Can I get some help with a Medicare question?

[Worldwar2]

It's my understanding that medicare requires you to be seen by a doctor once a year in order for them to cover supplies. Most DMEs that I know of require that prescription in order to send/give you supplies.

Now if someone knows of the actual rule/regulation for this requirement and has it documented on the Medicare website.....please share it....I have looked and looked and can't find it.

I looked and can't find this either. Requires further investigation. I'm going to call Medicare and maybe we can get this figured out. I'll let you know if I find out anything. Doesn't make sense... why would DMEs need a prescription if they can sell supplies without one?? Just extra work for them I would think -- when they could make big money without one.

[Pugsy]

why would DMEs need a prescription if they can sell supplies without one??

I think that what happens is that these DMEs come up with their own in house rules as to how old the RX has to be.
We all know that the complete mask packages require a RX but this once a year crap I think is probably the DME coming up with a blanket policy that they want to use for whatever reason.
They can do that if they want to. Nothing stopping them and there are a few insurance companies that do require a "yearly" thing. My DME has a notice in their office about those plans. Medicare isn't one of them on the list. I think it is just easier to implement a one size fits all plan than trying to figure out which insurance does what. Anyhow, that's must my opinion and I have no proof.
And doctors...they know even less how each insurance plan works.

And they cover their butts with "your insurance requires it" when that may not be true but most people don't know to question it.

I have seen many people say that their DME or their doctor told them that Medicare requires it and they believe what they are told but I have yet to see the actual proof. Not saying it isn't out there somewhere but I can't find it and I have looked and looked.

[ChicagoGranny]

Re: https://www.google.com/url?sa=t&rct=j&q ... XY&cad=rja

If you read this section of Table 3,

For patients who received a PAP device prior to enrollment in FFS Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device, and/or accessories, both of the following coverage requirements must be met:
1.
The patient had a documented sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; and
2.
The patient had a face-to-face clinical evaluation, following FFS Medicare enrollment, by the treating physician who documented in the patient’s medical record that:
a.
The patient has a diagnosis of OSA; and
b.
The patient continues to use the PAP device.

If either criterion 1 or 2 above is not met, the claim will be denied as not medically necessary.

In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.

... the final sentence leads you to believe that compliance information is not necessary.

However, moving on to the top of the next page,

1. For long-term PAP therapy, documentation from the supplier or physician must support that
the patient continues to use the PAP device.

... this sentence seems to say proof of compliance is necessary.

Then shortly following is this sentence,

Although medical records are not required to be submitted with a claim, they must be
available upon request. We suggest you consider gathering the relevant records at the
time you dispense the item to the patient. This practice minimizes having to go back to the
ordering physician later. Please be aware that medical records are required to support the
continued use of dispensed items.

So the key seems to be that doctors and DMEs will require proof of compliance, not because they are required to send it with claims, but because Medicare may require it at a future date.

Sorry, not a lawyer so YMMV.

[Baja]

Something just occurred to me - does Medicare require that you be compliant in order to get your supplies and see a sleep doctor even if they don't pay for your machine? If they do, then I am screwed. I don't mind paying for my supplies out of pocket, but I'm not going to pay another doctor to just tell me I'm not trying hard enough.

No compliance is required for the transition, but the new supplier will need a copy of one of your sleep studies. Typically your doctor sends them a DWO (Detailed Written Order) with all of the ancillary documentation they need. That can be any Medicare approved doctor, even a general practitioner.

I believe they require a face-to-face meeting with a doctor during the past 12 months for the initial supplier change, but you do NOT have to see a doctor every year. The annual reference is just the supplier documenting continued use, which they mark in your file every time you reorder supplies. I.e. "Patient confirmed they still need and use xpap."

[Janknitz]

That supposed requirement that you see your sleep doctor every year for a new RX MAY be state law in some states, and the big DME's probably require it of everyone so they don't have to sort out who needs it and who doesn't.

[Chevie]

That supposed requirement that you see your sleep doctor every year for a new RX MAY be state law in some states, and the big DME's probably require it of everyone so they don't have to sort out who needs it and who doesn't.

Just to clarify what you are saying, Medicare is a federal program and the rules are identical for all states.

If you are saying, independently of Medicare, states have laws on prescription requirements that vary, you are correct.

As far as Medicare requirements for CPAP and supplies, Granny posted a link to an official document and provided a good analysis. I learned something from that.

[Baja]

I can shed light on compliance vs continued use and the annual documentation requirements.

Compliance is the 90 day trial period for the initial machine. i.e. You used the machine 4+ hours for 70% of the days during a consecutive 30 day period.

Continued Use is what the suppliers are supposed to document in their files in case Medicare audits them.

This can either be doctor's notes OR supplier notes:
https://med.noridianmedicare.com/web/jd ... inued-need

Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used by the beneficiary. Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary:

1. Timely documentation in the beneficiary's medical record showing usage of the item, related option/accessories and supplies. i.e. Doctor's notes.

2. Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements. This is deemed to be sufficient to document continued use for the base item, as well.

3. Supplier records documenting beneficiary confirmation of continued use of a rental item

Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy.

So the only requirement is an annual refill for supplies or confirmation that you continue to use the machine. This can be a telephone call from the supplier where you confirm you are still using cpap, but do not need a refill at this time.

[SewTired]

It's my understanding that medicare requires you to be seen by a doctor once a year in order for them to cover supplies. Most DMEs that I know of require that prescription in order to send/give you supplies.

Depends on the state, some states allow you to have a forever prescription. Other states require new prescription anyway. Medicare appears to accept the forever prescriptions to a limit . It's unclear what that limit is. You don't have to prove compliance you can just stretch it and say you are using the machine. The primary compliance issue is the machine. If you're not using it at all of course, you wouldn't be ordering supplies.

Good luck and I get you. After significant improvement my sleep improvements have just stalled. I don't really have any problem using the machine, but I don't sleep long enough and keep waking up.

[mike1953]

https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

[PoolQ]

I think a lot of this comes down to preventing abuse and who would be responsible.

" If you're not using it at all of course, you wouldn't be ordering supplies" yep unless someone is selling them on EBAY for a few extra bucks, and yes some people would do this.

So the DME ships supplies for 12 months and then gets audited by insurance or Medicare and they say that the supplies were not necessary. Pulling back the payments. If you have a refreshed Rx then you don't have to deal with this possibility. Required no, CYA if you can get it, sure be nice. Will they not dispense without a refreshed Rx, don't really know, my guess that if pushed they will.

A doctor supplying equipment and supplies causes many of us to raise our eyebrows and a DME self certifying as a medical necessity is at least as suspect.