No-Show Patients a Stumbling Block to CPAP Payment

ATLANTA — Sleep therapy providers said last week they are
logging significant losses as a result of the new PAP policy
instituted Nov. 1, and some are appealing to physicians to
intercede with Medicare on their behalf.

Rob Brant, president of the Accredited Medical Equipment Providers of
America and owner of City Medical Services in Miami,
said 25 percent of his patients have refused to revisit their
physician within the mandated 90-day period after being prescribed
a CPAP. Under the new policy, CMS requires Medicare beneficiaries
to have a face-to-face evaluation by the treating physician between
day 31 and day 90 of the therapy.

But Brant said a quarter of his new patients are balking at
another visit. Their reasons range from being unable to afford the
copay to not being able to get to the doctor’s office; one patient
even thought the provider and the physician were working a scam
because the patient hadn’t heard anything about this requirement
from Medicare.

“This is a real problem,” Brant said. “I am not going to bill
for something I know I may have to be refunding to Medicare, so
there’s 25 percent I can’t bill. Most of the [providers] I talk to
say there’s 20 to 25 percent they can’t bill. I have no legal
recourse to get my equipment back, and now I can’t get paid.”

Kelly Riley, director of the National Respiratory
Network for The MED Group, Lubbock, Texas, said
the issue was a hot topic at a series of roundtable discussions she
hosted during the network’s annual meeting, held Feb. 17-19 in San
Antonio. “Without exception, the folks at the table indicated they
were having trouble with that exact same thing,” she said. She
noted some providers had taken aggressive steps including making
return appointments for patients during the initial evaluation, but
with limited success.

Patrick Clevidence of Medical Services Company in
Cleveland, Ohio, said his company has had its respiratory
therapists schedule the follow-up for patients. “You can set up the
appointment, but we still have no guarantee that the patient is
going to go,” he said. “It’s a sticky wicket.”

There’s been a little pushback from both patients and
physicians, too, he added. Physicians don’t like the extra time
required to do the face-to-face and prepare the documentation that
providers need, so it has been difficult at times to get that
documentation. And beneficiaries sometimes are not able to pay for
another visit or can’t afford the gas to drive into the doctor’s
office from the rural area in which they live.

“The patients are concerned that if they are not compliant, this
is not going to be paid for and they can’t afford this
[treatment],” Clevidence said. “It’s a little scary for the
patient.”

Robert D. Hoover, MD, senior medical director for Cigna
Government Services, the Jurisdiction
C DME MAC, said he is not aware of any problems.

“I have not received any complaints about this requirement from
beneficiaries or suppliers,” he told HomeCare Monday. “In
fact, in the discussions with several clinicians leading up to the
development of our policy, it was stated as standard of care to see
a patient for a return visit within the first four-to-six weeks
after being started on positive PAP therapy. Moreover, we received
numerous comments about the local coverage determination when it
was released back on July 18, 2008, and there were no comments
related to the timing or necessity of the follow-up face-to-face
visit.”

Hoover said the purpose of the follow-up visit is “to make sure
that the beneficiary is benefiting from the use of the PAP device
and that the symptoms that led to the prescription of the PAP
device are resolved or resolving.”

That’s all well and good, said Brant, “but Medicare has given us
no tools to handle this task. Without a piece of paper from
Medicare saying, ‘Look, you’ve got to do this,’ [many patients
won’t cooperate].”

Hoover said that the DME MAC medical directors published an

FAQ in November on what to do if patients are not compliant.
“One recommendation is to obtain an advanced beneficiary notice
advising the beneficiary specifically that Medicare coverage is
contingent upon adherence to the use of the device (four hours per
night, 70 percent of the night in a 30-consecutive-day period) and
a follow-up visit within the 31st to 91st day. We also detail what
options a supplier has if the beneficiary is unable or unwilling to
comply with the policy.”

Riley said some providers have taken that approach with some
success. Still, she said, there is no guarantee that patients will
be compliant. “We all know that this is a busy world, and if the
patient decides they would rather get their hair done that day or
they go on vacation or they get sick, they forget. The onus has to
be on the patient.

“The physician is in no better position than the HME provider in
following along behind the patient to make sure they get back in,”
she added. “Our industry is not used to that and it’s unfortunate.
But that’s where the success metric seems to change
significantly.”

Brant is hoping that physicians have greater leverage than HME
providers with Medicare. AMEPA is asking its members to urge
physicians to write a letter to Medicare “asking them to postpone
the follow-up requirement until these issues can be resolved. If a
patient refuses to return to the doctor’s office then CMS cannot
hold the CPAP provider financially responsible.”

Emphasized Brant, “We really shouldn’t be held financially
responsible because the patient is refusing to go back.”

Read the
DME MACs’ FAQ on the Jurisdiction C Web site.