clarification of criteria for 90-day compliance for Medicare

I'm up for my medicare 90-day compliance review and would like to know what criteria must be met in order to maintain medicare coverage! Additionally, if I'm deemed non-compliant, what's going to happen? I've read and and asked my sleep Dr. as well as dme and neither seems to address the bottom line facts of non-compliance.
I've been on this 90-day journey with little guidance or support except for my own online inquiries and thankfully this site! Navigating high pressure waters and total sleep changes at 48 yrs, old and an active participant in my therapy. lot of questions but for now this cloud of compliance hit me this thursday! Thanks for any input!

martinnga

I copyied this from another post I believe it is 2nd 6 month compliance thread. Hope it helps.
Greg

4betterO2 wrote:
LSAT wrote:
Medicare Compliance Rule...

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
This usual text is actually quite ambiguous, I'd like to see some definite interpretation, hopefully one that is "DME/Insurance-corroborated"?
Since the machine does not provide dated data in its summary, but only moving averages, what does the above mean in practicality?
What does anytime during the first three (3) months really mean?
Can the consecutive thirty (30) day period be looked at on any day, at the DME's discretion, i.e., "at anytime"?
Or - as I hope - is it that once you have achieved that consecutive compliant (21 days ≥ 4 hs in 30 days) period once, you no longer have to worry about what happens, in the rest of your initial 3 months?
This is actually a crucial subject in the winter, when a flu can take you off your machine 8-10 days, and it might be during the initial 3 months, throwing your surrounding 30 days consecutive period into non-compliance...
(Moreover, as opposed to BiPAP and CPAP, the ASV compliance requires a medical review by the end of 3 months but no earlier than 61 days, and of course, the machine compliance data will be looked at then, as well as its medical stats, so what the compliance terms really mean is very important, for coverage!)

It's pretty clear.

Your DME/doctor can check any time in the first 90 days to find a 30 day period where you had 21 days in compliance. He can check it on day 30, or he can check it on day 90. He can check it on day 90 and see that you were compliant for the period of day 14 through day 43.

If your doctor or DME is lazy, stupid, incompetent, or suffers from delusions of grandeur, and doesn't check it properly and document it, YOU get screwed. Unfortunately, you may have to figure it out yourself and browbeat them into doing it right.

If you have the flu or some other excuse for not being compliant, the insurance isn't going to waste money to buy equipment you aren't using. You've got 90 days to get your 30 days of compliance.

Your very welcome.
After all this time on this forum I finally get to help someone out. Plus I'm sure if there is anymore info or changes the Great Powers To be will chime in.

martinnga wrote: I'm up for my medicare 90-day compliance review and would like to know what criteria must be met in order to maintain medicare coverage!

In addition to the 70% of 30 days using the machine for more than 4 hours you will have to have a face to face meeting with the doctor.
Be sure and get that face to face before the 90 days is up.

If all the requirements aren't met Medicare can suspend payments for the machine and this forces you to return the machine or pay for it yourself.
Though they will typically try to work with people who have had problems making compliance but it requires special requests.
Best to just get it right first and not have to worry about it later.

I made sure I was in the clear by seeing my regular md between 61 day point and 90 days . I printed out the sleepyhead charts off my machine and told her I was doing fine, my avg hours of use and my reduced AH1, She put it my patient file. The rest of the visit was on my other medical problems. I knew she would not have an sd card reader or the time to fool with it. She was happy I obeyed her wishes to get the sleep study and the follow up .
Also I'm glad someone mentioned the time setting on the cpap machines It helps me to figure out my wake-ups and my bedtimes. Garbage trucks coming in, paper delivery ,fireworks, power outages and I know I need to challenge my memory about when I actually went to bed .

The DME RT put a scare into me in the beginning. She was upfront with me that if I didn't make 70%, medicare would not pay for my treatment.
At the time I was at 65%. I was struggling to get to 4 hrs every night and had a number of 3 1/2 hrs. Now I'm at 80%. I've learned that even if you have a bad night - under 4 hrs - it's beneficial to add more time via a nap if you just can't make your 4 hrs consistently.

