Who reports compliance to the insurance company?

I started my xpap journey last April. Had lots of contact with the DME at first, went through a couple of masks and switched from CPAP to BiPAP. Haven't seen them since though I did order some replacement supplies in October. I saw my doctor again in August for a follow-up. I am fully compliant and use the machine every night. I cancelled our appointment in November figuring I know from reading my own data that things are going fine. My AHI's are typically .5 and I feel great.

I've noticed from viewing my health insurance claims online that there have been no claims for the monthly machine rental since December. Apria billed me for one of my replacement items and I spoke to them sometime in January about it because it should have been covered by insurance. They asked me at that time if I was compliant and I said yes.

Lately I've been getting phone calls from a machine telling me I need to call Apria. I responded to the first few which were about the billing problem and then stopped answering them when one callback resulted in the operator not having any idea what they called me about.

So now I'm wondering--who reports compliance to the insurance company? Is the doctor responsible for that? In which case I need to go back for another visit. Or Apria? In which case how do they know? And if I'm not compliant, does the insurance company show up on my doorstep to re-possess my machine?

I posted here last year sometime about whether I needed to continue to see my sleep doc if things were going fine and the consensus seemed to be no and I'd decided not to. But maybe I should?

Thanks for your thoughts!

My sister who is Medicare aged, indicates they're all sorts of interested in compliance info. Have you talked to the insurance company about it?? I'd think Apria, the DME, should be asking if they can come verify your compliance by either reading it from the machine or from a memory source like a card or chip. Recording machine data and performance IS the job of the DME. If they have to ask you, they're behind the 8 ball. Not their deal if you're compliant, just finding out if you are so if somebody like the insurance company or your Doc are interested. All in just my opinion, heaven knows I don't get ANYTHING from my alleged DME but still argue with my insurance company that resources & hardware I've picked up and the knowledge of this forum FAR exceed anything the DME ever dreamed. Let us know!!
Kelvin

No one reports your compliance to the insurance company - UNLESS the insurance company requests the proof.

Even Medicare does NOT require that compliance data be provided for reimbursement. Medicare only requires that PROOF of compliance be made available IF requested. Generally, it would be the DME provider who would have to provide the proof of compliance IF it is ever requested.

Prior to fairly recently, local DME providers could get away w/just sending you a form letter for you to fill out and return to them at 3 months and at 12 months stating you were using your xPAP at least 4 hours a night and at least 5 nights a week. That is what I got from my first DME provider in 2007 and early 2008.

So it was some time after early 2008 that Medicare began requiring that providers must be able to PROVE thru data that the Medicare patient was compliant IF Medicare requested that proof of compliance.

I'm going to post on this from my experience, but it is far from the absolute on this.

I am a Medicare patient and I was lead to believe that reporting the compliance was on my doctor's shoulders. According to what I've been told, my Medicare plan (I have a Medicare Advantage Plan) requires compliance reporting and gets it from my doctor.

When I first got my equipment, I was told that I was REQUIRED to have a face-to-face appointment with my doctor 60-90 days after getting the equipment or they would not pay for it.

Thanks for the replies. I have a BC/BS HMO and now that I think about it, after each doctor's visit I have gotten a letter from the insurance company saying I was approved for a certain period of time. I'm thinking perhaps 3 or 4 month. So it may very well be that it's the doctor. I had an appt this past Friday but cancelled it due to the snow. I guess I need to reschedule. And keep going, at least until my machine is paid for which the HMO says is 18 months.

Thanks!

That is correct, Madalot, Medicare does now require that the scripting doctor see you w/in (I thought) 30 days and if I remember correctly 90 days after starting you on CPAP therapy. That is a recent policy.

However, many sleep doctors do NOT have the software to download the data. Their patients' insurance dictates which local DME provider that patient can get their equipment from. The local DME providers have the necessary software to download data from the xPAPs they usually provide. And which brand they provide often hinges on which manufacturer they can get the best bulk order price from. In addition to which the brand they prefer to provide this year may well be a different brand than the brand they preferred to provide last year because this year a different manufactuer provided the better bulk price incentive, often due to a new series of devices. The doctors would have to have the software for most of the xPAP brands on the market and THAT cost would most likely be prohibitive. So, most doctors leave it up to the local DME providers to do the data downloads.

Slinky --

You are correct. My DME does the download and sends it to my doctor. But I'm pretty sure it's the doctor that provides it to the insurance company.

Keep in mind WHO gets PAID FOR THE EQUIPMENT by the insurance company. Usually insurances pay for the xPAP on a monthly rental payment plan for a set number of months - usually 3 to 13 months.

Jersey Girl wrote:After sending in my data card with the info, they sent me a fresh card in the mail.

Seems to me if your insurance requires proof of compliance, they would send you the replacement card first. Otherwise, how do you account for the 3-4 nights it takes to get a new card in the mail?

LinkC wrote:

Jersey Girl wrote:After sending in my data card with the info, they sent me a fresh card in the mail.

Seems to me if your insurance requires proof of compliance, they would send you the replacement card first. Otherwise, how do you account for the 3-4 nights it takes to get a new card in the mail?

I asked that very question once when I waited almost 10 days to get my card back from a download. They said the machine stores the data even if the card isn't in. When I replaced the card, it did say that it was downloading the information to the card, or something to that effect.

Yes, the card downloads all - from the time you did the last download, so no days are missed! I am just very, very happy that I have the therapy and have had the added bonus of it not costing me anything.

I have also ordered up a card reader and downloaded the software, as I would like to start learning how to read the data on my own - with a little help from my friends here, of course!

My DME has never asked to see my machine or any data from it since I got it in late December so I doubt they are responsible for reporting anything in my case. I have had one follow up with the sleep doctor and they downloaded the data, reviewed it with me, made an adjustment and wanted to see me again in two months with the machine. They also mentioned that to be 'compliant' in the eyes of my insurance company I needed to be using it with good results for at least 4 hours per day.

I asked my sleep doc that same question last week. I am on Medicare and wondered if I really needed to see him once a year. His answer was, "I do. Once a year. It's a rather short form." He went on the say that he could assign the task to my PCP if I wanted him to.

amos

After the first week, I have never been asked, by anyone, to provide compliance information.