CMS reins in CPAP reviews

Friday, March 16, 2012

YARMOUTH, Maine - Providers should be able to catch their breaths now that CMS has told a recovery audit contractor (RAC) to ease up on semi-automated CPAP reviews.

"The audit hasn't been rescinded, but it's still a huge win," said Andrea Stark, a reimbursement consultant with MiraVista in Columbia, S.C., and a member of the AAHomecare HME/RT Council, which worked with CMS on this issue. "They will not send out any new request letters, but providers must still respond to any letters they've already received."

Connolly Healthcare, a Jurisdiction C RAC, has been asking providers for proof that patients had a qualified sleep study in cases where Medicare did not pay for the study. That's basically any patient whose study was paid for by a private insurer or who paid out of pocket--not uncommon for a condition that is often diagnosed before patients reach Medicare age.

The reviews left providers scrambling to dig up sleep studies like never before.

"It was difficult, if not impossible, to even figure out when they occurred," said Stacy Harms, manager of government affairs at AAHomecare. "A lot of them were more than seven years old and people were having a hard time to even get a copy of the study."

Adding insult to injury: The high volume of letters that some providers have received--one reported receiving 1,900. (See related story:

CMS has instructed Connolly to give providers more time to produce the studies if they ask for it, says Stark. Also easing the burden: Providers can give a blanket response for each patient, she said.

"They don't have to duplicate the sleep study for 13 different service dates," said Stark. "I would recommend that they include a cover letter that states all the service dates."



Why not just have a new sleep study ordered when a person reaches medicare age? Medicare pays for it and it will give all the RAC's, MAC's and PSC's nothing on which to put a notch in their belt. Just like oxygen the study should have a window of days pre and post the beneficiary's 65th birthday. A win win except for the patient needing the study but this is the new way medicare wants things done!

Because Medicare wants providers to feel uncertainty regarding payment. That fear of whether or not you will be paid curbs utilization more than anything else.

Gee, how nice of CMS to tell them to ease up and let us get back to the business of servicing our patients. That's real forward thinking of them!