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Medicare compliance
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Kristen Offline

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Machine: remstar pro c-flex+
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Location: USA

Post: #1
Medicare compliance
I am on Medicare and when I first got my cpap machine and equipment I was given a compliance list. Wear at least 4 hours a night for the first 30 days. Then between day 31 and 90, go back to my doctor so he could verify that I needed the cpap. then I read somewhere on my own that either days 30 to 90 or 30 to 180, I needed to use the cpap at least 4 hours per night for 70% of the nights.
I asked the DME people about compliance after 6 months and was told that the more I used it the more the benefit to my health but could never get an amount of time that Medicare required to keep getting supplies and seeing the doctor. Does anyone know anything about this? It seems odd that they would be so set in what to do the first 30 or 90 days and not care after that so I am not sure the DME knows what they are doing.
02-24-2014 02:05 PM
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Peter_C Offline

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Other Comments: Severe obstructive sleep apnea 1999/Just got an ASV machine

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Location: Akron, Ohio USA

Post: #2
RE: Medicare compliance
As I am to get on Medicare this summer, I too am curious, but I do not know any answers. My big question is what will they do since I have been on xPAP for so many years, order a new study?

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
02-24-2014 02:18 PM
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DNB128 Offline

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Location: Rochester, MN

Post: #3
RE: Medicare compliance
Kristen and Peter C,

70% of the days used must be greater than 4 hours for Medicare compliance.
02-24-2014 04:46 PM
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me50 Offline

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Post: #4
RE: Medicare compliance
(02-24-2014 04:46 PM)DNB128 Wrote:  Kristen and Peter C,

70% of the days used must be greater than 4 hours for Medicare compliance.


70% of 30 days has to be used 4 hours or more. If you don't, then compliance will start over and you have 90 days to become compliant or medicare will not pay for the machine. When compliant, medicare will rent the machine for a total of 13 months and then you will own the machine.

There is no requirement to see a doctor once you have your set up. At least that is how it has always been for me.

Hope this helps.
02-24-2014 04:51 PM
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jgjones1972 Offline

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Machine: ResMed S9 AutoSet
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Post: #5
RE: Medicare compliance
I have recently helped a relative on Medicare in getting started on CPAP and my understanding of Medicare compliance is this:

The "Compliance Period" is the first 90 days. To show "Compliance" you have to have a stretch of at least 30 consecutive days in which you have used the CPAP machine for at least 4 hours per night in 70% of the nights in that 30 day stretch. Once compliance is demonstrated, you must have a follow-up with the prescribing physician (I think this is so the physician can verify medical benefit/necessity).

So if you met compliance in the first 30 days and your Doc thinks it's helping, then you're good to go and Medicare will pay for the machine and supplies. If you haven't met the required criteria in the first 30 days, then you still have 60 more days to meet it. The way they see it is that once you have met "compliance" you have demonstrated your ability and willingness to use the machine enough for them to pay for it and the supplies. I'm pretty sure that once compliance is met and the compliance period is over, they just assume you will keep using the machine and they stop checking up on you.

If you can't meet the required criteria to be considered compliant within the first 90 days, then they feel your inability or refusal to use the machine as directed releases them from having to continue to pay for it and the supplies and they will terminate the lease and deny claims for subsequent supplies.


This is my understanding of it but YMMV. Some things vary from state to state. A local DME that operates in three different states (this one and two adjoining) has a little booklet they provide to Medicare patients. In that booklet they only list the follow up appointment as a requirement for compliance in two of the three states and they also have three different "Medicare Covered Supplies" schedules - one for each state, and all three are slightly different.

I'm not sure if this actually means the benefits are different in the different states or that the DME just provides a different level of service for people in different states - after all, it is a DME. Laugh-a-lot
02-24-2014 05:56 PM
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justMongo Offline

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Post: #6
RE: Medicare compliance
Regardless of who pays the bills, I believe you have to see the doc occasionally for him to keep your Rx for DME supplies current.
It's probably once per year; mine schedules me for 6 months.

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.
02-25-2014 12:05 PM
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herbm Offline

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Post: #7
RE: Medicare compliance
It's always worded as 70% of the days in a 30 day period.

But note: This is 21 days where the first date is withing 30 days of the last date -- probably easier to understand if it is giving someone trouble.

(30 * 0.70 = 21 days)

If you must be picky it is Noon to Noon for a 'day'.



You could of course just use it all the time and there will be no compliance issue. If you need it you REALLY need to use it.

Sweet Dreams,

HerbM
Sleep study AHI: 49 RDI: 60 -- APAP 10-11 w/AHI: 1.5 avg for 7-days (up due likely to hip replacement recovery)

"We can all breathe together or we will all suffocate alone."
02-25-2014 01:02 PM
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mjbearit Offline

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Machine: REMstar Auto AFlex DS550
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Location: So Cal

Post: #8
RE: Medicare compliance
Not to over simplify things, but when I go to bed at night, every night, I take my meds, put on my mask (my machine comes on automatically), turn off the light and go to sleep. In the morning I wake up, take off my mask, turn off my machine, get out of bed. That is 100% compliance and that is the most beneficial way to use a CPAP machine. I have data going back 603 days for this machine and I have 100% compliance for 603 days. On the downside, I am so used to the machine that is the power goes out I am awake within a minute or so and I can't go back to sleep until I get power!
Mike

As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
02-25-2014 04:54 PM
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herbm Offline

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Sex: Male
Location: Austin, TX

Post: #9
RE: Medicare compliance
mjbearit:

It's not complicated is it?

Just wear the thing.

Most people would never leave home NUDE (unless at a nudist camp or nude beach).

So don't go to bed without the mask.

Still 603 days is quite impressive. My 25 days pails in comparison, except for that one thing: If I am lying down the mask and machine are on.

I have no idea what would happen if the power goes out -- which it eventually will -- but likely I would in that case just sleep without it.

However, it was bothering me so last night I ordered a BIG UPS like the ones I use for my big screen TV and virtual machine host servers. Smile

I will soon get a measurement on how long the UPS will run the machine and let you all know.


Just wear the silly thing -- what a concept! -- it's not complicated.

Sweet Dreams,

HerbM
Sleep study AHI: 49 RDI: 60 -- APAP 10-11 w/AHI: 1.5 avg for 7-days (up due likely to hip replacement recovery)

"We can all breathe together or we will all suffocate alone."
02-25-2014 10:39 PM
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Kristen Offline

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Machine: remstar pro c-flex+
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Mask Make & Model: F&P Flexifit 431 full face
Humidifier: respironics stystem one
CPAP Pressure: 12
CPAP Software: Not using software

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Sex: Female
Location: USA

Post: #10
RE: Medicare compliance
100% compliance would be great but isn't possible for all of us. After a few days, I got a sore on my nose which just got worse the more I used the Cpap so I limited my hours. After I got a new mask I was able to use it for a longer period of time each night but even with Remzees I still have problems occasionally with the skin on my face getting irritated. I don't think I will ever be 100%.
02-26-2014 02:03 PM
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