How do I know if I am subject to compliance?

[ov10mech]

Just emailed Aetna. The equipment from my Sleep Doc came from Apria. Based on this response, Aetna doesn't even seem to know what compliance is.

* When items are received from a participating provider, your plan
covers durable medical equipment at 100%. A $5,000 calendar year
maximum applies.

* When items are received from a non-participating provider, your plan
covers durable medical equipment at 50%. A $5,000 calendar year maximum
applies.

Typically, when using contracted providers, CPAP machines are considered
rentals until the purchase price has been reached. If the machine is
returned prior to the purchased price being reached, the provider will
no longer bill for the rental.

Please clarify exactly what is meant by CPAP Machine compliance.

[jabman]

I believe that Insurance companies use compliance data to make sure you are using your machine. They don't want to pay for something that is not being used.
I would ask your insurance provider, if you haven’t already.

[Julie]

It means (99% of the time) that you need to show, by presenting the card from your machine, that for a certain period of time (few mos) that you've been asleep, with the machine going, for at least 4 hrs a night. They don't care if you sleep well, if you're upside down in a tree, or have your mask on backwards... just that you're 'complying' with usage as prescribed during that time. Ugh.

[archangle]

It usually means you've "used" the machine 4 or more hours per "night" for 70% of the days in a 30 day period.

"used" means you had the machine on, were breathing into it, and didn't have really bad leaks.
"night" is usually noon to noon. (or whenever your machine thinks noon is, if the clock is off.)
It's "per night," not just hours used. For instance, 8 hours one night and 0 the next only gives you one "night."

That's the most common definition, but it's possible your insurance will want something different.
In theory, your insurance should be able to tell you the requirements, but they'll often tell you one thing one time, and then give you a different answer later when they decide to deny your claim.
Most people find out about compliance when they get denied coverage after it's too late to do anything about it with no advance warning.
CPAP machines (and stupid DMEs) often get the numbers wrong.
If it's midnight and a DME (or insurance company) tells you it's dark outside, go check for yourself.

[kaiasgram]

Please clarify exactly what is meant by CPAP Machine compliance.

ov10mech, I thought this was part of Aetna's response to you, not that you were asking the forum what is meant by compliance. Would you clarify?

[Janknitz]

If you are on traditional Medicare (Parts A and B) you are most certainly subject to compliance requirements, REGARDLESS of which insurer has your Medicare supplemental policy. I'm not 100% positive for Part C Medicare (Medicare Advantage HMO's).

Otherwise, it depends on your insurer and the only way to know is to ASK your insurer, NOT the DME because they don't always know and may make incorrect assumptions.

[ov10mech]

Thanks you!!! Yes I know what compliance is . This is Aetna's response

Please clarify exactly what is meant by CPAP Machine compliance.

ov10mech, I thought this was part of Aetna's response to you, not that you were asking the forum what is meant by compliance. Would you clarify?

[kaiasgram]

Thanks you!!! Yes I know what compliance is . This is Aetna's response

Please clarify exactly what is meant by CPAP Machine compliance.

ov10mech, I thought this was part of Aetna's response to you, not that you were asking the forum what is meant by compliance. Would you clarify?

I love it -- the insurance company is asking you "what is meant by compliance?!"
Well I wouldn't assume that Aetna has no compliance requirements, only that the rep who emailed you has no idea what's going on.

[Roger2]

The best thing I would recommend for you if you already have crapia for your DME is to save every delivery receipt and bill and compare with what you actually got. You may need to use your camera to take photos of the equipment with serial numbers and visit the CMS website frequently to keep appraised of their rules and regulations. Don’t hesitate to call them on the telephone if you find any irregularities or anything that seems out of place such as charges and co-pay’s you think should not be there. If you don’t, the will literally walk all over you with their fraudulent billing practices. I found that they frequently charged for services they never performed on my billings from them and for equipment they never delivered.

If you find anything irregular, you should immediately notify CMS, and the US Inspector General’s office to alert them to a possible (and with Apria a probable) Medicare Fraud. From my own personal experience with this company which is in my opinion, the most crooked company in business today, they need to be prosecuted for these things and if you don’t make a complaint when and if you see it from their company, particularly from their billing department they will continue to do those illegal things to others.

[chunkyfrog]

Make sure you use the machine for AT LEAST 4.2 hours EVERY night,
even if you have to wear it while watching TV--just in case they decide to check the numbers.