Medicare compliance

[me50]

I can second what others have said about the first 90 days being the "compliance period". Medicare requires that you use the XPAP greater than 70% of the days greater than 4 hours a night.

I was also told by my sleep doc that a visit to the doc was required under Medicare annually.

I haven't ever been told that I had to see a doc annually. Do you mean you have to see a sleep doc annually or just any doc?

[PollCat]

I didn't have any real problem when I went on Medicare, they just needed a copy of the doc's script and a brief history regarding my CPAP therapy. My biggest issue with Medicare is the hoops you have to jumps through in order to get the equipment you want. They insist you buy from their 'approved' vendors, which usually ends up costing the system more than if they reimbursed you for buying the items from the DMEs on our suppliers list.

[vcottom]

100% compliance would be great but isn't possible for all of us. After a few days, I got a sore on my nose which just got worse the more I used the Cpap so I limited my hours. After I got a new mask I was able to use it for a longer period of time each night but even with Remzees I still have problems occasionally with the skin on my face getting irritated. I don't think I will ever be 100%.

Kristen, I had the sore(s) develop on the bridge of my nose. A different mask and some foam medical tape for a few weeks and all was well.

[Ghost1958]

Heres the Medicare skinny as I just finished the 90 days and have talked extensively with DME DOC and Medicare about the ongoing whatevers.

Doc orders test. That counts as one of your first face to face of the two visits required You get Test. Doc prescribes machine. You get the machine. Get an auto machine btw as it pays the DME the same for an auto or a straight cpap machine


You will need to take your SD card in to the DME for download in 30 60 and 90 days. Of that 90 days you need to be over 4 hrs on the machine for 70 percent of the 90 days. During the 90 days you will need to have another face to face with a doc about your apnea not before 30 days and not after 90 days. That is your 2nd and last required face to face visit

Once that period is over which I just completed, Medicare will pay 80 percent you will pay 20 percent of everything based on what medicare pays. NOT what the DME charges. In 13months you own the machine. Medicare will keep paying 80 percent of supplies. Replace your machine every 5 yrs. All that is needed for that continue is you to see a doc annually and get a letter of re certification that you benefit from the machine and its medically necessary to give to your DME so they can continue to bill for your supplies.

Thats it. The Medicare cpap shuffle LOL.

[JJJ]

Heres the Medicare skinny as I just finished the 90 days and have talked extensively with DME DOC and Medicare about the ongoing whatevers.charges.

I had a sleep test and the doc wrote the prescription, and I have a copy of it. I returned the machine to the DME after a couple of weeks and bought my own out of pocket (local Craigslist). I never completed any compliance requirements. I never saw the doc again after getting the test results. Yet when I want a new mask or other supplies I go to my DME and Medicare pays.

I should also clarify that if a DME agrees to accept Medicare then they cannot charge anyone more than the Medicare allotment for the item. So if I need a new mask that companies on our supplier list charge $100 for, but Medicare says the charge should not be more than $50, then the DME can't charge me more than 20% of the $50, or $10. They are not allowed to charge me the difference between the $50 Medicare payment and their normal retail. They have to settle for the $50.

The latter point is the reason for a crisis that I find in my community. I live in a fairly high cost area of the country. There are few doctors and clinics here that will accept Medicare patients. Several physician friends have told me that if they accept Medicare patients they will be bankrupt in a short time. Medicare just doesn't pay enough to cover even the costs of the service. Yet at the same time Medicare pays through the nose for machines.

[Ghost1958]

Heres the Medicare skinny as I just finished the 90 days and have talked extensively with DME DOC and Medicare about the ongoing whatevers.charges.

I had a sleep test and the doc wrote the prescription, and I have a copy of it. I returned the machine to the DME after a couple of weeks and bought my own out of pocket (local Craigslist). I never completed any compliance requirements. I never saw the doc again after getting the test results. Yet when I want a new mask or other supplies I go to my DME and Medicare pays.

I should also clarify that if a DME agrees to accept Medicare then they cannot charge anyone more than the Medicare allotment for the item. So if I need a new mask that companies on our supplier list charge $100 for, but Medicare says the charge should not be more than $50, then the DME can't charge me more than 20% of the $50, or $10. They are not allowed to charge me the difference between the $50 Medicare payment and their normal retail. They have to settle for the $50.

The latter point is the reason for a crisis that I find in my community. I live in a fairly high cost area of the country. There are few doctors and clinics here that will accept Medicare patients. Several physician friends have told me that if they accept Medicare patients they will be bankrupt in a short time. Medicare just doesn't pay enough to cover even the costs of the service. Yet at the same time Medicare pays through the nose for machines.

I in my area have never ran across a Doc Hospital or DME that would not accept my medicare plan. By looking at the billing statements im sent by my plan it appears Medicare pays quite enough to more than cover the services and supplies at least in my area.

You are correct though in that I only pay 20 percent of what Medicare pays not what the DME charges. Of course when it comes to supplies the DME's charge much more than what the same costs on the net or to someone not being covered by medicare. I am my wife is not. If I go to the DME to buy a supply it costs me much more should I want to just pay in cash than it does to get that same supply for my wife because I am covered and she isnt at present.

The two face to face encounters are I think a fairly recent thing began by Medicare but they were required for Medicare to cover the machine or supplies. Keeping in mind that I have just now gotten thru the 90 days so my experience is extremely recent and as I said and was told by the doc and DMe the face to face and annual recertafication note didnt used to be required. And I do not think they were retroactive.

[Mike1953]

Your guide to Medicare’s Durable Medical Equipment,
Prosthetics, Orthotics, & Supplies (DMEPOS)
Competitive Bidding Program
https://www.medicare.gov/Pubs/pdf/11461.pdf

[Ghost1958]

I can second what others have said about the first 90 days being the "compliance period". Medicare requires that you use the XPAP greater than 70% of the days greater than 4 hours a night.

I was also told by my sleep doc that a visit to the doc was required under Medicare annually.

I haven't ever been told that I had to see a doc annually. Do you mean you have to see a sleep doc annually or just any doc?

It can be a nurse practitioner as long as a MD signs off on it. Strickly a formality and I think more the DMEs idea really. But mine says they cant order supplies and bill them to my plan without the annual note from the Nurse prac, or just your regular doc.
Doesnt have to be a sleep doc. doesnt even have to be a sleep doc to write your first prescription as long as your tested and diagnosed with SA.