What will insurance companies really accept as compliane?

[cherylann]

My DME told me 4 hours a night - on average. I submit my data card on Sept 22 and as of right now, I only have an average of 3:38 hours with 16 days greater than 4, 26 less than 4, and 1 not used.

[archangle]

My DME told me 4 hours a night - on average. I submit my data card on Sept 22 and as of right now, I only have an average of 3:38 hours with 16 days greater than 4, 26 less than 4, and 1 not used.

Some insurance companies may do differently, but I believe most work on the number of days greater than 4, not an average. I've read Medicare requires >4 hours for 70% of the nights for 30 consecutive days. (21 out of 30) I can't say what your insurance will require. It's probably NOT 50% of the nights. 70% is a lot more likely.

Many DMEs are liars and fools, so don't count on what they tell you the requirement is.

Call your insurance to get the correct answer, although you can't really trust their customer service people to give you the right answer either.

Wear it for 4 hours every day until Sept 22. Even if you have to sit awake for several hours wearing it.

[EO_123]

Put it on and watch tv before bed. But you are making an effort, so I would be surprised if they don't work with you. I think they are looking to weed out the people who never plug it into the wall.

[ems]

DME doesn't know if you are sleeping or not. Better to use it when you are sleeping obviously... but, just wear it to show compliance when you are reading or watching TV.

[rested gal]

I may be wrong, but I think the minimum "compliance" most insurance companies want to see (to continue paying for the machine) is 70% compliance over a 30 day period. Someone better with math than I am can figure that out for you .... I think I've read that 70% usage translates roughly to averaging at least 4 hours a night, at least five nights a week.

If I thought I were in danger of not meeting minimum compliance -- perhaps struggling the first month with keeping the mask on -- and I really, really wanted to keep using CPAP (and having insurance pay for the machine) I'd start logging the needed additional hours by wearing the mask/using the machine during the day, or in the evening before bedtime, while I was awake. Perhaps watching TV or reading while using it. Neither the machine, nor the downloaded report, nor the DME, nor the insurance company know if a person has been sleeping or not while using the machine. The machine does know if a breathing person is attached, though. So just turning it on and walking away wouldn't work.

[chunkyfrog]

Nobody asked for my card--not insurance, the doc, or the DME.
I wonder if they will once I'm on Medicare.
I expect to use the machine I already own for a few more years; and just use Medicare for my masks & stuff.

[cowlypso]

Yeah, my insurance company never asked for the card to be read. They called me twice and asked some questions. Once after a week, and then again at maybe 3-4 weeks out (ironically, their phone call woke me up from a nap while I was using my CPAP!). They asked how many hours I was using it on average, if I was using it every night, if there were any problems that were keeping me from using it, and probably some other questions. That was it. They took my word for it and never requested hard data. Of course, I was rather obnoxious with them when they interrupted my nap, then I didn't get to the phone on time, and spent the next hour trying to get in touch with them so I could go back to sleep (I was sick). I kept telling them how stupid it was that they woke me up from using my CPAP to ask me if I was using it ("Well, I was using it, until you woke me up!").

[cherylann]

Thanks everyone. I'll work out the math using the various 70% scenarios you have mentioned, but with only 13 days left it is going to be tough. Doing the four hours a day while not sleeping isn't practical for me since I work which burns up 10 to 12 hours most days. And I even if I had the time to do that, reading or watching TV is out since I wear glasses. But, since I haven't been sleeping worth a damn since being on this therapy - two hours at a time is about all I can tolerate the mask - I am thinking about just trying to stagger my sleep for a while and see if that helps. Instead of going to bed at midnight or 1:00, I'll go to bed for a couple of hours when I get home from work then get up for a couple of hours, then go back to bed, etc.

How does the timing on the machine work? I always look at it in the morning and it gives the amount of hours for "last night" but then later it shows zero. When does one night end and the next begin on the machine?

The reason I asked if the insurance company actually asks for the report or download rather than relying on the DME to tell them is that when I was questioning them about it, reading between the lines I gathered that they are going to tell the insurance what they want to hear. It is certainly not in their interests for me to return the machine if the insurance company won't pay.

[archangle]

I may be wrong, but I think the minimum "compliance" most insurance companies want to see (to continue paying for the machine) is 70% compliance over a 30 day period. Someone better with math than I am can figure that out for you .... I think I've read that 70% usage translates roughly to averaging at least 4 hours a night, at least five nights a week.

Everything I've heard indicated that compliance was based on number of nights for which you got more than 4 hours. A night either counts or it does not.

I think someone had mentioned one company requiring nights of 5 hours.

Number of days over what time period may vary, too.

[máirtín]

I think you should be calling your DME and/or sleep doctor every day that you only use the machine for 2 hours. You should be bugging someone big time until you have a machine and a mask that work for you, IMHO.

