Replacement Schedules for Medicare Continuous Positive Airway Pressure Supplies

WHY WE DID THIS STUDY

Since 2009, OIG has identified reducing waste in health care services as a top management challenge for the Department of Health and Human Services (HHS). In 2012, HHS's CMS found that beneficiaries receiving continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea may have received more supplies (e.g., masks, tubing) than medically necessary; however, the quantities did not exceed the established replacement schedule. Providing more supplies than necessary may lead to wasteful spending.

HOW WE DID THIS STUDY

We requested CPAP replacement supply schedules in effect as of January 1, 2012, from 50 fee for-service State Medicaid programs and from 4 fee-for-service Federal Employees Health Benefits (FEHB) plans. We compared the replacement schedules for 15 types of CPAP supplies with Medicare's schedules. Additionally, we collected recommended replacement schedules from five sleep disorder clinicians and four manufacturers.

WHAT WE FOUND

For supplies for which State Medicaid programs specified frequency schedules, 39 percent of frequencies were less than those under Medicare and 51 percent equaled those under Medicare. Only 10 percent of frequencies exceeded those under Medicare. Additionally, many State Medicaid programs have either recently changed their schedules or have initiatives underway to do so. Two FEHB plans had no specific replacement schedules; the plans determined coverage on the basis of medical necessity. Sleep medicine clinicians emphasized the importance of proper mask fit, but research suggested that once proper mask fit is established, replacement of masks is less frequent than Medicare allows. Finally, manufacturers recommended specific replacement frequencies for only a few types of supplies, but those recommendations were often to replace those supplies on an as needed basis and potentially less frequently than under Medicare's replacement schedule.

WHAT WE RECOMMEND

We recommend that CMS review the CPAP supply replacement schedule and revise the national coverage determination or request that the Durable Medical Equipment Medicare Administrative Contractors revise their local coverage determinations as appropriate. CMS did not concur with our recommendation. CMS stated that failure to consider noncompliance or the potential impact of supplier fraud or abuse would bias the estimate of a clinically appropriate refill rate. Although our report does not include this specific information, we continue to believe that our evidence is sufficient to warrant the recommendation that CMS review the supply replacement schedule and make revisions as appropriate.