What is ethically reasonable to ask of us?

Medicare now demands that I visit a Sleep Doctor once a year to continue to get supplies (masks, head straps, hoses, and I guess filters.) I see someone who does not want to see a sleep doc to get a new prescription for a machine, when the last time they saw a doc was four years ago.

On one hand, it seems we are being pushed through hoops by Insurance providers (including Medicare) as a means to discourage us from seeking medical care by raising our personal cost, aggravation into not seeing doctors. On the other hand, my condition can change a lot in a year.

Seems this group believes that monitoring data is good, but a lot of folks are not capable of reading their data, and coming to a good conclusion as to how their therapy might be changed. We have a lot of folks here who have found that sleep doctors can't make a good conclusion as to what should be done for their therapy, so a sleep deprived person is not able to make decisions for themselves seems reasonable.

If you were testifying to Congress as to what the laws should be for xPAP, what would you tell them they should do?

Put on their masks and go to sleep.

And just how do you know that Medicare "demands" that you see a doctor once a year?
DME told you?
Doctor told you?

I will repeat this same question I have asked over and over again when I hear this...show me in the Medicare regulations where they "demand" this once a year thing to continue to get cpap supplies.
Has anyone ever actually seen it in the Medicare rules and regulations? I have looked but I can't find it. Doesn't mean it isn't there but I want to see it in writing on the Medicare website and not rely on "my DME" or "my doctor" because they have been known to speak with forked tongue.

Meanwhile...I just got a new mask about 3 weeks ago....and there was no mention that Medicare required me to see anybody especially my sleep doctor whom I haven't seen in over 5 years.

Good point Pugsy, so you demand that Medicare needs to be clear with everyone what the rules are?

Medicare likes to send a few documents which begin with, this might not be accurate when you get it, or it might change at any time. Kinda of like having a credit card.

Actually, Last year, I paid like $30.00 as a Sleep Doctor Co Pay. (Pay before seeing doctor) and 140 miles of gasoline, plus lunch, which was over ten dollars. I guess this year I will have to take a peanut sandwich, but lunch seems like the least of the costs.

Since you said nothing, you must believe that no one, should be required, to see their doctor beyond the first visit after getting machine.

We can self-pay, if we like.
I prefer to "play the game", and let Medicare and my supplement pay for what I paid the premiums for.
Insurance is always a game and a puzzle; it may be wrong to make care this difficult,
and it may constitute a tacit death panel, but until we can get it fixed,
IT IS THE ONLY GAME IN TOWN. FIGHT OR DIE.
Of course it's not ethical!

purple wrote:Since you said nothing, you must believe that no one, should be required, to see their doctor beyond the first visit after getting machine.

No, please don't assume that. That's not what I meant at all. Please don't ever assume that because I don't say something that I believe something one way or the other. I think that is up to the patient and the doctor and something they have to come to an agreement of the minds on.

I meant only what I said...I hear stories where someone says their DME told them that they had to see the doctor once a year because "Medicare requires it"....and I hear stores of someone being told by their doctor that they HAVE to be seen once a year because "Medicare requires it" but know one has ever showed me in writing where Medicare really says that.
I hear it but it's always been the DME or doctor who is cited as the source and for all we know it could simply be the DME and doctor deciding to make their own in house rules and hey...they can do that. Nothing wrong with them making their own rules at all and if we play in their sand box we play by their rules.
What I have a problem with is...if they are making their own rules they should be honest about it and quit pawning it off on Medicare as the excuse.

Me personally see the sleep doctor once a year? I see no need to. I have a good handle on my therapy and I have no complicating factors and I am a fairly intelligent person and if I run into trouble then I will see my sleep doctor.
It's not my place to advise someone else to do what I do or believe what I believe.
If my sleep doctor and my DME decided to change their own in house rules so that I had to see the doc once a year then I guess I would see him.
Or if I actually find it in the Medicare rules...and my DME decides to follow the letter of the law ...then I will comply if I have to but I have enough sources for equipment I don't have to. All I ever get from my DME is one mask ever 6 months. Everything else I find cheaper elsewhere anyway.

So really all I mean is IF this really is a Medicare regulation and not some sort of in house rule (which they can do) then where is it? I just want to see it because I won't believe it until I see it.

I am trying to pin down exactly what the Medicare regulation should be. I read here is a lot of frustration with both rules and how in competent DME's are.

How about we make it a rule that everytime the DME messes up, they have to mail me a check for $25.00. Or how should a DME be punished for simply -messing up orders, delaying. I guess it would be impossible to do anything about what someone says on the phone to one. Maybe we can require that all communications by by email, and no vague statements allowed.

