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Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - Printable Version

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Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - FormerFed - 01-10-2020

Just wondering if I’m getting into another endless loop with my apnea treatment and if anyone has advice they would share w/me.  I have been on a successful CPAP program since April 2016, and enrolled late last year in Medicare.  My DME phoned this week advising Medicare won’t cover supplies until I can provide the DME a “doctor’s followup”, which they say needs only be a note or a Xerox of his notes to document that I’m adequately controlled and am compliant.  The last I saw my sleep doc was 2016.  My AHI was 6 at my January 2016 sleep study, I began CPAP in April and he saw me 3x over the next several months, each time, after CPAP, my AHI was consistently 0.0 or 0.1, at times going up to 0.2 or 0.3.  He was delighted and told me I didn’t need to come again unless things started changing or I had any problems.  I never did, I’m still getting those great numbers and 100% compliant except for 3 weather-related power outages.

Unfortunately when I phoned to see him for this Medicare thing, I learned he had left private practice, he is now a hospitalist.  Two docs could see me now – one who was there in 2016 with whom I had bad experiences, and one who is new to me, a PA.  I set an appointment with the PA, but got a call from staff that same day that I needed to move the appointment to earlier in the day because they had to see me as a “new patient” since I hadn’t been in since 2016 and she would not have time to do everything she needs to do.  I had scheduled, initially, the last slot of the day because the parking is a nightmare unless you get in there first thing in the morning or come in very late in the day.  I get it that the PA would not want to rubber-stamp an approval on something that happened nearly 4 years ago, but I never did get a “new patient” visit with the sleep specialist at that time and I don’t know what to expect, and when changing this appointment the staff couldn’t explain it to me.  My misgivings are that, except for the therapist and the doctor who has left, I was treated pretty shabbily by the sleep medicine section of this practice when I first entered the world of apnea and CPAP and I don’t want to have a proven-successful program tweaked and upset while I am automatically marched down some path of unnecessary exams and testing.  The DME says the therapist cannot do the Medicare followup.  My primary is in the internal medicine side of this practice, and I asked him if he could do the Medicare followup at my upcoming checkup - he said it was better for me that the PA do it to assure I was still being effectively treated.

Has anyone reading this come into a new practice already on a CPAP program that has been working for them?  What happened there?  Has anyone here done one of these “Medicare followup” visits?  What happened?  Were you able to make Medicare happy?


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - Gideon - 01-10-2020

Common procedure.
I had to redo the diagnostic procedure, an overnight sleep test. My Dr., a new to me Sleep Doc. recognized the fallacy of this since I was showing her charts that showed (recent development at the time) that I was doing terrible with an APAP at very high pressures and wrote it up to be a split study with a biLevel. So far so good.

I told them I don't sleep without my PAP, the usual response, you'll do fine. Well, I didn't sleep enough to qualify for the 2 hours I needed to be "diagnosed" (118 minutes of sleep) The Tech said he would cover it when describing why he didn't put me in a mask. He said I definitely had Apnea. I had to redo to get the titration done (APAP/BiLevel).

Yes, normal for medicare


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - OpalRose - 01-10-2020

Medicare can be a bit tricky.  Yes, you've been successful and compliant with your treatment, but they don't know that, since you haven't been back to a doctor.  What they will want is documentation or proof that you've been compliant.  

I have the same issue with my regular family doctor, as he doesn't want to treat or write scripts for anything Sleep Apnea. So, I show up once a year to my Sleep Doctor/Pulmonologist and he documents everything.  You have to "play" Medicare's game if you want continued coverage.  

Start printing out reports from ResMed and OSCAR software to show you've been using the machine and for how long.  Bring all that with you to your appointment.  Possibly bring a copy of your SD card along too.  

Good Luck!


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - Zorki1c - 01-10-2020

When we changed Medicare Advantage providers they told me they wouldn’t pay unless I got a a new sleep test and evaluation. Now my machine sends a report to the DME every day so it might be that if I changed insurance again I wouldn’t have to do it.


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - FormerFed - 01-10-2020

Thanks!  I'll now know not to pitch a fit if I hear similar instructions.  I really do try to be a helpful patient and I'm not ever comfortable arguing with someone I don't even know, but learned enough from my and others' experiences that sometimes busy people really aren't paying full time and attention and just don't leave you any choice.  Sounds like you had to go thru a hassle but at least came to a good resolution with it - hope so!


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - FormerFed - 01-10-2020

Thanks!  I was hoping my card would do my talking for me, but hadn't thought about bringing printouts.  Appreciate the annual checking-in idea, too … I'll put a note in my calendar to do that as a preemptive strike!  Re/Medicare, it's actually nice to see that the government does take time to find out about what they're paying for before they pay it … sometimes!  What I fear is that by simply trying to get the Medicare question addressed, I have stepped into some tangling side-tracking mess by having to see a new doctor!


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - greatunclebill - 01-10-2020

my experience with medicare is that in addition the letter you're talking about they will also want a copy of your latest sleep study whenever it was. so you might want to start asking about that and not be surprised if they ask first. your original study should be good and will be filed where you had it done. some docs probably would rather do a new study than dig up your old one


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - FormerFed - 01-10-2020

I kept my Blue Cross insurance as a supplement to Medicare and did wonder what would be so bad if I just did nothing, have Medicare go ahead and deny CPAP gear and then have BC/BS continuing to pay the share they have been paying all these years.  But it seemed a foolish thing to do, so here I am.


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - FormerFed - 01-10-2020

Thanks!  The doctors' offices are in the building adjacent to the hospital where the study was performed - I expect they'll make me into a badminton birdie in the process of finding and securing a copy, but that's okay, I'm retired, I have the time!  I do have things that one of the sleep doctors printed off for me, maybe it'll suffice.  He was a great guy, gave me a lot of confidence that I was doing the right thing going on CPAP.  The first doctor who "treated" ne wouldn't even see me, just signed me up for a study and signed a report about me that included information about someone else - not me.  I stayed unsure that I wasn't being evaluated per someone else's sleep study!  And though I learned eventually that he had put in the record that I should have CPAP, he never put my CPAP prescription into the system to go to the therapist - I went months thinking I must not have had bad enough apnea to be able to get a CPAP.  And the staff was a very thorough firewall for him - I was in the dark for months.  Finally, thru my primary, I learned in a completely separate conversation that I was supposed to be on CPAP.  His internal medicine section is in the same practice as this sleep medicine section, and his nurse clued me in that there was a respiratory therapist there who was very good and I should get time with her and get her to help me get on track with what my primary had hoped to see happen for me in the sleep medicine section.  She got to the bottom of the trouble and got me on track with the CPAP prescription and appointments to followup my progress, and had me test-drive various masks to find out what worked best.  AND, seeing how the doc had messed me up, she clicked a few keyboard clicks and simply transferred me from his care to a new doc who had recently joined his staff.  New guy went through our visits quickly but was very informative and great at explaining things to me.  Hope I find the PA is as good a new-hire as he was!


RE: Cpap vet getting Medicare coverage and a "new patient" exam - need advice please! - 70sSanO - 01-11-2020

Not a Medicare expert, but I don’t believe you can’t use BC/BS as a supplement unless it is truly a Medicare supplement; and there are different supplement options.

You can’t have two prinary insurances. Either it is BC/BS or Medicare with or without a supplement. A supplement will pay what Medicare doesn’t (within the plan).

John