I think if you have primary CSA or CSAComp as opposed to OSA, you might get more time to be compliant but I'm not 100% certain and perhaps someone else would know and could answer that.

if you are using Sleepyhead or Rescan software, it displays your level of percentage of compliance.

but check your preferences in sleepyhead, I am pretty sure it has an option to ignore missing days.. make sure that selection is turned off until after your doc or DME has signed off.

Also important to note: 4.0 hours may get rounded down in your machine's memory--making you "non-compliant"
Always get AT LEAST 4.1 hours (or more). If you are not "asleep" for part of that, no one will know.

I was at DME yesterday for a compliance check for insurance. She showed me the screen as she was working and chose the selection for the best 30 day average. Other than the prices for equipment and supplies, I have a very good DME and they work hard to make sure that everything is working to my expectations and that I have insurance coverage.

$66.00 billed to insurance company for a $8.00 hose just kills me.

Dan6 wrote:$66.00 billed to insurance company for a $8.00 hose just kills me.

Yeah but they likely won't get anything near that when it all comes down to allowable amount.
Mine was $56 for one of those $8 hoses last summer but it ended up around $13 being allowed and I paid only about $2.50 or so for my copay.
There's almost always a huge write off down to the allowable amount for anything they bill.

chunkyfrog wrote:Also important to note: 4.0 hours may get rounded down in your machine's memory--making you "non-compliant"
Always get AT LEAST 4.1 hours (or more). If you are not "asleep" for part of that, no one will know.

Yes I was rounded down last week or so when I was getting exactly 4.0 hrs. It was rounded to 3.5. Two nights ago hrs were 4.5 last night 5.5 now % is at 3.9. It takes awhile to get back to at least 4.0. It is better to go over 4.0 hrs as you say.

Pugsy wrote:

Dan6 wrote:$66.00 billed to insurance company for a $8.00 hose just kills me.

Yeah but they likely won't get anything near that when it all comes down to allowable amount.
Mine was $56 for one of those $8 hoses last summer but it ended up around $13 being allowed and I paid only about $2.50 or so for my copay.
There's almost always a huge write off down to the allowable amount for anything they bill.

I know that there will be some adjustment but I am still feeling the sting of $74.00 for pad liners before I met my deductable. I can buy them in town for $23.95, it's all in the coding! I need the cpap to live a good life so will do what it takes to make it work and will learn from buying mistakes.

This is my first experience with home medical equipment and it just seems like suppliers/DMEs are the only ones that benefit from having prescription masks and machines that take a perscripion and a tech to change the pressure. I can see the need for a prescription for the machine so only people who need/benefit from it get one, but after 3 months If I want a new mask I should be able to buy one otc anywhere. All this drives up the cost of health care for no good reason. Have a good tech though, when I told her that I changed the settings on from 4-20 to 9-18 she just smiled and said it looks like it is working well for you.

Sorry for the rant...

Dan6 wrote:I know that there will be some adjustment but I am still feeling the sting of $74.00 for pad liners before I met my deductable. I can buy them in town for $23.95, it's all in the coding!

Ouch..don't blame you there.
Don't worry about the rant....we all have had our share.

It's a racket for sure..that $8 hose is the cost online...and we know they are making money too.
I paid $20 in Las Vegas on a Sat morning for that same hose because some dumb a@@ forgot to pack hers.
But hey, it was Sat morning and the ONLY place open that had one. I guess it was pretty cheap considering the circumstances...bet I won't forget again.

Shop smart on the items that you can find elsewhere...do the math...it is worthwhile to let the outrageous prices go toward a deductible to maybe save you some money later or are you like me...rarely going to meet a deductible.

Even if the amounts are going to meet a deductible or a copay, they are still 1st written down by the insurance company or Medicare & then YOU pay your part of that LESSER amount.

"MY" experience has been that those "lesser" amounts are pretty close to what you would pay if you bought it online.
So, I always at least run it through insurance / Medicare - to use up the deductible.

Actually, since I am now on Medicare, my BC/BS supplement pays 100% of both the Medicare deductible & the Medicare 20%.

Now, if you decide to NOT run it through your insurance or Medicare, that is a different situation.