Compliance Data for Insurance Company

I wondering, generally, if an insurance company wants to be sure you are compliant before they will pay, what data do they ask for and/or rely on? Is it just a progress report from the doctor? Possibly specific data from machines that record data? Do all machines at least record compliance data? It seems the ResMed Compact didn't have any type of card at all, if I remember correctly. But the ResMed Escape II w/EPR did have some sort of card. And my current Respironics M Series BiPap Auto has the smart card, and I believe is fully data recordable.

Of course I'm thinking ahead, so I know what compliance is as seen from the insurer's perspective, which I'm sure isn't the end all/be all of good xPAP therapy. But at least they will pay.

Joe

Most insurances just check for compliance. They want to see that you use the machine for a minimum of 4 hours per night. They don't care if it's helping or not, so long as you get your 4 hours in.

Brenda

The local DME suppliers have been getting by w/just sending you a form letter for you to sign stating that you are using your xPAP every night and for how many hours a night if you didn't have a reporting capable xPAP or if they hadn't done a download from your fully data capable CPAP to provide to your insurance when and if requested but Medicare has either recently adopted or is considering adoption of a requirement that there be actual proof of compliance data via the xPAP. Compliance data being number of hours per night and regular use as number of nights used.

Once every 2 months or so, I receive a new card in the mail with a mailer to send my old card to the DME. They print the report and forward this to the insurance company. I know they are doing this because for 1 period they forgot to send me a card and the insurance company carbonned me on the letter they sent back to the DME stating they would not paid the claim unless they got a copy of the report. Since at the time all I had was the Plus - they can't be looking at anything but compliance (not that some secretary would understand the details if they wanted to look at that: unless she was on CPAP )

SleepyJoeMS wrote:I wondering, generally, if an insurance company wants to be sure you are compliant before they will pay, what data do they ask for and/or rely on? Is it just a progress report from the doctor? Possibly specific data from machines that record data? Do all machines at least record compliance data? It seems the ResMed Compact didn't have any type of card at all, if I remember correctly. But the ResMed Escape II w/EPR did have some sort of card. And my current Respironics M Series BiPap Auto has the smart card, and I believe is fully data recordable.

Of course I'm thinking ahead, so I know what compliance is as seen from the insurer's perspective, which I'm sure isn't the end all/be all of good xPAP therapy. But at least they will pay.

Joe

From what I've read, IF an insurance provider is checking compliance, they consider anything greater than 4 hours per night and 70% of the time (nights) as their compliance benchmarks. That should give users a LOT of wiggle room to satisfy the folks who are helping pay for the equipment. All CPAPs keep track of the usage hours and some convert the nights greater than 4 hours to a number, too. If there is no data card, the whole machine may have to be taken in to the DME.....or they may come to visit the patient to verify the numbers. In some difficult cases.....or cases with difficulty, the doctor or DME may have to write up some kind of note to the effect that the patient is having difficulties adapting, but is still "trying".

I purchased all of my stuff outright and then submitted an invoice to my insurance provider for reimbursement. They got the (correct) impression that I was going to be very serious about making my therapy work......especially when (they knew that) I had purchased the software to monitor my nightly data......because I tried to get them to reimburse me for the cost of the card reader and software......they wouldn't, but I tried.

Den

Thanks all for this info. It seems to explain some of the reporting criteria that seem to be consistent across machines, such as the > 4 hours and 30 day averages, for example.