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Yep, my sleep clinic, not my DME supplier, scheduled me for an appointment 30 days after starting PAP therapy and had me bring my Elite's data card w/me to download the data.

Almost 3 months after starting PAP therapy my DME sent me a form letter asking me to fill out some questions about compliance. H*ll's bells, my Elite could be sitting in the closet and I could lie on the form and what would my DME know or care?

I don't think my sleep pulmo was any more interested in proof of compliance than he was whether the PAP was helping, needed tweaking, pressures adjusted, etc. At least that was the impression I got and they've certainly been one bell of a whole lot hetter than the DME is seeing that I got the best fit w/my mask!! AND better at fitting it!

Hi Guys,
I only wanted to point out that apparently practices, policy, and guidelines vary among insurance plans. While I would have readily agreed that insurances would follow medicare guidelines, my personal experiences with my BCBS lately have shown me that.... not necessarily so. (Actually two issues with xPaP therapy and one issue with a home health care provider that was totally unrelated to xPAP therapy).

The learning for me was: Don't let your DME or your home health care provider interprete YOUR insurance coverage. Check it out yourself.

(Recall the line from Pirates of the Carribean... ' The Pirates Code... well it more of a guideline.')

Cheers,

I just want to add one word of caution to the statement about checking your coverage yourself.

Be VERY careful when doing this. From my side of the road I see this regularly cause much more harm than good.

There are 3 reasons from what I've seen:
1) The people you talk to aren't the experts.
2) Patients often don't know HOW to ask the questions
3) The insurance regs are so freaking complicated hardly anyone can figure them out.

Here is a classic example and something I've specifically myself seen more times than I care to remember:

- Doctor writes a prescription for a BiPAP for a patient with OSA. Doctor faxes us prescription.
- We check the paperwork over and determine that the patients insurance will not cover the item.
- We contact the patient and inform them it's not covered. Patient is obviously unhappy about this.We try and explain why but the patient is of course very upset over this. Patient says, "My doctor told me he orders these all the time! What is the matter with you people?!". Patient hangs up.
- Patient calls his doctors office. They say, "Of course they are covered. We write orders for these all the time."
- Patient decides to check for himself. He calls his insurance. Conversation goes like this aftering getting all the specific policy/patient info:
- - "Ok. My doctor says I have Sleep Apnea and that I need a BiPAP."
- - "OK sir. Give me a moment to find that item."
- - "It's a DME item. I found the code on the internet. It's E0470."
- - "That would require a physicians prescription Sir."
- - "I have a prescription already. Is this something that is covered under my policy?"
- - "Yes Sir. I show the E0470 is a covered item."

Now. From the sounds of all that, it sure sounds like we are idiots and don't know what the hell we are doing, doesn't it?
The problem is the following question is ALSO required to get the full answer:
"What are the coverage criteria required to get that item?"
Then you would find out the long laundry list of specific medical conditions that have to be met IN ADDITION to having OSA before a BiPAP will be covered.

Another great example are Bedside Commodes. These are ordered every single day for patients. The problem is the only time they are covered is when a patient does not have a bathroom on the floor of their home that they are staying in. This rules out darn near everyone.
But if you called your insurance and asked if a Bedside Commode was a covered item, you would be told yes it is.

It's almost like the old 'ask a genie for a wish but get it all turned around on you' sort of thing. The answers are technically correct, but not really the true answer.

Just one bit of caution from past experience is all.

mattman

Slinky wrote:Yep, my sleep clinic, not my DME supplier, scheduled me for an appointment 30 days after starting PAP therapy and had me bring my Elite's data card w/me to download the data.

Almost 3 months after starting PAP therapy my DME sent me a form letter asking me to fill out some questions about compliance. H*ll's bells, my Elite could be sitting in the closet and I could lie on the form and what would my DME know or care?

Heh. Just one comment to this to. I don't know squat about your provider and they may very well be complete garbage for all I know!

BUT - the one thing to remember is that there is a lot of 'behind-the-scenes' communication between MDs and us all the time. For example, I mentioned we get compliance data from doctors whenever possible. Usually, this will be completely without the patients knowledge. There just isn't any reason to call the patient just to tell them we are calling their doctor.

Just a thought is all, not trying to defend anyone!

mattman

Hi mattman;
I don't say this to be argumentative, but I decided to take you up on your challenge to ask the insurance company rep ..."what is the coverage criteria for BiPaP". Nancy Wxxxxxxx on 1/15/07 at 3:30 stated:
A valid prescription and a PSG that shows AHI greater than 5.0"

That's it, that's all....and that's MY insurance.

I really have a problem with the implication that the DMEs are the insurance "experts", only ones qualified to tell me what my insurance company requires.

