Medicare "Smart Card" monitoring

Tired Ma,

Just tagging this up, will comment more and give a few more specifics after this CPAP setup.


AKCPAPGUY

Once you get on Medicare, doesn't all other insurance become secondary?

JeffH

Jeff,

That is not always the case, one example is if an individual is still working. There are other situations where Medicare would be the secondary, but most of those involve children.

Tired Ma,

Even though Medicare is your secondary insurance and even though they may not pay anything towards your CPAP, the DME who provided it too you CAN be audited by Medicare and be fined for not adhering to Medicare guidelines. They could be fined and even lose their Medicare status, this is why they are holding you too Medicare's guidelines. The Thread that Jules linked (Thanks Jules) in her post has a link to the exact Medicare guidelines, it is a fairly long read, but it will explain alot of your questions. You can PM me questions if you have any as well, I can't guarantee taht I'll get back to you today, i usually forget to sign on at home, and can't from work.

no the software is expensive so they wont provide a copy for you, and really, you dont need a copy. The DME downloads the information off the card and forwards it to your insurance. They should be able to provide you with a copy of the report as I would believe this would become part of your medical record protected under HIPAA.

Regarding the smart card (I am an RT and cpap user) the card records your usage as well as some useful clinical data like percentage of leak, pressures, etc. The information not only helps the provider but also your doctor. A good DME/home care company will automatically forward the reports they download off the card to your doctor(s). For insurance, both private and medicare, most will require that a 60% compliance is proven via the information recorded by the smart card or they will not pay for it and you will be stuck with the bill. Usually this is only for a few months and then the insurance usually pays for the machine outright and then it is yours to keep. I dont work in home care but this has been my experience both in talking with other cpap patients and my own cpap machine. My machine probably cost me around $300 out of pocket the rest was covered by my insurance....so only being charged $150 is pretty good in my book. Most good DMEs will be willing to arrange a payment plan as well. I do not know if Medicare will pay for the machine outright or not, but it would deffinetly be more cost effective for them to do that than to pay a rental fee since most cpap patients use them for life.

ruthven78 wrote:Regarding the smart card (I am an RT and cpap user) the card records your usage as well as some useful clinical data like percentage of leak, pressures, etc.

I will provide this onlyif they provided somthing besides the basic bottom of the line machine which will only tell them how long it was used (no real data)which is all medicare is interested in. Not interested in how good the therapy is.

If you will fill in your profile you will get a lot better answer

Jerry

I recently got a new machine, M-Series Bipap Auto. I got the machine on the 22nd of December. I received a telephone call from my DME, they asked me to read them the data from the display window of my machine so that Medicare would continue to pay for the machine. The way the lady talked she will call me every month until I have had the machine for 13 months. Also she said I needed to get an appointment with my sleep doctor with in a month as per Medicare. I already have an appointment so no problem there I see him in a week. I know when I go to his office he wants me to bring the machine. Also the DME seemed to indicate that as long as I was using their supplied machine I needed to see the sleep doctor ever month or so due to Medicare requirements? Go figure.
Also Medicare is now my Primary Insurance and BC/BS FEHB is my Secondary.

Medicare only requires proof of compliance once (between the 31st day and the 90th day). Within that time your physician is required to provide proof that cpap has been beneficial. So you have to have the compliance download and the physician visit. Your DME will do your download and request the notes from your physician. As long as you have shown improvement and your download shows you've been using your machine for more that 4 hours a night 70% of the time over a 30 day period then your done with medicare. If after the 31st day your compliance is not acceptable then you have to continue to try to get your compliance in line, you have 90 days from time of setup to achieve this if not then medicare says they won't pay and the patient becomes responsible. Some DME's will continue the compliance process beyond the 90 days if continuing improvement in compliance is shown. They will have to eat the rental costs after 90 days but once you comply medicare will then continue to pay. DME's are not required to do this, they can, after 90 days if non compliant require the patient to pay the cost. At that point it is the patients decision to continue or not.

As a DME provider I'd like to offer my perspective if it will help. The company I work for has been much more proactive in following these recent Medicare rule changes, however I know a lot of companies that weren't being as proactive and are now backtracking.

The Medicare guidelines require the provider to have compliance information on file documenting usage within their standards and must present it if asked, such as in the event of an audit. Providers aren't required to submit the documentation with the claim though, so it seems some DME's may not be as diligent as they should.

In terms of Medicare being a secondary insurance, I've dealt with numerous patients with similar coverage. Even if Medicare is secondary to a primary private insurance the provider is required to follow Medicare guidelines. If you want Medicare to pick up any of the cost you'll unfortunately have to jump through those hoops.

The good news is you have a provider who seems aware of the Medicare guidelines. However, it does seem they didn't necessarily put your care first. Give them a break though if your RT is doing a good job. These Medicare guidelines are new for everybody and I'm sure they're just trying to make sure this goes right for you just as much as for their own billing.

I'm going to be honest, those of us 'regular' people at your friendly neighborhood DME companies aren't in it for the money. We don't get paid that well and we work very hard and usually very long hours. But we're all in it for the same reasons, you the patients.

I hope that helps. Good luck with therapy!

We need to STOP this creepy invasion of privacy. I refuse to have the federal government monitor me in my bedroom and while I sleep. What will they and other companies want to monitor next? How soon will they expect us to get chips implanted in our bodies for the monitoring -- something that's been possible and in trials since around 2004. I'm not a conspiracy nut nor any kind of wacko (I prefer to think not, at least), but this is science fiction territory -- dystopian SiFi, at that -- and we really need to say "This is where we draw the line. Back off!"

