Your med. necessity form may be in limbo

[Dawei]

For Medicare (and possibly for other insurance coverage too), your sleep doc must sign a medical necessity form when he or she orders a sleep study. The DME needs that form when they apply to Medicare for coverage of your machine and accessories. Then, the 13 month rent-to-own period begins and you are billed monthly.
The new wrinkle, I just learned from my DME, is that when Medicare put in place a new plan to save money in Nov. 2008, they changed their med. necessity signature requirement. It used to be that any qualified sleep doc could sign the form on behalf of the sleep doc who ordered your first study. That was changed to require that only the sleep doc who ordered your initial sleep study must sign this form.
So, what if that doc is no longer there? In my case, that doc retired a few years ago and my recent sleep study was ordered by another doc at the same sleep center. As a result, there is no signed med. necessity form for the newer sleep study, and as a result of that, the DME cannot submit paperwork to Medicare for coverage.
Is this crazy or what!
The DME told me I am certainly not in limbo by myself. For now, the DME says I don't owe them anything, but I know that without that signed med. necessity form, I will become liable for the full cost of the machine and accessories at some point, since there is no free lunch.
Do any board members have additional info on this situation? That is, other than my observation that Medicare needs a reality check (again).

[Dawei]

Correction. It was from the hospital sleep center, not the DME, that I just learned about the new Medicare requirement for the doc who ordered the orig. sleep study to sign the form for any follow-up sleep studies. I have the definite impression my DME knows nothing about it. Sorry about that goof on my part.

[SuperSleeper]

So, is it still true that for Medicare purposes, any doctor can write a prescription for CPAP?

Or are you saying it's changed from that?

[Dawei]

Super--Very good question! My recent experience has been that any sleep doc can still write for a sleep study, machine and mask. That's happened in my case within the past year. I got the sleep study, and Medicare paid (they must have since I didn't). Then, two different sleep docs at the same sleep center wrote scripts for two different machines for me plus a couple different masks. Again, no problem from the DME that was communicated to me. The glitch came when filing with Medicare for my purchase of the second machine (the doc wrote a new script for me to switch my Elite for an AutoSet and the DME complied both times). The DME provided the machine, but I haven't received a monthly bill for it for the past 9 months (9 of the usual 13 to rent-to-own months). That's because there is no medical necessity form on file, and that, I learned from the sleep center today is due to Medicare's rule requiring the doc who ordered the initial sleep study to sign all future med. necessity forms. So, the hang up, as I understand it, is not the Rx's but that med. necessity form.
Somewhat confusing, I know.

[SuperSleeper]

This is kind of strange, because I know that Medicare patients have gotten their regular (non-sleep doctor) doc to write a script for auto-CPAP without even going to a sleep study of any kind.... and Medicare paid for the machine.

So, that's why I'm asking if that has now changed...

[cbramsey]

Correction. It was from the hospital sleep center, not the DME, that I just learned about the new Medicare requirement for the doc who ordered the orig. sleep study to sign the form for any follow-up sleep studies. I have the definite impression my DME knows nothing about it. Sorry about that goof on my part.

Did the hospital sleep center give you a source for this assertion? Just curious.

[zonk]

A letter of medical necessity is different from the prescription

[Dawei]

Well, folks, I received a call today from my DME telling me that they discovered that the form for showing medical necessity for my file was lost somehow back about when I had the sleep study and when the sleep doc wrote a Rx for my new machine. They don't know how it was lost/misplaced or whatever. Part of this portion of the explanation being offered included her telling me about their new computer system some months ago and how difficult it has been to learn the new software or whatever. The DME staff member went on to say that the most recent med. necessity form, after my most recent call about the situation, they hand carried to the sleep center where it was signed last week by a nurse practitioner and all the necessary paperwork is now in their file allowing them to go ahead and charge insurance for my almost 9 month old machine.
This, of course, was a totally different story than what I heard yesterday from the sleep center as to why the med. necessity form had not been signed, which I described in the earlier post. When I told the DME about the story I heard from the sleep center, the DME manager said that the sleep center woman I spoke with, whom she knows, must have been thinking about something other than the med. necessity form because she (at the DME) was unaware of any recently enacted medicare requirement for only the doc who ordered the initial sleep study to sign all future med. necessity forms for that pt. She went on to say that the nurse practitioner at the sleep center usually signs all these med. necessity forms on behalf of the sleep docs.
Well, it certainly dropped my jaw. I suggested to the DME person that she might want to touch base with the sleep center to learn about what they had told me re: new signature requirements for the form.
At the end of the conversation, I asked if they (the DME) send the med. necessity form in to Medicare. She said no, they keep it in their file to have on hand if Medicare decides to do an audit anytime in the future.
How the sleep center and my DME could have such differing stories is something I can't comprehend. But IF (important word) the DME version is the correct one, it means that nothing has been changed by Medicare and there is no new requirement for which doc signs the med. necessity form---heck, it can even be a nurse practitioner!

[SuperSleeper]

So, someone correct me if I'm wrong here..

Things have not changed with Medicare requirements, as far as we know (correct?)...

Can I can safely assume these things, in other words?:

1. You need a prescription to obtain a CPAP machine under Medicare.

2. For Medicare to pay for CPAP rental/purchase, that prescription does not need to be from a "sleep doctor"... (it can be from any type of doctor such as a general practitioner or primary care physician).

3. For Medicare to pay for CPAP rental/purchase, the prescription is all that is necessary (not a certificate of medical necessity).


Now, tell me which of the above statements are still true or if one isn't true, why and where can we find the official Medicare documentation to support this?

And again, I'm asking about what Medicare requires, not a DME who has their own set of "company policies".

Can someone enlighten me here?

[zonk]

Can someone enlighten me here?