One of the things DME suppliers need to have a clear idea of is CPAP (Continuous Positive Airway Pressure) insurance verification. With a growing number of people experiencing sleep disorders, particularly OSA (Obstructive Sleep Apnea), the demand for CPAP devices is also on the rise.
The All-Important Sleep Study
On first contact with the patient, the supplier must find documentation of the sleep study test and its findings. As you probably know, it is through this test that sleep disorders such as OSA are identified.
Sleep apnea or OSA is a condition affecting many Americans. Obstructions in the upper airway affect the regular breathing process while sleeping, causing apnea. OSA is measured through a sleep study, which results in a CPAP device being recommended depending on the seriousness of the OSA condition.
CPAP is the most commonly suggested treatment for sleep apnea and involves patients wearing a nasal or face mask while sleeping. The mask ensures a positive air flow into the nose to ensure that the airway remains open.
Using the CPAP Device
Most patients using the device experience immediate relief from symptoms, coupled with improved mental and physical capabilities. However, it isn’t without its drawbacks, with some patients reporting discomfort while wearing the device though it did help them in their sleep.
People usually get used to the CPAP device in 2 to 12 weeks while experiencing temporary and mild side effects such as sore eyes, nasal congestion, abdominal bloating and headaches. Being temporary, the symptoms eventually disappear or fail to cause significant issues. Some patients do need assistance in getting the mask fitted to their face. According to research, less than half of the users discontinue it.
OSA Diagnosis and Sleep Test Documentation
As the supplier, you need to ensure that the patient has an OSA diagnosis. Polysomnography, or sleep study is a test for diagnosing various sleep disorders including OSA. Carried out at a hospital or a sleep center, the sleep study records brain waves, blood oxygen level, breathing, heart rate, and movements of the eyes and legs. Documentation of OSA detected during the sleep test is essential for CPAP reimbursement, and must be presented when the patient meets the supplier.
- The sleep test detects the AHI (Apnea-Hypopnea Index) of the patient, which is the average of the number of apnea or hypopnea incidents in each hour of sleep.
- The polysomnogram needs to be based on at least two hours of recording without using a CPAP device.
- A patient only qualifies for the device if he/she has a total AHI of 15 events or more per hour, or an AHI between 5 and 14, with documented symptoms such as impaired cognition, moodiness, insomnia, too much daytime sleepiness, ischemic heart disease, or history of hypertension or stroke.
- And you must also ensure that these AHI results on the sleep study are similar to what the patient mentioned to you at intake.
Medicare Coverage for CPAP
Medicare offers coverage for a 3-month trial of CPAP therapy for patients with Medicare Part B, diagnosed with OSA. The coverage may be extended if the patient meets in person with his/her doctor and the doctor documents in their medical record that the CPAP therapy is helping the patient.
In Original Medicare, the patient pays 20% of the Medicare approved amount for the rental of the machine and purchase of other supplies such as tubing and masks. The Part B deductible applies. Medicare pays the supplier of the DME to rent the machine for the 13 months the patient has been using it without interruption. After the 13 months, the patient owns the machine.
It is important to know that Medicare coverage is available for the DME only if the doctor/supplier is enrolled in Medicare.
DME for OSA and Medicare’s Competitive Bidding Program
Patients living or visiting certain areas may be affected by Medicare’s Competitive Bidding Program. If the patient is getting competitively bid equipment and supplies, Medicare provides coverage only if these are provided by contract suppliers.
Some Points to Note
- A Medicare insured patient can stay with his/her supplier who hasn’t got a new Medicare contract if the supplier participates in the program as a “grandfathered” supplier. A “grandfathered” supplier can continue to rent DME to the patient if the patient was already renting the equipment when the program started, and the patient can continue using this supplier until the rental period for the equipment ends.
- Patients starting to rent additional equipment from a “grandfathered” supplier after the program starts will not be provided coverage for the equipment by Medicare.
- The supplier is required to let the patient know in writing 30 business days before the program begins whether they will or will not become a “grandfathered” supplier.
- A supplier who doesn’t have a new Medicare contract and does not plan to become a “grandfathered” supplier is required to notify the patient and pick up the DME from the patient’s home after the program starts.
- If the patient changes to a Medicare contract supplier, the old supplier must work together with the new supplier so that there is no break in service.
- Current Medicare rules stipulate that the patient owns the DME after renting it for 13 months. However, if the patient switches to a Medicare contract supplier instead of using a “grandfathered” supplier or other non-contract supplier, his/her 13 month rental period will start once again and the patient does not own the equipment until after the new rental period ends.
- Patients who own the equipment must obtain replacement accessories and supplies for the equipment from a contract supplier so that Medicare can help pay for these items. Repairs and replacement parts needed can be obtained from any Medicare-approved supplier.
Insurance verification for CPAP devices is extensive. Professional insurance authorization services could help in this regard ensuring that the patient is covered for the prescribed device.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.