Does Medicare Require An Annual Recertification of Medical Necessity?
My sleep doctor says I need to see him annually if I want to have Medicare continue to pay for my CPAP supplies (as it has for 8+years).
Does Medicare require an annual recertification of medical necessity for CPAP supplies? I've searched the CMS website, but haven't found an answer to this question.
I know (or think I know) that a determination of medical necessity can be made by any licensed M.D., so I assume I can skip going to a sleep doctor and simply rely instead on my PCP for this, but the question is whether the determination must be recertifiied annually even if the original determination and related prescription specified a 99 year period of need?
AndyB
11-15-2023, 08:43 PM
(This post was last modified: 11-15-2023, 08:46 PM by Nightynite.)
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Andy, All you need to do is go to your regular PCP and they can just fax your DME and state you’re compliant with your cpap and it is treating your apnea. I will take a printed out MyAir report to show my PCP that I use the machine nightly and that satisfies him. You don’t need to do any other sleep test or anything like that.
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Transfer your care to your regular doctor (treating physician). You can discuss your VPAP with him and how it benefits how you feel. Get away from the sleep specialist. His objective is to get you into more sleep tests, consultations and visits. You do not need a sleep specialist. The sole purpose of a certified sleep medicine provider is to sign off on sleep reports submitted for diagnosis of obstructive sleep apnea. Many try to convert patients to on ongoing patient/ specialist relationship with routine visits and continuing tests. This is completely unnecessary and not required for ongoing care. Read this section of the How to Deal With a DME wiki https://www.apneaboard.com/wiki/index.ph...Sleep_Test
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
I have never had to report anything to anyone after the initial report to my insurance company, showing compliance, back when I first went on the pap machine. My regular doctor's nurse practitioner took care of that. I was on Medicare from the beginning.
Machine: ResMed AirCurve 10 Vauto
Mask: Bleep DreamPort Sleep Solution
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Dunno but sounds to me like some doc has attempted to gift himself with consistent billing and cash flow from your ongoing "required" visits that aren't truly necessary.
Like with drugs, just say no.
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RE: Does Medicare Require An Annual Recertification of Medical Necessity?
My DME says they need a new script once a year. Not a real issue as I also see my sleep doc (who is also my ENT) at least twice a year for other issues. Every time I see him, he sends a script to the DME. My sleep doc loves my Oscar report. My wife's sleep doc couldn't care less.
Homer
Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies. Monitors are also Advisory Members, just with Extra Work assigned.
Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Medicare desires compliance data (usage, not if it is actually working) while they are "renting" the machine from the DME. Once that rental stops, the machine becomes yours. The prescription is just for getting the device, mask, and other supplies. My GP sends in a script whenever I need a new machine.
In the many years I have been a CPAP user, I have seen my sleep doc twice. My GP has taken care of it since.
PaulaO
Take a deep breath and count to zen.
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Are you saying that Medicare requires evidence of compliance throughout the entire 13-month rental period? Because that is not what my doctor told me yesterday, or what the DME provider said.
On my DME delivery ticket for the CPAP, it says "Medicare - minimum of 4hr+ for 21/30 days. Once compliance is met, a face to face visit is required no sooner than 31 days from setup but no later than 90. Compliance needs to be met by the 90th day from CPAP/BIPAP setup. Usage dates from setup.", and on other paperwork says "The visit will need to be between 31 and 90 days after receipt of your machine. The visit will also need to occur after you have met your usage compliance. During your follow-up visit, your provider will need to review your therapy usage and document in your medical record that you're using and benefiting from therapy. For those with Medicare getting a BIPAP or ASV device, the visit with your health care provider will need to be between 61 and 90 days after receipt of your machine... After making your appointment, please contact us so that we can request the records from your doctor. Failure to meet the compliance requirements may result in insurance denying your PAP therapy claim and leave you financially responsible." (emphasis theirs, not mine)
Their paperwork also said "Medicare requires your PAP supplies order be updated yearly. Please call your physician before your current order expires."
The information I received from the doctor after my sleep study said "If we are starting you on CPAP you MUST schedule an appointment 31-90 days after the day you get your machine. If you fail to come to this appointment your insurance company will take your machine away and make you repeat your tests. To keep your CPAP you must show you can use your machine for 70% of days, greater than 4 hours a night within a 30 day period. You have 3 months to complete this. It is NOT an ongoing requirement afterwards."
At my appointment yesterday (45 days), the doctor told me that he would be sending his report to my DME that I met the compliance requirements, and that was all that was needed. He also said that I probably only need to see him every 2 years if there are no issues, and that I could just call or message him if I needed changes to my pressure or for prescriptions.
From everything they told me, I am "done" proving to Medicare that I need and can successfully use the machine, and can still keep it even if I stick it in a closet. Of course, it's still a rental for another year, so if I die, the DME would take it back.
If anyone knows if this is incorrect, please chime in.
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
cps22, your summary is correct to meet Medicare requirements for reimbursement of an initial new machine. As far as I know my replaced Vauto has not required any compliance demonstration or face-to-face. The 13 month rental is just the way the purchase is structured, and it seems Medicare has that all worked out as they pay what they have authorized, not what is invoiced. Invoices to insurance seem aspirational, but I'd hate to get stuck with those costs without the insurer running interference.
I have to get prescriptions renewed annually, and my GP accommodates that routinely on request. I make sure to hand my doctor a printed copy of a compliance report at the annual exam and let him know everything is working great, and that pretty much takes care of it. He has file material and encounter notes the staff can use to respond to the DME.
RE: Does Medicare Require An Annual Recertification of Medical Necessity?
Thanks for confirming, as I was unclear whether Paula02 was saying that you needed to be in compliance throughout the rental period.
But as far as the OP's original question, the info sheet my DME gave me does say that Medicare requires the supplies order to be updated yearly. So presumably a new Rx is needed for the DME to bill Medicare, but the OP should be able to get that through his PCP.
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