What Happens If You Fail Compliance?

[mike1953]

the DME reports compliance to the insurance not the physician. The only time a physician gets involved is when the insurance requires a face to face visit and the DME has to obtain physician documentation that the pt is using greater then 4 hours a night and benefitting from PAP therapy. Alot of times the physicians do not document properly and the notes don't work.

The physician not the DME is involved with the compliance process. The DME gets the information from the patients machine then forwards it to the physician who is required to meet face to face with the patient to file the compliance report to the insurance company. Maybe you should be more familiar with the Medicare compliance rules which most insurance and DME's follow.

[rtrtrt]

You are somewhat correct, however the physician does not tell Medicare the pt is compliant. The DME informs Medicare that they have the compliance results that are required to continue billing via modifier. Only in an audit are the documents (download and notes) submitted to Medicare. In the instance of private insurance which does not require a face to face visit the physician is never involved.

[rtrtrt]

ps it's the DME who follows the pt to ensure they are meeting compliance and help them where necessary and to ensure the user sees the physician between the 31-90 day.

[Thatgirl]

I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

Why not?


Den

.

Lots of issues. Started it with the Simples Full Face mask. Lots of claustrophobia with it. I sleep on my side and had problems with leaks around my nose and such when rolling over on my side. Finally, with wearing the mask a lot while distracting myself and such I was able to calm down and leave the mask on longer. Then I started with having dizziness, lightheadedness, and headaches wearing the mask. Called my doctor at this time and went back to the DME. DME ordered me a hybrid mask. Took over 3 weeks to get it because they lost the paperwork. Finally got it and they sent me the wrong size. Still haven't gotten the replacement size. Doctor just told me to take Ambient. I tried that once and just laid awake feeling paranoid and having hallucinations when I had the cpap on. Once I took the cpap off I fell asleep and had a peaceful night sleep.

[Thatgirl]

I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

You have the Airsense machine, do you have wireless function on (airplane mode off)? Are they getting your compliance info wirelessly? Big Brother maybe watching

No, I left it on. Not really worried about the DME checking up on me.

[Thatgirl]

I've been in touch with my DME over my mask issues. Should be getting the next size of the mask tomorrow. They pulled my data once, just to show me what they can see. It hasn't been three months yet. Maybe 2.

Hopefully your next mask will resolve the major leak issues you are having. If not, then it is time to schedule and appointment for a face-to-face, and take your machine and mask in and let them solve it in-person. You seem motivated and have become active here, but you're going to have to be more assertive with your DME to solve the leaks, or you can't succeed. By doing that, you'll at least establish a record that you are trying, but have equipment issues. Equipment failure can be a legitimate reason for noncompliance, but you need to take that initiative.

I did meet with them face to face and they had me bring my machine in. They thought the hybrid would be best for me, but didn't have any in stock, hence why they ordered one. Still haven't gotten the hybrid in the large size.

[Thatgirl]

I don't think compliance is a requirement for my insurance, but I'm not 100% sure. I have had my machine nearly 3 months and despite trying to use it daily, and trying multiple masks and playing with the settings, I haven't been over 4 hours any night. Is it an automatic that your machine is gone if you fail? Or do they ever give you another chance?

Could you be more specific as to exactly why you haven't been able to make it 4 hours even once in 3 months?

If you're just putting your mask on and taking it off at the first sign of a problem or discomfort, then I'm not sure that constitutes "trying". Unless you're among the very, very lucky this is not a real pleasant journey. It takes hard work, dedication and a stronger desire to live than to be comfortable for a shorter time. Harsh maybe, but it's the reality of it. This isn't a good hobby for the unmotivated, if that's the problem.

The good news is that you've come to the right place for help. I know of nowhere else you can find the kind of help and advice you'll get here, and most here will also coddle you a bit as well. I guess my personal opinion is just that you have to get all the gracious help offered here and use it, but only you can supply the moxie to put it to use.

Definitely have been trying to suffer through things, but I need my sleep too, and I swear, I could lay awake all night and not sleep with the cpap at all some nights. Trying to keep the mask on longer each night and wearing it while awake and distracted has helped. Based on advice here, I increased my minimum pressure to 6 and decreased ramp. That helped a lot. I am optimistic about the hybrid mask when I finally get it! Was really hoping that I would have gotten it by now. I also ordered the Tap Pap from cpap.com. Might try that tonight.

[bill-e]

I guess I'm lucky as my insurance, Blue Cross/Blue Shield does not have a compliance requirement. Not that I don't use my machine, I use it 100% of the time...I just don't like the babysitting.

[BlackSpinner]

Other people have had their machines repossessed by the DME on failing compliance because they don't get paid if you don't meet compliance and your insurance needs it. Only a doctors note about valid issues will allow you to keep the machine longer.

[mike1953]

Other people have had their machines repossessed by the DME on failing compliance because they don't get paid if you don't meet compliance and your insurance needs it. Only a doctors note about valid issues will allow you to keep the machine longer.

Thank you BlackSpinner, ftftft seems to believe the DME controls that issue. I have twice posted the Medicare procedures which most insurance companies follow and that is what the procedure says. Thanks again, have a great day.

[BlackSpinner]

Other people have had their machines repossessed by the DME on failing compliance because they don't get paid if you don't meet compliance and your insurance needs it. Only a doctors note about valid issues will allow you to keep the machine longer.

Thank you BlackSpinner, ftftft seems to believe the DME controls that issue. I have twice posted the Medicare procedures which most insurance companies follow and that is what the procedure says. Thanks again, have a great day.

There are posts on the forum by people who had the DME come in and take the machines away.

[cathyf]

Other people have had their machines repossessed by the DME on failing compliance because they don't get paid if you don't meet compliance and your insurance needs it.

I suppose that's how you get used low hour machines out there being sold...

[palerider]

Other people have had their machines repossessed by the DME on failing compliance because they don't get paid if you don't meet compliance and your insurance needs it. Only a doctors note about valid issues will allow you to keep the machine longer.

Thank you BlackSpinner, ftftft seems to believe the DME controls that issue. I have twice posted the Medicare procedures which most insurance companies follow and that is what the procedure says. Thanks again, have a great day.

There are posts on the forum by people who had the DME come in and take the machines away.

well, that only makes sense, since the DME sells the machine, the insurance co reimburses the DME, if the patient fails to comply, the insurance company doesn't reimburse the dme, and .... well, it ain't the insurance company coming and repoing the machine, no matter what doofus says

[Lukie]

More concerning is the fact that you are not getting full treatment at 4 or less hours and the apneas are doing damage to your heart and brain. Sometimes we can let ourselves be intimidated by the mask and machine. I don't know how many masks or types of masks you have used but if you keep at it you will find the right one and start keeping the mask on for 7-9 hours. On a night when you don't have to get up and work the next morning, make yourself wear the mask for 8 hours no matter what. Success breeds success and soon your will be using it every night for eight hours.

[novatom]

I'm glad I read this. I started my therapy last Tuesday night and, seeing as I had a horrible night of no sleep and was planning on going out on New Year's Eve (plus an event on NY day), I skipped my CPAP therapy on New Year's Eve. I have been faithful ever since, using it more than 4 hours on average per night (despite the lack of sleep). I don't know whether the terms of the 4 week therapy period were drilled into me enough, so I thought it was OK to skip one night (out of 4 weeks). I didn't realize the insurance companies were that strict. Thanks for the heads up.