One of the frequent questions our reimbursement help desk gets from CPAP suppliers is:
“Does Medicare allow a second trail if the patient fails to document compliance in the first 90 days?”
The answer:
“Yes, Medicare permits a second CPAP trial under certain circumstances, but Medicare doesn’t pay for a second trial.”
Failed trials are costly, and CPAP users are significantly more complicated to service after failing their first attempt. Perhaps the better question is,
“How can suppliers help CPAP users benefit from therapy during the initial trial?”
Next Episode: Thursday, December 14, 2023
Ninety days may seem like a long time, but it is not. To help suppliers get the most out of CPAP therapy, persistent communication is critical in the first four weeks to:
- Educate the patient,
- Evaluate the patient’s commitment and the therapy’s effectiveness, and
- Establish the financial consequences for patients that are not progressing toward compliance.
Educate the Patient at Set Up DME suppliers are likely the most knowledgeable about the coverage requirements stipulated in any given patient’s insurance plan. All parties – the patient, the supplier, and the supplier’s physician – are the most interested in therapy early in the process, so suppliers are better able to create true understanding during this time. It is infinitely more difficult to create understanding once the patient has the machine or is frustrated with it. Starting early establishes productive two-way communication.
Make sure the patient understands that their plan doesn’t pay for them to possess the machine, they only pay after there is evidence they use and benefit from it. Failure to meet those requirements means they have to:
- Give the machine back, or
- Pay for it out-of-pocket.
And perhaps most importantly, let new patients know that CPAP equipment is a complex therapy. It takes time and adjustment to get used to it. Prepare the customer for common complications and the remedies before they experience them. Collaborative communication is as important to a successful trial as mastery of tedious insurance rules.
The First Four Weeks Matter Habits are created early, so frequent communication early in the trial has a positive influence on compliance. We suggest suppliers connect with the patients at least once, if not twice, before the end of the first week. Find out:
- How often they are using their machines?
- Are they having any discomfort?
- If they are not using it, or taking it off after a short interval, why?
Also, suppliers should encourage customers to return to the retail location periodically for check-ins and mask fittings. Customers should always bring their machine’s SD card so they can review the data with the supplier and identify any problems.
Setting expectations early promotes interaction, and increased patient interaction increases adaptation to the treatment and the likelihood of meeting their plan’s compliance criteria.
Consider Ending the Trial Early for Non-Compliant Patients If the patient repeatedly fails to demonstrate significant improvement in usage during these interim mile markers, suppliers should start to discuss impending financial consequences and the likelihood that the patient’s insurance will not cover future rentals by the end of the fourth week.
In fact, we suggest suppliers set an internal deadline of not more than 60 days to accomplish one of the following:
- Patient Compliance, or
- Equipment return.
“Yeah, but doesn’t Medicare allow 90 days?” you ask.
Technically, yes, but it may be more beneficial to cut your losses a little sooner than you normally would otherwise.
Limiting your initial trial to 60 days for PAP customers that are not progressing toward compliance preserves 30 days should the patient want to try again later. That is valuable because an actual second trial is not reimbursable.
