Happy New Year To All,
I am attaching a letter to be used by your office to the referring doctors and sleep labs you are connected with for Sleep Studies. As you may know the rules for an appliance being billed to Medicare have changes, and you need to be on the side of preventing your office from not being paid.
You must ask your patient if they have been on a CPAP and for how long, so you can now use that for billing purposes. My way this year is to let all the referring providers know in advance so instead of putting them on a CPAP first they understand that being paid by Medicare will require the doctor to explain to patient the limitations when choosing a Durable Medical appliance.
Being proactive will help your office and your patients.
[Physician’s practice name and address]
Dear Dr. [Physician’s name(s)],
Under the Medicare Same or Similar policy, two or more different treatment methods which are used to treat the same condition cannot be concurrently reimbursed. This rule applies to all DME and is relevant to the treatment of OSA.
Due to this rule, patients’ oral appliance therapy claims can be denied by Medicare if they have claims for CPAP that have been paid within 5 years. Reimbursement can still be obtained on appeal, but it is a cumbersome process for patients and requires physician and CPAP supplier documentation.
As we work together to help treat this important population, I suggest that you bring this policy to your patient’s attention when reviewing treatment options. If oral appliance therapy is a viable therapeutic option, please ask them to strongly consider it.
For patients initially prescribed CPAP, it is much easier for patients who are intolerant to transition to oral appliance therapy if done within the first 90 days.
Patients who become CPAP intolerant after the first 90 days can still be reimbursed for oral appliance therapy, but it requires specific documentation from the treating physician and the CPAP supplier.
As we all try to navigate this policy to ensure that our patients receive the best possible care, please do not hesitate to reach out to me to discuss changes to our treatment protocols that can help expedite the process and make life easier for you and our patients.
cc: [If applicable]