[Muse-Inc]

ResMed machines roll the last night's sleep data into the averages at noon. The challenge might be if your machine's time is not set with clock time.

[EO_123]

I think you should be calling your DME and/or sleep doctor every day that you only use the machine for 2 hours. You should be bugging someone big time until you have a machine and a mask that work for you, IMHO.

I think this advice is spot on. You shouldn't have to be worried about compliance to this degree. Your DME could be doing a lot more to help you and make this work for you. I really don't think you have the right mask yet. Call you DME every day until something works.

[rested gal]

I may be wrong, but I think the minimum "compliance" most insurance companies want to see (to continue paying for the machine) is 70% compliance over a 30 day period. Someone better with math than I am can figure that out for you .... I think I've read that 70% usage translates roughly to averaging at least 4 hours a night, at least five nights a week.

Everything I've heard indicated that compliance was based on number of nights for which you got more than 4 hours. A night either counts or it does not.

I think someone had mentioned one company requiring nights of 5 hours.

Number of days over what time period may vary, too.

Dunno. I don't have to answer to an insurance company or a doctor, so I'm just going by what I've read, too. Different insurance companies do have different requirements. There are some that never check compliance, or are very casual about it. Medicare is the strict one, I believe; and with Medicare it takes more (face to face meeting with the doctor - doctor reporting that the patient is benefiting from "cpap", etc.) than just fulfilling the 70% usage requirement.

Encore Pro (used by the DME for downloading compliance from Respironics and Philips Respironics machines) states the overall percentage number for "usage" on the Compliance page. Mine currently says "83%" usage and is interspersed with a LOT of straight weeks when I was not using the machine. I switch back and forth between different brands of machines. I'm actually 100% compliant with using "cpap" -- but it's not always the same machine.

If all the insurance company wanted to see was a report from the DME of at least 70% usage within 30 days, I don't think it would matter if some days (or even a whole week) had gone by with no usage at all during the month. As long as the overall usage number for the month hit 70%, I'd think that would meet the compliance requirement, regardless of how those hours of use occurred. I don't think the insurance company (or the DME) would be concerned at all with looking for a minimum number of hours per day when what they really want to see is the overall usage percentage number for the month.

When a DME talks about "4 hours a night", I think they're just using that number as a guideline that would easily achieve "70% usage for the month." I don't think they mean it HAS to be used at least four hours each and every night. As long as a person logs enough hours during the month to hit 70% usage, I think that's all that matters for "usage compliance" purposes.

[archangle]

Dunno. I don't have to answer to an insurance company or a doctor, so I'm just going by what I've read, too.

Medicare makes it abundantly clear that it's counting the days of >4 hours. "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."

Encore and Encore Pro report "Percent of Days with Usage >= 4 Hours" and "Percent Days with Device Usage". Respironics machines report "Days>4". Resscan reports days>4 (although you can change the 4 hours to a different number.) S9 machines have a "Days>4 hours" report.

Some S8 machines reported "usage" as "the number of sessions that the S8 Series II device was used in a usage period (USAGE)", but it doesn't call that "compliance." I'm guessing this "usage" number means number of nights it was used no matter how long.

You've got to stop and consider what else could be meant by "70%." It's obviously not doing CPAP 70% of the hours in the week. That would be 16 hours average per night. It could be 70% of standard 8 hours per night, but that would be worse than 4 hours per night. i.e. 5.6 hours average per night. It could be "turned on 70% of the nights", but I think no insurance is going to accept that without hours attached. With that, you could simply wear it for 10 minutes a night.

I did a lot of searching, and everything I could find indicated that insurance compliance was based on "number of nights with greater than 4 hours."

Cherylann, you may still be able to get 70% with the remaining 13 nights, depending on when your 16 "good" days are. Medicare uses 70% of any 30 days in the time period. Your insurance MIGHT be different but a lot of them follow what medicare does.

[cherylann]

I did a lot of searching, and everything I could find indicated that insurance compliance was based on "number of nights with greater than 4 hours."

Cherylann, you may still be able to get 70% with the remaining 13 nights, depending on when your 16 "good" days are. Medicare uses 70% of any 30 days in the time period. Your insurance MIGHT be different but a lot of them follow what medicare does.

No, I can't. I did get 4+ last night, so I've now got 17 days >4. There are 11 days left in the 55 day compliance period and I need 21 more. Now 55 days seems a strange period for compliance, but I started using the machine on July 29 and have to return the card on Sept 22. I'm thinking that the compliance period is 30 days and the DME is going to look for a 30 day range within those 55 days that has 21 (70% of 30) days >4.

But, the DME told me they were looking for an "average" use of 4 days - those she was vague about that. I'm at 3:38 average per day right now so I think I can get to 4. But, I'm calling the insurance company tomorrow to get the real story.