What Happens If You Fail Compliance?

I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

Gotta ask the company... they're not all the same of course.

Has your DME been checking on you? Have they been asking for your SD card to see how much you have been using the unit? If they have not over the past 3 months you may be in the clear, but, they could ask for the machine back if they check.

I've been in touch with my DME over my mask issues. Should be getting the next size of the mask tomorrow. They pulled my data once, just to show me what they can see. It hasn't been three months yet. Maybe 2.

It would be a cold company that would take away your machine when you are showing that every night, you tried to use it, but were not always successful. Not to say there aren't any out there like that, but if it was me, I wouldn't worry.

Thatgirl wrote:I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

Why not?


Den

.

Most insurance companies follow the Medicare guide lines for compliance.
Below are the compliance requirements from Medicare for a CPAP or BiPAP to be covered after the initial 3 months

COVERAGE BEYOND THE FIRST THREE MONTHS OF
THERAPY:
Continued coverage of a CPAP or BiPAP beyond the first three months of
therapy requires that, no sooner than the 31st day but no later than the 91st day after
initiating therapy, the treating physician must conduct a clinical re-evaluation and
document that the beneficiary is benefiting from PAP therapy.
For PAP devices with initial dates of service on or after November 1, 2008, documentation
of clinical benefit is demonstrated by:
1. Face-to-face clinical re-evaluation by the treating physician with documentation
that symptoms of obstructive sleep apnea are improved; and,
2. Objective evidence of adherence to use of the PAP device reviewed by the treating
physician.LCD Information
Adherence to therapy is defined as use of PAP ≥ 4 hours per night on 70% of nights during
a consecutive thirty (30) day period anytime during the first three (3) months of initial
usage.
If the above criteria are not met, continued coverage of a PAP device and related
accessories will be denied as not medically necessary.
If the physician re-evaluation does not occur until after the 91st day but the evaluation
demonstrates that the patient is benefiting from PAP therapy as defined in criteria 1 and 2
above, continued coverage of the PAP device will commence with the date of that reevaluation.
Beneficiaries who fail the initial 12 week trial are eligible to requalify for a PAP device
but must have both:
1. Face-to-face clinical re-evaluation by the treating physician to determine the
etiology of the failure to respond to PAP therapy; and,
2. Repeat sleep test in a facility-based setting (Type 1 study).

In most cases your equipment provider will be able to download compliance data off of your CPAP/BiPAP and print a report to show adherence to your equipment per medicare requirements. Many physicians also have the ability to download your equipment for prof of compliance.

Thatgirl wrote:I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

You have the Airsense machine, do you have wireless function on (airplane mode off)? Are they getting your compliance info wirelessly? Big Brother maybe watching

It depends on your insurance as to what happens. Some insurances will give you another trial others don't. Not all insurances require the face to face follow up visit with the physician either.

Thatgirl wrote:I've been in touch with my DME over my mask issues. Should be getting the next size of the mask tomorrow. They pulled my data once, just to show me what they can see. It hasn't been three months yet. Maybe 2.

Hopefully your next mask will resolve the major leak issues you are having. If not, then it is time to schedule and appointment for a face-to-face, and take your machine and mask in and let them solve it in-person. You seem motivated and have become active here, but you're going to have to be more assertive with your DME to solve the leaks, or you can't succeed. By doing that, you'll at least establish a record that you are trying, but have equipment issues. Equipment failure can be a legitimate reason for noncompliance, but you need to take that initiative.

I think you need to change your perspective a little...

If you were the CPAP Compliance Police, what would you consider "compliance," then how well does that fit the "official" description?

If I were in that position I would first ask if anyone officially told you the need to wear it 4 hours a night. After that I would ask what you did to try to improve your usage. Did you contact the DME or the doctor and let them know that you are having problems? Did you follow up with their suggestions?

I think an argument can be made for intent. If you are trying to make things work, I think your intent goes a long way even if the numbers don't add up.

On the other hand if you aren't trying and aren't letting the "official" people in charge of your therapy know of your difficulties, then the "numbers" may rule. Still, I think you should get a second chance but keep in mind that you need to check in often and let everyone know how things are going. It is best to nip the problems in the bud so you can get on with your therapy and get to the point where you are springing out of bed in the morning fully rested.

HoseCrusher wrote:I think you need to change your perspective a little...

If you were the CPAP Compliance Police, what would you consider "compliance," then how well does that fit the "official" description?

If I were in that position I would first ask if anyone officially told you the need to wear it 4 hours a night. After that I would ask what you did to try to improve your usage. Did you contact the DME or the doctor and let them know that you are having problems? Did you follow up with their suggestions?

I think an argument can be made for intent. If you are trying to make things work, I think your intent goes a long way even if the numbers don't add up.

On the other hand if you aren't trying and aren't letting the "official" people in charge of your therapy know of your difficulties, then the "numbers" may rule. Still, I think you should get a second chance but keep in mind that you need to check in often and let everyone know how things are going. It is best to nip the problems in the bud so you can get on with your therapy and get to the point where you are springing out of bed in the morning fully rested.

The Doctor not the DME is the main contact with the insurance for compliance. All the DME does is report compliance to the Doctor. The face to face with the Doctor within the 90 days shows the insurance you have indeed meet and are receiving benefit from the use of your Xpap. If the user keeps the Doctor and DME informed of the problems the Doctor may follow the reevaluation procedures for the patient. Four hours over a twenty-four hour period is not the much.

I would be less concerned with complience and more concerned with successful therapy.
The people at the DME would all recognize my voice on the phone, hearing that voice at least twice a week until I was successful at getting a full nights sleep, every night with the machine and a nice low AHI.
If the problem is mask leaks, you have three basic issues. Is it the right mask and right size for you. Is it properly adjusted to fit you. Are your pressure settings appropriate. Until these issues are all solved the DME and the doc would hear from me frequently.

Thatgirl wrote:I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

Could you be more specific as to exactly why you haven't been able to make it 4 hours even once in 3 months?

If you're just putting your mask on and taking it off at the first sign of a problem or discomfort, then I'm not sure that constitutes "trying". Unless you're among the very, very lucky this is not a real pleasant journey. It takes hard work, dedication and a stronger desire to live than to be comfortable for a shorter time. Harsh maybe, but it's the reality of it. This isn't a good hobby for the unmotivated, if that's the problem.

The good news is that you've come to the right place for help. I know of nowhere else you can find the kind of help and advice you'll get here, and most here will also coddle you a bit as well. I guess my personal opinion is just that you have to get all the gracious help offered here and use it, but only you can supply the moxie to put it to use.

the DME reports compliance to the insurance not the physician. The only time a physician gets involved is when the insurance requires a face to face visit and the DME has to obtain physician documentation that the pt is using greater then 4 hours a night and benefitting from PAP therapy. Alot of times the physicians do not document properly and the notes don't work.