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Getting to Know CPAP Insurance Verification

by | Mar 30, 2016 | Blog, Insurance/ Eligibility Verification

Insurance Verification(Continuous Positive Airway Pressure) CPAP insurance verification should be at the top of the list for suppliers of these DME devices. Medicare and private insurance providers have detailed guidelines, and insurance authorization and verification services can really help suppliers ensure that patients approaching them have CPAP devices covered under their insurance plan.

CPAP devices help in improving sleep. And with more and more OSA (obstructive sleep apnea) patients each year, CPAP therapy is increasingly being sought after.

The Detailed Insurance Verification Process

It is important that you ask the patient specific questions to ensure he/she is covered under Medicare or other private insurance and qualifies for the device. Private insurance carriers have different documentation requirements which you need to be aware of:

  • Make sure that you have an appropriate and comprehensive insurance verification form. Your patient must hand it back to you thoroughly completed.
  • The patient must have an OSA diagnosis and also have an AHI (apnea-hypopnea index) of 15 or above per hour.
  • The patient could also have an AHI ranging between 5 and 14 per hour but with the documented symptoms including moodiness, insomnia, impaired cognition, excessive sleepiness in the day, or history of hypertension or stroke, or ischemic heart disease.
  • The physician’s order must clearly document any of these symptoms while the patient’s file must contain the sleep study’s copy.
  • It is also important to verify the real results of the sleep study to know if they are similar to the information given to you at the time of the patient intake.
  • If physicians have recorded apnea episodes as per the Respiratory Disturbance index or the old policy, they must get converted to the AHI.
  • When transmitting and billing claims to DMERC, it is important that a “KX” modifier is added to CPAP and the supplies, which is proof that the required documentation is in place.

Medicare Coverage

Medicare does cover a CPAP therapy 3-month trial for those diagnosed with obstructive sleep apnea. However, if you report that the patient is really being helped by the CPAP therapy in the medical record after you have met in person, Medicare could cover for a longer period. Patients need to be covered with Medicare Part B.

The patient needs to pay 20% of the amount approved by Medicare for renting the CPAP machine and buying the tubing, masks and related supplies, with the Part B deductible applying. Medicare pays the supplier the rent for the machine if the patient is uninterruptedly using it for 13 months.

What the Physician Evaluation must Involve

At the physician evaluation, the patient must display signs of OSA, while an evaluation of the neck circumference and Body Mass Index (BMI), upper airway and cardiopulmonary system evaluation, and Epworth Sleepiness Scale must be conducted. This must happen before the baseline sleep study. In the event of the patient already using CPAP while becoming a Medicare patient, the initial baseline must meet the Medicare requirements. If the initial baseline does not meet Medicare criteria, the aforementioned face-to-face physician evaluation must be repeated.

Evaluation after Home CPAP Treatment Begins

Once the patient begins home CPAP treatment, patient compliance has to be documented after 31 days of usage, but before 90 days are completed. A download of the usage of CPAP plus a face to face re-evaluation with the physician must be done, with the latter documenting the improvement of the patient’s syndrome. The documentation of the physician must reveal that the symptoms of the patients have improved. CPAP adherence refers to usage that is equal to or greater than 4 hours on each of the 70% of nights in a consecutive 30-day period in the first 3 months.

CPAP insurance verification experts would have a clear and updated picture of the requirements of various insurance providers and can therefore help suppliers with this laborious task that begins right when the patient approaches the supplier for the device.

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