I don't take offense at your comments at all, Mattman. I appreciate them. Heck, I appreciate comments from ANY of those who work for or own a DME supply place. It never hurts to hear/read both sides of any issue.

And it is interesting, also, to read the different experiences that different DMEs encounter and procedures/policies they go by.

In Kansas for BiPAP to be covered there has to show documentation of failure on CPAP and have proof of Central Apneas. CPAP is covered with an AHI of 5-15 with documentation of daytime sleepiness, or AHI over 15 straight out. BiPAP's being covered are few and far between.

In browsing the MyMedicare website I found it interesting when I was referred to the CPAP information I had to indicate what state I live in. (Am I to assume that there may be some differences in Medicare coverage between the states? Why else?)

It was also interesting to note the following:

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.
Original consideration for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N)
First reconsideration for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R)

Other Versions

Continuous Positive Airway Pressure (CPAP) - Version 1, Effective between 04/01/2002 - 04/04/2005

Yet when you click on the option to view the pdf file on Other Versions, Version 1, Effective between 04/01/2002 - 04/01/2005 you get:

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.
Original consideration for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N)
First reconsideration for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093R)

Other Versions

Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) - Version 2, Effective between 04/04/2005 - N/A

The bold emphasis is mine. So which guidelines do you go by? Version 1, the Original? Version 2, the First reconsideration? The "Other Version"???

The references to Auto PAPs was interesting as well. And seems to be somewhat open to various interpretations. I take it only that Medicare does not recognize an Auto in place of a sleep study done in a proper sleep lab. It seems many DMEs use it as an excuse to deny providing an Auto. For instance my DME telling me Medicare won't pay for an Auto even when my sleep pulmo scripted one. (I haven't pushed this issue yet being willing to see if the pressure changes to my Elite will accomplish our goal, Mine and my sleep pulmo's - NOT the DME's).

dataq1 wrote:Hi mattman;
I don't say this to be argumentative, but I decided to take you up on your challenge to ask the insurance company rep ..."what is the coverage criteria for BiPaP". Nancy Wxxxxxxx on 1/15/07 at 3:30 stated:
A valid prescription and a PSG that shows AHI greater than 5.0"

That's it, that's all....and that's MY insurance.

I really have a problem with the implication that the DMEs are the insurance "experts", only ones qualified to tell me what my insurance company requires.

A couple of things here. Although before I say anything I want to make sure and say that I don't take any conversation as being argumentative and I ABSOLUTELY welcome anyone challenging anything I say. Long as it's done in the spirit of discussion man, I'm all for having someone check my work. Don't take anything I or anyone else says as gospel if you aren't comfortable with it.

1) While it could certainly be true that that really is all there is to it, I VERY strongly suspect you did not get the complete answer, just like I illustrated above. I would be nothing short of astonished if they did also at the very minimum require a diagnosis of OSA. Now, that may very well have been implied in your conversation but it proves my point - It was not specifically mentioned when she gave you the statement of what's required. You may have known it was implied. She may have known it was implied. But what if one of you DIDN'T know that? And that's exactly what I'm getting at.

2) As far as the providers being the experts.. why wouldn't it make sense? Who actually deals with filing claims and working denials all day every day? The people answering the phone at your insurance company or the people at your DME? Who's entire working life revolves around figuring out what will be covered in your specific case?
Look at it this way - who has your information in front of them and is therefore able to make an informed comment about your very specific case? Someone on the phone who just has your policy information and your name/dob/ss# etc and maybe if you are lucky your past claims... or the person at the DME who has your prescription, your Sleep Study/Titration Report, your hospital notes, previous claims, etc....

mattman

To Slinky:

(Am I to assume that there may be some differences in Medicare coverage between the states? Why else?)

I think there is some difference in criteria though I'm not sure. My entire career has been within Region C (Southeast) for Medicare, so that's what I really know. There are differing reimbursement rates for every state, that I do know.

The bold emphasis is mine. So which guidelines do you go by? Version 1, the Original? Version 2, the First reconsideration? The "Other Version"???

While this doesn't exactly answer your question in a manner you can go and use... The version WE go by is the version in the big freakin DMEPOS Manual we have to buy every year.
That's the one publshed by Palmetto and is therefore the one that is legally binding for us. It's also about 1,000 pages long.

