CPAP Basics - 5 - Insurance and Reimbursement

In as much as The Group knows what is important or not, and more important, what is needed or not, we need to throw some meat into the Rock Soup.

Towards that end, a topic often overlooked until it is too late is insurance coverage. Respironics offers an excellent summary document:

http://www.healthcare.philips.com/pwc_h ... _Hints.pdf

And a good Rule of Thumb is:

The patient has complete control over the direction of their diagnosis and treatment.

That said, some (many) insurance providers will require certain pathways (HST instead of in-lab NPSG, preferred (LOL) DME providers, etc.).

TS2, that is something that should be investigated beforehand.

Consequently, perhaps a more accurate Rule of Thumb would be:

The patient has complete control over the direction of their diagnosis and treatment until proven otherwise.

Unfortunately, by the time people get to the forum (or a book), a heckuva lot of water has passed under the bridge.

mollete wrote:
Consequently, perhaps a more accurate Rule of Thumb would be:

The patient has complete control over the direction of their diagnosis and treatment until proven otherwise.

Unfortunately, by the time people get to the forum (or a book), a heckuva lot of water has passed under the bridge.

Very true. I found the forum a couple hours after I picked up my machine. I was very fortunate that my sleep doctor is really good (also a cpap user). And he prescribes a full data machine because he wants to view that full data. So, my DME wasn't able to downgrade me.

My mom had a different sleep doctor, and she spent 20 years with a couple bricks and no followup. Masks that hurt. An ahi that looked good but didn't take into consideration longer apnea events,. etc. She is back on track now, because of this forum. I had no idea my machine had data, but within days of getting my machine, I was viewing my data, and that got my mom interested in trying again. And now she has the same doctor, same machine with full data and a better pressure. She uses her machine every night now, and feels better. This forum helped her by helping me.

You're right (no surprise), that is an excellent summary document.

Possible related topics in this area (in deference to your presumptive nonsupport of dial wingin'): the patient's right to refuse medical treatment and its effect on insurance coverage for xPAP)--does changing settings constitute "refusing" treatment and can it affect coverage? What is "informed consent" to CPAP?

What to do if you don't have insurance (get APAP scrip from family doctor and auto-titrate with a used machine bought from reliable online source, e.g.).

Thanks mollette, I'm bookmarking this document. For better or worse my insurance (individual, self-employed) does not cover DME. I've had to buy everything including two machines (APAP and VPAP) in less than a year, but in "a few " more years I'll be Medicare eligible. I'm sure this document will be revised by then, but I'll be keeping an eye on it so I'm well informed and prepared.

I like Drowsy Dancer's question about people who don't have insurance. When the choice is between going untreated and essentially dial-wingin' what advice would you give that person? (Earnest question because I respect your expertise.)

After reading this, the table near the bottom that gives the replacement guidelines - I'm shocked my DME hasn't sent me a new water chamber too. They send everything else that is possible to replace - mask, pillows, headgear, tubing (lots of tubing), filters etc. Its good to know the accepted guidelines of the process, broken down this way with flowcharting makes it easier to understand. I got the most out of the replacement table, since I'm in the 'replacement' stage now, not the 'new machine' stage.

Thanks Mollette for this great resource.
Jen

This is a very useful thread. Not surprising, but these guidelines read very similar to my insurance (aetna). I should like to clarify that for medicare and many other private insurance companies, the AHI and RDI (as defined on the second page of the document linked by the OP) do not include respiratory effort related arousals (RERAs). For this reason many insurance companies do not out-of-the-box cover CPAP treatment for UARS. Through some sort of miracle my doc was able to appeal this and I did get coverage. So if you are in this situation, fight it, or find a doctor who will!

*Bump* in case others missed seeing the document linked to in the first post.

Good terms to know when searching for specific coverage policies from your provider are NCD (National Coverage Determination) and LCD (Local Coverage Determination). Also, make sure you have the current policy version.

https://www.noridianmedicare.com/dme/co ... evices.htm

mollete wrote:Good terms to know when searching for specific coverage policies from your provider are NCD (National Coverage Determination) and LCD (Local Coverage Determination). Also, make sure you have the current policy version.

https://www.noridianmedicare.com/dme/co ... evices.htm

What IS Noridian Administrative Services, anyway? Is it the sole administrative contractor for all of Medicare?

Not "sole", but they have a lot:

http://cms.hhs.gov/medicare-coverage-da ... AAAA%3d%3d&

mollete wrote:In as much as The Group knows what is important or not, and more important, what is needed or not, we need to throw some meat into the Rock Soup.

Towards that end, a topic often overlooked until it is too late is insurance coverage. Respironics offers an excellent summary document:

http://www.healthcare.philips.com/pwc_h ... _Hints.pdf

And a good Rule of Thumb is:

The patient has complete control over the direction of their diagnosis and treatment.

That said, some (many) insurance providers will require certain pathways (HST instead of in-lab NPSG, preferred (LOL) DME providers, etc.).

TS2, that is something that should be investigated beforehand.

Consequently, perhaps a more accurate Rule of Thumb would be:

The patient has complete control over the direction of their diagnosis and treatment until proven otherwise.

Unfortunately, by the time people get to the forum (or a book), a heckuva lot of water has passed under the bridge.

Im trying to load this file but it keeps connecting and then gives this error:

An error occurred while processing your request.

Reference #97.16829c18.1487608962.415f1f

would this be on my end or on the forums?

thx!

Carlover wrote: Im trying to load this file but it keeps connecting and then gives this error:

An error occurred while processing your request.

Reference #97.16829c18.1487608962.415f1f

would this be on my end or on the forums?

It won't load for me either.
This was an old post with an old link and phillips respironics redid their website and moved a lot of their documents.
It's not you or the forum but instead a broken link because the document file was moved by phillips respirsonics.

Pugsy wrote:

Carlover wrote: Im trying to load this file but it keeps connecting and then gives this error:

An error occurred while processing your request.

Reference #97.16829c18.1487608962.415f1f

would this be on my end or on the forums?

It won't load for me either.
This was an old post with an old link and phillips respironics redid their website and moved a lot of their documents.
It's not you or the forum but instead a broken link because the document file was moved by phillips respirsonics.

Ok thx

Pugsy wrote:

Carlover wrote: Im trying to load this file but it keeps connecting and then gives this error:

An error occurred while processing your request.

Reference #97.16829c18.1487608962.415f1f

would this be on my end or on the forums?

It won't load for me either.
This was an old post with an old link and phillips respironics redid their website and moved a lot of their documents.
It's not you or the forum but instead a broken link because the document file was moved by phillips respirsonics.

I just started browsing here. Apparently, the Wayback Machine (archive.or) arvhived it in 2015. Here is their link to the original document. http://web.archive.org/web/201511230423 ... _Hints.pdf

That is a very good document with good definitions. Was it removed dur to updated Medicare rules?

I notice that the DME cannot auto-ship supplies, but Lincare seems to currently do that even though their email says you need to contact them first.