Compliance Questions

[Dart67]

I have a couple of questions concerning compliance rules.

Is it normal for a 20 year user of CPAP to have to go through all of the usage compliance and 13 month rental requirements for a "Replacement" machine ?

Can I make changes to my settings during this compliance period without affecting insurance payments?

Thanks in advance,

Herb

[OpalRose]

Yes, it is normal procedure, although seems crazy to most of us.  

If insurance is paying, they will expect you to meet compliance regardless that you have used a cpap for many years.

And yes, compliance has nothing to do with making pressure changes to a machine, although some DME’s will try to scare you into thinking so.  Insurance won’t care about that.

Compliance:
Cpap usage must be a minimum of 4 hours per day (70% of the time) for 30 consecutive days.
This must be accomplished within the first 90 day period.
Must also have a face to face doctor appointment after the 31st day, but before the 90 day compliance period is up.
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[Dart67]

Yes, it is normal procedure, although seems crazy to most of us.  

If insurance is paying, they will expect you to meet compliance regardless that you have used a cpap for many years.

And yes, compliance has nothing to do with making pressure changes to a machine, although some DME’s will try to scare you into thinking so.  Insurance won’t care about that.

Compliance:
Cpap usage must be a minimum of 4 hours per day (70% of the time) for 30 consecutive days.
This must be accomplished within the first 90 day period.
Must also have a face to face doctor appointment after the 31st day, but before the 90 day compliance period is up.
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Thank You OpalRose..

[OpalRose]

Your Welcome!
I may not have that wording exact, but that's pretty much what you need to follow. The only way to avoid all of that is to buy your own machine outright and avoid insurance and DME nonsense. But if you have decent coverage, then that's the way to go.

After 13 months, you will own the machine.

[Janyn]

This is what I was trying to get to the bottom of with my insurance (Cigna.) I couldn’t understand what the point of compliance was if I had to rent to own the machine anyway? If I’m not compliant so what? I’m going to be paying for the machine anyway so what am I missing here? Do they pay for supplies or part of them and some of the machine? This is very confusing and they post no information at all about this process.....

[OpalRose]

This is what I was trying to get to the bottom of with my insurance (Cigna.) I couldn’t understand what the point of compliance was if I had to rent to own the machine anyway? If I’m not compliant so what? I’m going to be paying for the machine anyway so what am I missing here? Do they pay for supplies or part of them and some of the machine? This is very confusing and they post no information at all about this process.....

You normally should not have to pay for the entire cost of the machine. A lot depends upon your insurance coverage. If you have to meet a high deductible, then it may be better to check online and compare costs. Sometimes, it’s cheaper to buy outright.

If your going through a DME, then they can check on your coverage before you decide. Then call your insurance and see if what they tell you matches what the DME tells you.

As long as insurance pays for any part of a Cpap machine, you will be expected to meet compliance.

[SarcasticDave94]

Yep pretty much the above mentioned. If you want King Insurance to pay out of the treasury, they demand you bow to the rules of the compliance throne. That goes for machine or supplies that you want King Insurance to pay for. If high deductibles make it cheaper to buy your own, no compliance thrones to bow to.

Whether or not insurance is paying, monitor and adjust for best therapy results with OSCAR data charts and knowledgeable AB members input. I actually told the control freaks I adjust my machine; some of those docs or DME cronies think I'm an insane criminal for daring to self adjust and self advocate. Personally I don't care what they think about me, I adjust with knowledge. My results of my home cooked settings are way better than Dr. Duck concocted, which was wrong on a cosmic level. I corrected it in minutes or I could make an appointment for next Thursday at 3 and they'll adjust it remotely the following Monday. Which would you do?

[Hydrangea]

I just want to add a tidbit in case anyone else is reading, and has different insurance.

Not all insurance requires compliance.

My original DME (which was associated with my sleep "doctor") said I had to meet compliance, but when I called my insurance company they said they do NOT require compliance. My insurance company said if they required compliance with CPAP, nobody would get CPAP machines (in other words, they believe people generally don't tend to be compliant enough to fit the rules of "compliance", but they still NEED CPAP therapy).

So, before you make yourself jump through unnecessary hoops, you might consider calling your insurance company and asking if they indeed do require compliance.

And, in your situation, Dart67, I might be inclined to call my insurance company and ask if they'd be willing to waive the compliance requirement, as you've been compliant for 20 years. Maybe you could offer to show them your data from the last few months, to show that you're compliant. Who knows? It's worth a shot!

AFA renting the machine before you own it... that seems to be typical for insurance companies. I think it's so they can get more money from us through our deductibles (13 months guarantees your paying more for it in 2 different years' of deductibles).

[SarcasticDave94]

That's a good point mentioned Hydrangea. Maybe it helps someone not be tied to compliance.

[Janyn]

I want to clarify that the stated compliance it not correct at least not for my insurance (CIGNA) my compliance is 70% of the time 21 days of each 30 days for the first 90 days, not total. Then the doctor face to face meeting must take place prior to the 90 day point from receiving the CPAP machine.