Sleep Apnea Patients Must Show PAP Compliance Before Device Purchase or Resupply
How does my insurance company know if I’m using my device?
In response to the insurance companies requirement that you prove you are using your device BEFORE they will pay for it, PAP device manufacturers have developed ways to more easily obtain that data, called “compliance data” or “usage data.”
These are the most common ways of obtaining the data:
- Smart card. Each PAP device has a data card, or memory card, located inside of the device that stores your usage data on a rolling basis (usually around 12 months of data). It’s a small card like the memory card used in a digital camera. The card can be removed (the data is also stored inside of your device) and sent to your physician or equipment provider to download the data and generate a report. There is no wireless transmission of data, but this does require additional steps such as mailing in the data card or scheduling an appointment with the equipment provider to have the data downloaded.
- Attachable modem. A separate modem can be purchased and attached to a PAP device. It uses cellular service to transmit the data on a regular basis. Modems can be used for short period or for the entire length of therapy. Data is transmitted about an hour after the machine stops being used.
- Wireless-enabled PAP device. The newest devices have built in modems that use Wi-fi, Bluetooth or cellular service (or a combination of them) to transmit your data. Assuming that it has access to a wireless signal, the machine will automatically relay usage data to the patient’s care provider about one hour after the machine stops being used.
- With both the attachable modem and the wireless-enabled devices, if for some reason a wireless connection is not available, the data can also be stored on the data card inside the device.
What information is being tracked?
Data-capable CPAP machines collect several statistics pertinent to successful CPAP therapy, such as hours the device was used, time spent sleeping, apnea-hypopnea index (AHI), and leak rate. With this information, treatment specialists can monitor a patient’s progress, check his compliance, and prescribe changes in therapy as required. Some devices even allow for remote trouble-shooting like checking to see if the device is working properly and making changes to the pressure settings (by prescription only).
Most insurance compliance guidelines require that you show proof of using your device for a minimum of 4 hours per day at least 22 days out of a consecutive 30 day period within the preceding 90 days (in the past 3 months).
Where does the data go?
It depends on the type of monitoring device and the manufacturer of your device. At the very least, the data is obtained by your equipment provider who is billing your insurance to obtain payment for the device. The report will be sent to your insurance company. The data is securely stored by your provider and you have the right to request your medical records, if desired. Your physician may also wish to see your compliance data in order to better manage your therapy.
How often will I need to show proof of compliance?
This also depends on the requirements of your insurance plan. For several years, many insurance companies, including Medicare, have required proof of usage in order to pay for the on-going rental or purchase of a PAP device.
Proof of compliance for replacement supplies
Recently, insurance companies are also requiring proof of usage on a yearly basis before they will authorize the payment of replacement supplies. Replacement supplies are the additional masks, cushions, filters and tubing that must be replaced at regular intervals to ensure optimal performance of the PAP device. Replacement supplies are usually shipped to you by your equipment provider every 90 days.
If you are a sleep lab please send us your prescription for CPAP and BiPAP to: firstname.lastname@example.org or call 310-539-2868
Insurance Accepted for CPAP supplies
- PPO Plans:
- ANTHEM BLUE CROSS
- BLUE SHIELD OF CALIFORNIA
- HEALTH NET
- UNITED HEALTH CARE
- Prior to any set up, we make certain the device is a covered benefit under the insurance plan. We will notify the patient in advance of any up front costs associated with their deductible and co-payment. We will see that the patient has a full understanding of treatment options and cost and will obtain pre-authorizations if needed.
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IntelliPAP® AutoAdjust® CPAP System
- CPAP pressure automatically adjusts to meet patient needs.
- Whisper-quiet operation – 26 dBA!
- SmartFlex® Exhalation Technology included.
- Exceptionally small footprint fits easily into the home environment and carry-on luggage.
- Includes discreet carry bag that can be easily expanded to hold additional accessories which is great for travelers.
- Optional integrated heated humidification system easily docks into the bottom of the unit without requiring a separate hose or power cord.
- Auto on/off automatically starts the flow of air after breathing into the mask and stops the flow of air when mask is removed.
- Delay pressure ramp eases the machine to the prescribed pressure – allowing the user to fall asleep at a lower pressure. (0-45 minutes in 5-minute increments and .5 increments for pressure)
- SmartCode® compliance tracking encodes usage data that can be communicated to a clinician.
- Optional SmartLink® Therapy Management System provides detailed patient therapy data, including oximetry.
DreamStation sleep therapy system.
- EZ-Start, Auto-Trial, Opti-Start
- Pressure range: 4 - 20 cm H2O
- Flex Comfort: C-Flex, C-Flex+, A-Flex
- Humidification modes: Fixed, Adaptive, Heated Tube
- Ramp (5-45 mins): Standard, SmartRamp
- Altitude compensation: Automatic
- Advanced Event detection: Standard
- Flow Waveforms: Standard
- Modem Compatibility: Standard (optional Cellular Modem or Wi-Fi Accessory)
- Built-in Bluetooth Connectivity: Standard
- Dream mapper Compatibility: Standard (by mobile app or web)
- Oximetry Compatibility: Standard (optional accessories)
- Check mask Fit feature: Standard
- Performance check: Standard