CPAP Resupply Fraud: When the Shipments Outlast the Treatment

CPAP resupply fraud occurs when a supplier knowingly bills Medicare for replacement supplies without the required refill request, delivery or medical need. A mask can arrive at the patient’s door while the machine it belongs to sits unused. The employee handling refill calls may hear that treatment has stopped. The billing department may still see an account ready for another claim. The connection between those records is where an insider can show what the business knew.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In CPAP billing, the useful evidence follows the patient from the initial treatment trial through each refill and any decision to keep charging after use stopped.

What the First Three Months of CPAP Use Establish

Continued Medicare coverage after the initial three-month trial requires documented use and a clinical re-evaluation showing that the patient benefits from treatment. The machine’s usage record and the treating practitioner’s assessment answer different questions.

Under Medicare’s positive airway pressure policy, adherence means at least four hours of use per night on 70% of nights during a consecutive 30-day period within the first three months. The treating practitioner must conduct the re-evaluation no earlier than day 31 and no later than day 91 after therapy begins, and document that the patient is benefiting.

CPAP adherence records missing after the initial rental period leave a gap in the evidence for continued coverage. A prescription shows that treatment was ordered. The usage record shows whether the patient used the machine enough to meet the adherence requirement. The clinical re-evaluation supplies the documented benefit.

Why CPAP Supplies Keep Billing After the Device Is Owned

A CPAP machine becomes the patient’s property after thirteen paid rental months. Replacement masks, cushions, tubing, filters and headgear can keep the supplier’s relationship with that patient going long afterward.

The 2024 Medicare payment data put the scale in view: about $236.8 million for PAP devices against about $971.2 million for the replaceable supply stream. The smaller, recurring items account for much more money than the machines.

Once Medicare has paid the full rental period, it treats the patient-owned machine as medically needed when considering replacement accessories. The supplier can keep billing for supplies after the rental payments end, but those claims still depend on refill requests, continued use and what the supplier actually furnished.

For a resupply employee, the commercial pressure is easy to recognize. Keeping the patient in the replacement program keeps the revenue coming. For someone reviewing claims, the question is whether each shipment follows the patient’s continuing treatment and request, or simply the supplier’s calendar.

Was the CPAP Resupply Request Documented After Shipment?

A CPAP resupply request documented after shipment does not satisfy Medicare’s refill-documentation requirement. The request must occur and be documented before the supplies ship. A later attestation from the supplier or patient is insufficient under CMS’s standard documentation requirements.

Before dispensing a refill, the supplier must contact the patient or designee and document an affirmative response. It may not automatically ship on a predetermined schedule, even if the patient previously authorized that arrangement. Contact may occur no sooner than 30 calendar days before the expected end of the current supply. Delivery may occur no sooner than ten calendar days before that end.

If the warehouse ships first and the call center fills the gap later, the sequence itself matters. The call record, the response and the shipment date can show whether the supplier obtained the request before dispatch or tried to complete the file after the claim was already in motion.

Was the PAP Mask Still Functional When It Was Replaced Since 2024?

Since January 1, 2024, Medicare no longer requires the supplier to document whether a PAP mask still works before replacing it. The supplier must document the patient’s affirmative refill response before shipping. The change also removed the former duty to assess how much of each item the patient had remaining.

The contact window changed too: the old rule counted fourteen calendar days back from delivery or shipment. The current rule counts back from the expected end of the supplies the patient already has.

A maximum replacement schedule still cannot supply the patient’s response. That matters to an employee whose work queue generates a replacement order whenever the next interval arrives.

We connect the rule that applied then to the patient’s response, the shipment and the supplier’s instructions.

What Happens When a Patient Stops CPAP but the Supplier Keeps Billing?

When a patient has stopped CPAP but the supplier still bills monthly rental, Medicare’s PAP policy expects the supplier to find out that use has stopped and stop billing. The relevant records include machine use, patient communications and the claims submitted after treatment ended.

Device rental and replacement supplies leave separate billing trails. A monthly rental claim concerns the machine. A mask or tubing claim concerns a later supply shipment with its own refill documentation. Set against the patient’s stop-use notice, the two billing trails show whether the supplier stopped charging when it learned that treatment had ended.

The oxygen case against Rotech Healthcare gives this problem a concrete parallel. In its 2018 settlement announcement, the Justice Department said Rotech admitted knowingly billing Medicare for portable oxygen contents that patients did not use or require, and billing regardless of whether the contents were delivered. The company agreed to pay $9.68 million.

A former billing employee brought that case. Its lesson for the CPAP insider is the connection between the patient’s use, the supplier’s knowledge and the continuing bill. Medicare and taxpayers pay for supplies patients do not use, while suppliers that stop billing give up that revenue.

When Resupply Services Become a Sales Incentive

Manufacturer-funded patient calls can also influence which masks a supplier sells. In 2016, Respironics agreed to a $34.8 million settlement of allegations that it offered free call-center services to suppliers buying its sleep-apnea masks.

The whistleblower’s complaint alleged that the service was free for patients using Respironics masks but carried a per-patient charge for competing masks. It described the incentive to move an entire patient roster to the manufacturer’s products:

The alleged inducement sat inside the work of contacting patients for replacement supplies. For an employee who sees product choices and service invoices, that makes the manufacturer agreement part of the story. Who pays for the calls, which patients qualify for free service and what happens when the supplier chooses a competing mask can explain why a particular product keeps being ordered.

ResMed faced the same kind of allegation. Its 2020 settlement of more than $37.5 million resolved claims that included free telephone call-center and patient-outreach services that helped suppliers order sleep-apnea resupplies. The whistleblower complaint alleged that ResMed paid all renewal-service costs when its products held a dominant share of the supplier’s sales. The incentive reached beyond an individual mask: moving more patients to that manufacturer could make the supplier’s whole renewal service free.

What Are Some Red Flags for Medicare Fraud?

In CPAP resupply, the warning signs are concrete: a refill response entered after shipment, rental claims continuing after a stop-use notice, or instructions to keep billing despite missing treatment records. The strongest account connects those discrepancies to who knew about them and what the supplier did next.

We work through the use data, refill calls, shipments and claims with you to show where the supplier’s account stopped matching the patient’s treatment. An employee can explain what the patient said, which record was missing and why billing continued.

When You Know Why the Billing Continued

If you work in CPAP billing, resupply or clinical operations and know why shipments or rental claims continued after treatment stopped, speak with our whistleblower experts. Your knowledge of the refill calls and billing decisions can help us build a CPAP whistleblower case around what happened after the patient stopped using the machine. We stay with you through the process and bring in healthcare fraud whistleblower lawyers who understand respiratory-equipment billing.