Providers request CPAP do-over

Sunday, March 1, 2009

MIAMI - The Accredited Medical Equipment Suppliers of America (AMEPA) wants CMS to delay its new CPAP requirements after providers here came across an unexpected obstacle: patients.

The rules, which went into effect Nov. 1, 2008, require patients to meet with their physicians between 31 and 90 days after beginning treatment. This check up is to help ensure patient compliance, and Feb. 1, 2009, represented day 90 for some patients.

"We thought, 'We'll do our best to live with the new rules,' but the patients aren't (doing their part)," said provider Rob Brant, president of AMEPA. "Now we're stuck not getting paid."

In addition to the delay, AMEPA wants CMS to issue an official beneficiary letter that explains the new requirements, like it did with national competitive bidding. The association has also asked doctors to contact CMS in support of the delay.

Providers report that some patients have had a laissez-faire attitude toward meeting the CPAP requirements.

"The patients don't care if they have to go back to the doctor or not," said Jack Marquez, owner of Doral-based Cobra Medical Equipment. "They already have their equipment. Some of them want to comply, but they can't get to the doctors."

Another problem: Some patients don't believe the requirement exists.

"We've given them a copy of the requirements, but unless they see it on official Medicare letterhead, they don't believe it," Brant said.

Providers can use advanced beneficiary notices (ABNs) to notify patients that, if they don't meet the requirements, they may be on the hook for payments, according to industry attorneys.

"Even if you don't get the ABN upfront, it's OK to get it before the next month's claim if you learn that the coverage criteria aren't met," said Lisa Smith, a healthcare attorney with Amarillo, Texas-based Brown & Fortunato.  "If they didn't get the face-to-face, you can get the ABN to cover future months. Just make sure the ABN is very specific about why Medicare might deny the claim."

Brant acknowledges that he didn't use ABNs, focusing instead on explaining the requirements and helping patients schedule follow-up visits.

"At the time of delivery, they agree to the follow-up, but once they have the equipment in hand, it's an inconvenience," he said.

Of course, providers have the option of picking up the devices, something many are reluctant to do.

"It's a business decision," Smith said. "How aggressive do you want to be about leaving it out there or getting it back, if you are not getting paid for it?"