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.