Private pay CPAP requirements go step further

Friday, November 9, 2012

YARMOUTH, Maine – A new sleep management program aimed at improving patient compliance for Anthem Blue Cross Blue Shield members could mean more paperwork for providers.

Two key facets to the program: Providers must submit prior authorizations for all sleep therapy-related equipment and supplies and renew them annually; and providers must document patient compliance quarterly for the first year, and then annually thereafter.

"We are trying to make sure that patients stay engaged over the long term in their treatment and don't fall out of participation," said Mike Backus, senior vice president of product strategy at AIM Specialty Health, an affiliate of WellPoint, which owns Anthem Blue Cross Blue Shield. "In other words, we want to make sure they keep using the device on a regular basis so that their condition can get better."

WellPoint began rolling out the program, which will be administered by AIM Specialty Health, in October.

Documenting compliance on an ongoing basis will be a big change for many providers, they say.

"It's very unusual for us to formally document compliance after the first 180 days—that's just how we operate," said Scott Lloyd, president of Extrakare in Atlanta. "Having to extend that is going to be a challenge."

For some providers, it’s not so much the act of collecting additional paperwork, as it is the added expense of collecting that paperwork.

"It may take a little longer to get the patient set up, but I don't think it will be much of a problem," said Eric Parkhill, vice president of clinical operations/corporate compliance for Home Medical Professionals in Gainesville, Ga. "It's going to increase our administrative costs considerably."

The changes are a bit of a departure from Medicare guidelines, which require providers to prove patient compliance only within the first 90 days of treatment. If that's good enough for Medicare, why not for AIM Specialty Health, say providers?

"AIM has suggested, here, that proving compliance in the first 90 days is not enough," said Lisa Getson, executive vice president, government relations and corporate compliance, for Lake Forest, Calif.-based Apria Healthcare. "We find that patients, when they do become compliant, continue with it."

But AIM Specialty Health says it has analyzed claims data that shows patients may start out compliant, but they don't always stay that way.

"People start to fall off the curve, and at three, six, nine and 12 months, more and more people have fallen off the curve," said Dr. Tom Power, medical director for AIM Specialty Health. "When you look at it at two years it can be as high as 70% (who aren't compliant). We need to know why they are not compliant. Maybe they are just not a candidate for PAP therapy."


It may be spimplistic of me but doesn't all this additional expense because of compliance criteria create a real hardship for DME companies.  At some point patients need to be responsible for thier own health needs.   It seems overkill to add all this additional expense and also inconvience for the patients, additional physician visits, additional visits to check compliance all for a device that costs a provider $450 or less.  Also most of the available data does support the fact that the first 3 months are the most important to compliance.