By the time one of us needs a new machine, we are assuming that the machine we want
will NOT be covered by Medicare, and probably not very well by any Medicare supplement.
Now I'm trying to get copies of the CPAP mask and equipment formularies
for different companies/plans --BEFORE we sign on the dotted line.
Nobody seems to want to talk to us.

redwoodsriver wrote:We need to STOP this creepy invasion of privacy. I refuse to have the federal government monitor me in my bedroom and while I sleep. What will they and other companies want to monitor next? How soon will they expect us to get chips implanted in our bodies for the monitoring -- something that's been possible and in trials since around 2004. I'm not a conspiracy nut nor any kind of wacko (I prefer to think not, at least), but this is science fiction territory -- dystopian SiFi, at that -- and we really need to say "This is where we draw the line. Back off!"

How silly. Nobody is forcing you to ask Medicare to pay for your machine. Just buy your own machine out of pocket and then nobody will care whether or not you use it. If you want to have them pay for it, then expect to have them make sure you are somebody who is using it. Not one of those who gives up on it right off the bat and sticks it in the closet. Why would you want us taxpayers to pay for machines which sit up on the top shelf in people's closets?

It seems that the folks who complain about the cost of government services are the same ones who complain about the rules necessary to keep the costs down from what they would be without rules.

Nate

I just got my new unit from Medicare/Medicaid and all they asked for was 1 compliance download in the first 90 days and a follow up Doctor visit. They do randomly automated calls(that are messed up) and ask if I am using my machine which I find annoying but can live with. The 13 month screw Medicare rental policy while being annoying, makes a kind of sense because it gives you time to make sure it's the right type of pap unit for you. For me the 13 month deal is to long but then again for someone with special needs it may take that long to nail down.

I just wish that they would figure out a way of making it so we could use online suppliers again but they made that change to protect Brick & Mortar pricing. It's pure crap when my local DME can charge 480$ for a Mirage Quattro( 180$ cpap.com) and then have Medicare pay for some, then hit Medicaid up for most of the rest, and then have some trickle down to me. Then charge 80$ on top of that for the head gear that comes WITH the mask. Yes, I know I can and do specify without head gear and do realize it's so people with bigger or smaller head gears can get the size they need, but the DME's love to charge it every single time they can. When I asked about this the reply was "You don't pay for it so why do you care?"

I wonder how many people realize that they will charge for headgear every 3 months so they can hit Medicare and then Medicaid for the next 3 month period all the while both programs are paying for head gear that comes with the mask. They even tried to do it on my Swift FX which HAS no sizing.

I am not kicking about paying some for my gear I had no issue with 80/20 for online buying but with this scam that Medicare did to itself, its no wonder why the program is going broke.

Has anyone noticed this is an old post -

Medicare "Smart Card" monitoring posted by Tired Ma on Fri Dec 26, 2008 9:41 pm

For the record - as mentioned by others - it is up to the DME to record and store this data "in case" they are audited by "Medicare" and not up to the user. Tho many of us here could provide that info if the need ever does arise.

I think this provider was worried about getting paid and I stand by my earlier post in this thread that I would not want to be doing business with a provider like this. After all there must be a reason why they are worried.

Guest wrote:Medicare changed their regulations FOR NEW patients using CPAP machines effective Nov. 1st 2008
This is why the DME is overly concerned. There are many ways for your doctor and the DME to confirm you are using your CPAP - and a 'smart card' provides documented data they can put in their files should/when Medicare audits them.
The new rules require, for new patients, that during the first 90 days - and after at least 30 days - that you meet with your doctor and that he/she can document you have used your cpap at least 70% of the time for a 30 day consecutive period. If you have not, Medicare will stop paying for the device.

If your hubby has been on CPAP since before Nov 1, 2008 - this regulation (to my understanding) should not apply.

This appears to be true in my case. I have Medicare primary and United Healthcare supplemental. I picked up my bipap machine on January 25, 2012. I had an appointment with my sleep doc in February. I had to take my SD card.
I have another appointment at the end of March and, again, I have to bring my SD card. DME said Medicare would not pay without the appointments. My sleep doc is a pulmonologist and the appointment in February was mostly a pulmonology thing.

hades161 wrote:
I wonder how many people realize that they will charge for headgear every 3 months so they can hit Medicare and then Medicaid for the next 3 month period all the while both programs are paying for head gear that comes with the mask. They even tried to do it on my Swift FX which HAS no sizing.

I am not kicking about paying some for my gear I had no issue with 80/20 for online buying but with this scam that Medicare did to itself, its no wonder why the program is going broke.

I am lucky to have an intelligent, knowledgeable and honest DME, unlike others who have been less fortunate. My understanding from talking to him is that Medicare no longer permits DMEs to automatically bill for replaceable supplies and send them out to the patients. Instead, he is required to have the patient specifically request supplies and sign a written request form each time. So, for example even though Medicare permits you to order nasal pillows for the Swift FX twice a month, you will not get them that often and the DME will not be permitted to bill that often unless you actually request them each time in writing. If you don't need them that often, you don't get them and he cannot charge for them that often.

At least that is my understanding of the current Medicare rules.

What has been the experience of others on replaceables?

Nate