Congress can be effected by suggestions, right now the only folks they hear from are the Medicare regulators, and DME's, (and I think some conservatives who want to use rules to get folks from using Medicare, some liberals who want to tell everyone how to dispense medical care.)

purple wrote: How about we make it a rule that everytime the DME messes up, they have to mail me a check for $25.00.

Sounds like a plan to me.
I would be happy to just get a buck for every lie that gets told to a patient...I could build my dream house real quick.

Pugsy wrote:

purple wrote: How about we make it a rule that everytime the DME messes up, they have to mail me a check for $25.00.

Sounds like a plan to me.
I would be happy to just get a buck for every lie that gets told to a patient...I could build my dream house real quick.

some people here would have gotten RICH off of either of those deals *lol*

If we get to write the laws, I would mandate efficacy data capable machines for everyone, and stop such practices as parting out masks for higher reimbursements.

I don't see the point in requiring a yearly check in with a doctor who may have NO data, or may have compliance data. So what? We've seen people here who are 100% compliant for years, but when we help them access data (if they even have data) we find that the therapy was doing them no good.

Any doctor can fulfill the visit requirement (if, indeed, there really is such a regulation--I've never seen it), but very few will do any more than this:
Doctor: "Are you using the machine."
Patient: "Yes but I don't feel any better."
Doctor: "Good, keep using the machine."

Thanks, a lot, doc.

Pugsy:

I couldn't find any recurring medical exam requirement either.
What I did find was the BCBS of North Carolina publication of what is covered and how it is qualified.

http://www.bcbsnc.com/assets/services/p ... es_osa.pdf

No mention of anything after the first compliance period.

purple wrote:Medicare now demands that I visit a Sleep Doctor once a year to continue to get supplies (masks, head straps, hoses, and I guess filters.) I see someone who does not want to see a sleep doc to get a new prescription for a machine, when the last time they saw a doc was four years ago.
...
If you were testifying to Congress as to what the laws should be for xPAP, what would you tell them they should do?

I'd tell them recognize Rule 4B as a legitimate way to score hypopneas for demonstrating the need for a CPAP under Medicare regulations.

The biggest problem I have with Medicare (which does NOT cover me---yet) is that Medicare only recognizes hypopneas if they are scored under "Rule 4A", which demands that there be a 4% drop in the O2 saturation level. Rule 4A ignores the fact that many people do not have this big of a drop during their hypopneas. The American Academy of Sleep Medicine recognizes the fact that some people repeatedly arouse before the desats happen and they have an alternative standard (Rule 4B) for scoring hypopneas. Under Rule 4B, if the airflow decreases by 50% and there is an associate arousal in the EEG OR a 3% drop in the O2 saturation, a Rule 4B hypopnea can be scored.

Here's my beef with Medicare: There are people who have very different AHIs based on which criteria is used to score the hypopneas. We've got a current thread Help Reading Sleep Study? by Hopefullady who is trapped in this mess: She's on Medicare and her Rule 4A AHI = 2.9 and so Medicare won't cover a CPAP for her, but her Rule 4B AHI = 19 and she's got all the usual daytime symptoms of OSA and she's got some heart problems. If she were under employer-provided health care, she'd be officially diagnosed with OSA based on her Rule 4B AHI and her insurer would likely pay for the machine with no questions asked.

I'm also someone who has very different diagnostic AHIs based on how you choose to score the hypopneas: Under Rule 4B my diagnostic AHI = 23.8. Under Rule 4A my diagnostic AHI = 3.9. My employer provided health insurance had no problem covering my equipment. But who knows what's going to happen once I retire and I need Medicare to cover my supplies. If they're still insisting on only counting Rule 4A hypopneas and if I have to have another sleep test, I very well might not qualify for CPAP coverage under current Medicare guidelines.

Medicare has a Certificate of Medical Necessity:

CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA


Go to CMS.gov
Centers for Medicare and Medicaid Services
CMS Forms


SECTION B: Information in this section may not be completed by the supplier of the items/supplies.
EST. LENGTH OF NEED (# OF MONTHS): _________ 1–99 (99=LIFETIME)

I forgot to include:

For items that require a Certificate of Medical Necessity (CMN), the CMN can serve as the written order only if the narrative description in Section C is sufficiently detailed. See Chapter 4 of this manual for information regarding CMNs.

Spring 2015 DME MAC Jurisdiction C Supplier Manual Page 5

I think it is reasonable for insurers and Medicare to require evidence of ongoing need for ongoing treatments. Perhaps every year is a bit much, but I don't think it is patently unethical.