of the CPAP machine. Just remember, that if billing is stopped it delays how long the machine must rent and if delayed for too long the “re-start” will have to be completed.
I always give the warning in nearly every entry I have written, and I feel that there should be nothing different here! The cause of this lack of communication is due entirely to DME providers. Now in defense, these rules are always changing, but that is absolutely no excuse. Sometimes patients are hurt by the system and fail to meet the compliance or adhere to any other situation that is needed. So before you entirely rely on your DME company, or if you have any doubts, do your research. There is a vast amount of information available to you! I hope that this information helps you along the way with starting your CPAP therapy, or continuing it!