For kicks though, here is the current LCD for our area for a CPAP since you went looking:

I'll PM it to you. I previewed it and it's just way too much to include on the board. Check your PM's.

mattman

My most recent experience with a provider was a national home health care provider who insisted that my insurance company would not pay benefits for home wound care if the patient was not homebound. They went so far as to discharge (the patient) over a holiday week-end because they learned that the patient was not homebound. I argued with the supervisor for sometime, but she was resolute.
Following the holiday, I called the insurance company who had been paying claims for this service for several weeks. I was told, after checking with my policy, that there is no requirement for homebound to continue to receive benefits for this service.
I called the home health care provider and told them to check with my insurance company and call me back. When the provider called me back, they apologized with the following explanation: "Many of the insurance companies require that the patient be home bound to obtain coverage for this service. We're sorry, we can readmit and start up tomorrow."

Yes, the DMEs no doubt spend a great deal of time dealing with insurance companies, but I doubt that any would declare themselves superior to the insurance company as it applies to interpretation to a specific policy.

Certainly the consumer should be cautious about accepting interpretations.
But to rely just on the DME's (or other provider's) interpretation is not always the wisest.

As I mentioned before my wife has worked at a number of doctor's offices in the past 40 years. She tells me that in every case, the office policy was to tell the patient to contact his insurance company for any questions. The office policies were very clear.... do not try to interpret someone's insurance.

Mattman, I did not really consider what you said to be a challenge. rather I wanted to check with my insurance to see how they would respond to your question about criteria. I'm sorry to say that my level of confidence with my insurance company his higher than with my DME.

BUT.... that's just me!

And I do enjoy a good discussion!

Best,

[quote="KansasRT"]In Kansas for BiPAP to be covered there has to show documentation of failure on CPAP and have proof of Central Apneas. CPAP is covered with an AHI of 5-15 with documentation of daytime sleepiness, or AHI over 15 straight out. BiPAP's being covered are few and far between.

Which insurance is this? My insurance is through my employer and they also cover employees who are Kansas residents. They require an AHI of > 5 and an Rx specifying a BiPAP, no matter what state the pt is located. I am resisting the urge to mention that it must have something to do with ID.

dataq1 wrote: Yes, the DMEs no doubt spend a great deal of time dealing with insurance companies, but I doubt that any would declare themselves superior to the insurance company as it applies to interpretation to a specific policy.

Certainly the consumer should be cautious about accepting interpretations.
But to rely just on the DME's (or other provider's) interpretation is not always the wisest.

First off, let me say I'm very sorry to hear what happened regarding the wound care scenario. To forcibly discharge a patient over a weekend regardless of the situation is just terrible service. It's not something I personally would never allow.

Without a doubt we can very easily come up with situations on both sides of this opinion to support our views. The fact of the matter is, is that as long as we are all human - we are all going to make mistakes. I make mistakes, those who work for me do as well. We strive for perfection but we are fallible. So are those at the insurance companies, so are we all as patients too.

I will continue to stand by the people who deal with the claims every day as knowing more than any random telephone operator at an insurance company. Literally, our business depends on them knowing the regulations inside and out specifically as they apply to whichever patient we are filing a claim on. If we are wrong, we don't get paid and we go out of business (if we get it wrong very often). In the worst cases, our very certification/accreditation/liscencing will be revoked if we get it wrong, we instantly go out of business and those of us making the decisions can face prison time.
Compared to the people you are calling whom, if they get it wrong, are lucky if someone even remembers their name long enough to complain about it.

What it boils down to though is I frankly don't care where anyone gets thier information, as long as it's correct!

Really though, my primary point was if you get contradicting information don't just assume someone is talking out thier rear. It could just be miscommunication!

Now it's time for 24 then strapping up the mask. G'nite!

mattman

mattman wrote: What it boils down to though is I frankly don't care where anyone gets thier information, as long as it's correct!

Really though, my primary point was if you get contradicting information don't just assume someone is talking out thier rear. It could just be miscommunication!

Agreed! Correct, accurate information is the goal.

You can always avoid contradictory information if you only use one source.

That's where you and I seem to disagree. I'm suggesting that one should check a DMEs assertions (if they "seem" off-base) with their insurance company.

Have a good xPAP night!
If there is a contradiction between the insurance company and the DME, I would think that I would want the two to talk and resolve the discrepancy.

In the final analysis, it's the insurance company that cuts the check for the DME. They are the one who gets to make the call.

Sorry for not hopping back in here sooner. I've been busy.

Thanks for the illumination Mattman. I'm sure you can see how it looks to me. I'm not "offended" by my DME, just becoming more and more likely to not use their services.

My suggestion for your company would be to not highlight any passages unless there's a specific reason to do so for that patient. It just leads to miscommunication and frankly a subtle undertone of "we think you're so dumb we have to highlight parts of this so that you'll read them." I don't know how I would assume anything other than "this was specifically meant for me" when it's highlighted, but that's just me.