insurance wony pay

hi my husband has used a cap machine since may 2000.he had a new sleep study jan. 31 2004.dr wrote rx for new machine with water.this is a different ins. not the same company that bought the first machine.any way this bill has beenunpaid since jan 2004 and monthly rental fee building up cause they wont pay.finally after all this time they say its not a medicial necissaity.even though they have a doctors rx.we have to write a letter of appeal because claim denied.dont know what to write.any suggestions. thanks for any input. : :idea:

as long as accountants are deeply involved with making medical decisions and deciding what you need and what you don't need, this will be a problem. the "simple" solution is to let accountants "count" let doctors "doctor", let nurses.... forget that.

of course it's not gonna happen. it's only simple in concept.

be assured that some highly paid actuary in a glass tower far far away has properly grimaced over that very issue and decided (on your behalf) that breathing is an unaffordable luxury. and what do doctors know, anywaaaaayz ?

Sharon,

What you can do is tell them what can happen when a person who has OSA doesn't have it treated. In other words, it leads to...which would cost the insurance company more than this essentially will.

Good luck. Insurance companies can be very tricky and difficult to deal with. If this isn't covered in your husbands policy, chances are you will be stuck with the bill. When I called my insurance company because the reading of my sleep study wasn't covered in network, though the sleep study was, the agent was rude and said well if you would have had a different plan your sleep study wouldn't have been covered at all. Nice agent right?!!!!

Best of luck...let us know what happens.

Melinda

Start with talking to the sleep center about the denial and ask them to look at the report they gave you to see if they put something down that would lead the insurance company to deny the claim. Mention to the person who is reviewing the report that the insurance company says it isn’t a “Medical Necessity.” That process should illicit information from the sleep center about the minimum AHI values being used to determine when they consider OSA to be a medical problem. I believe different insurance companies use different minimum values.

With that information in hand, try to understand why the insurance company denied the claim by ringing them up and ask them why they haven’t supported the claim especially when the documentation is indicating otherwise. This is an important step to get the values they disagree about to make that statement. With the insurance companies reasons in hand, pass the information along to the doctor and get some feedback about how they view the situation. In some situations, the doctor can make a call and get things cleared.

Once all of the above is handled, and if the insurance company’s reasons still seem capricious, it is time to contact your state’s Insurance Commissioner and file a complaint. Often the state will have a consumer group that will help you with insurance companies that won’t behave well. If the state’s consumer group doesn’t help, well it might be time to hire some legal support or complain to the employment company that where you are getting the insurance coverage, if you aren’t buying it directly. Often they will provide support and get things cleared. If they can’t or won’t, well there are messages in both outcomes that can lead to a different insurance company going forward.

The insurance company could have just randomly kicked it out and denied it as standard practice. This has happened to me numerous times this year. I just appeal and have my doctor send proof of treatment and they pay. Keep calling them and keep appealing. It is a battle of persistance. Who ever is left standing pays.

Ted

I posted a related question a few days ago, asking if insurance would pay for software / card-readers. JG posted a meaningful reply, citing someone's experience, to the effect that if you whine loud enough and long you might just get what you want ANYWAY, even though it's clearly NOT covered. (That's my condensed version of his reply).

The next question is: Is it worth the trouble? For a humidifier ($160 ?), I'm not sure how many hours I would invest in that. On the other hand, I spent DAYS disputing a $5 claim on behalf of my oldest kid, versus the IRS. And "we" prevailed. That was SOOOOOOOOOOOOOOOO satisfying. But there it wasn't really about the $$$$$. Can't even say it was a moral issue. Just felt good.

-Ric

(with apologies to all IRS agents with OSA that routinely hang out here, nothing personal)

When air moves across something wet, like our air passages, it dries them out. Air that is compressed looses moisture from the pressure and heating systems reduce the air in a home often below safe levels. When heating systems are running, many people like to keep the thermostat down below daytime levels to make sleeping more comfortable. When the air is cold, it can be uncomfortable to have it piped directly into a nasal opening especially when we just jump into bed.

All these issues can be mitigated with a heated humidifier when they become a problem. When these issues don’t exist, you can leave the humidifier off, but I would still keep water in the chamber so that some moisture is in the air you’ll be breathing.

In my case a humidifier has certainly made being compliant to the treatment each night a lot easier and more comfortable, so I’m giving it a strong Buy recommendation.

Roger-

And I just proved that to myself last night. I have a passover humidifier. It's getting cold around here. Air is getting dry. I woke up at 2am (went to bed at 11pm) and the air blowing in my nose was COLD. So cold it was uncomfortable. I tried to keep the machine on and get back to sleep. No dice. So I went into the bathroom and emptied the passover. The water was like icewater. I refulled it with hot tap water. Not scalding. Just hotter than "warm". Hooked it back up and .... VOILA! ... right back to sleep. At 5:30 when the alarm went off... it was blowing cold air again. Seems the system is working like a mini swamp cooler. Evaporative cooling at its finest. Unfortunately... it's not pleasant because as you all know, the colder air can't hold as much moisture.

Anyways.... the conclusion of this little science experiment is that a heated humidifier MUST be my next purchase. And SOON. I'm determined to be compliant and the ways my system is set up right now, I just can't. I'm guessing that the humidifiers are probably more important for folks in colder climates, but ... I could be wrong.

Titrator wrote:The insurance company could have just randomly kicked it out and denied it as standard practice. This has happened to me numerous times this year. I just appeal and have my doctor send proof of treatment and they pay. Keep calling them and keep appealing. It is a battle of persistance. Who ever is left standing pays.

Ted

Ted's right! Often, I think that the insurance company is in the business on being obstainant... the more difficult they can be, the less they have to pay out and us poor customers that have our everyday lives to live, don't have time for the professional "pain in the butts."

sharonleeb wrote:hi my husband has used a cap machine since may 2000.he had a new sleep study jan. 31 2004.dr wrote rx for new machine with water.this is a different ins. not the same company that bought the first machine.any way this bill has beenunpaid since jan 2004 and monthly rental fee building up cause they wont pay.finally after all this time they say its not a medicial necissaity.even though they have a doctors rx.we have to write a letter of appeal because claim denied.dont know what to write.any suggestions. thanks for any input. :

thanks to all that replyed.roger the advise you gave was very helpful.sleep study clinic is helping me with appeal wont go into details, but looks like were headed in right direction.will keep everyone up to date.( itll take weeks)thanks again.