More Madness

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
User avatar
JQLewis
Posts: 180
Joined: Fri Apr 11, 2014 10:05 am
Location: New York City

More Madness

Post by JQLewis » Sat Aug 23, 2014 5:52 am

OK, this is complicated, so please bear with me.

I had requested that two different doctors write scripts for machines to replace my current brick, my PCP and a sleep doc (who is the head of sleep medicine at Beth Israel Hospital in NYC). I thought the script from my PCP hadn't been submitted. I thought the script from my sleep doc had. Apparently the opposite is true. The script from my PCP was approved, and AFAIK, the sleep doc never wrote a script.

I got a letter from my insurance company telling me a purchase had been approved, but it offered no specifics, except the DME equipment number and that the "place of service" was Integra Partners, a firm which handles paperwork for DMEs. I called Integra and they told me that the DME requesting the purchase was Borbas, my current DME, the one that supplied the brick. I had given their name to both my PCP and the sleep doc.

So now to Borbas, and they told me that the purchase approval was for the original script for a brick written by the first sleep doc I'd seen. According to my insurance company the approval was for the script written by my PCP. Borbas claimed that they never got a script from my PCP and the only thing they'd gotten from my new sleep doc was a request for compliance data on my brick, which they sent.

So back to my insurance company. I get a supervisor on the phone and she confirms that the script is for a new machine scripted for by my PCP. She tells me that she'll get it straightened out. That was Tuesday and Friday (yesterday) I called her back, not having heard from her. Again I was assured she would straighten the matter out and call me back and she didn't.

I'd been trying to get a copy of the script from my sleep doc, without success. Now I realize why. I was actually at my PCP's office on Tuesday to see another doctor. If I knew he'd written the script I would have tried to get a copy from him then. Now I have to wait until Monday. I'll have to go to his office and be prepared to sit there all day, and then maybe I'll get a copy of the script.

My instructions to him were to write a script for an autoset with full data capability. Today I was told that the script he wrote made no mention of this, but they couldn't tell me what the script did say. I may need him to rewrite the script, so I can't alienate the guy. Not till I succeed in getting what I need, anyway.

As far as the sleep doc goes, I have no idea what to think. He indicated that he was going to check on the leak data from my machine, even after I told him it was an Escape and had no leak data. I know he asked for the compliance data and received it from the DME, but apparently he did nothing after that.

1- I assumed the DME was simply lying. The rep from my insurance company said maybe not. She said the script may have come directly to the insurance company, then to Integra, then to the DME, and that the DME might not have gotten it. AFAIK this is wrong, and the script was originally sent to the DME, then to Integra, then to the insurance company and back again. I know the DME got the purchase approval, they're just trying to claim it's approval for for a different script. Why don't they specify these things? Why make their approval so vague?

2- If I have to get my PCP to write a new, more specific script, what should it say?

3- What should I do about this new sleep doc? If he's just one more bad doctor in a long line of bad docs, I should keep looking. He's the only doctor I've consulted with who seems to think data is a good idea. That's in his favor, but he seems to have dropped the ball regarding what he promised to do for me.

If the insurance company "straightens things out" with the DME, and they call me and offer me an S9 autoset (or anything worth taking), I'm going to grab it. But then I have a machine and no doctor. I don't even know how they'll decide what the pressure range should be.

_________________
Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Sleepyhead, Sleep Studies done 3/14, AHI 85.6
Sleep Study-Titration Study
Help find the undiagnosed. Send me a PM if you'd like to help (http://osaaction.org)

User avatar
LSAT
Posts: 13229
Joined: Sun Nov 16, 2008 10:11 am
Location: SE Wisconsin

Re: More Madness

Post by LSAT » Sat Aug 23, 2014 6:18 am

You obviously know the law...you posted it on another of your posts.

http://www.hhs.gov/news/press/2014pres/ ... 0203a.html

According to HPPAA law you are entitled to copies of ALL your lab tests and prescriptions. You need to write a letter to your doctor quoting the law. Then you need to find another doctor and DME.

_________________
Machine: ResMed AirSense™ 10 AutoSet™ CPAP Machine with HumidAir™ Heated Humidifier
Mask: Fisher & Paykel Vitera Full Face Mask with Headgear (S, M, or L Cushion)
Additional Comments: Back up is S9 Autoset...... Buckwheat hull pillow

User avatar
Krelvin
Posts: 1977
Joined: Tue Jun 06, 2006 5:23 pm
Location: Metro Phx Area - Dry Heat!

Re: More Madness

Post by Krelvin » Sat Aug 23, 2014 6:46 am

If you saw your PCP and he wrote an RX for you why did you not have him/her give you a copy right then? Did you do this over the phone?
Current Settings PS 4.0 over 10.6-18.0 (cmH2O) - Resmed S9 VPAP Auto w/h5i Humidifier - Quattro Air FFM
TNET Sleep Resource Pages - CPAP Machine Database
Put your equip in your Signature - SleepyHead v1.0.0-beta-1
Kevin... alias Krelvin

User avatar
Jay Aitchsee
Posts: 2936
Joined: Sun May 22, 2011 12:47 pm
Location: Southwest Florida

Re: More Madness

Post by Jay Aitchsee » Sat Aug 23, 2014 7:26 am

JQLewis wrote:2- If I have to get my PCP to write a new, more specific script, what should it say?
Here's a generic Rx or order provided by our host: http://c0149421.cdn.cloudfiles.rackspac ... on-LMN.pdf
and FAQ regarding them. https://www.cpap.com/cpap-faq/Prescriptions.html
Additionally, modifiers such as "fully data capable" or "leak monitoring capable" could be used.
Even better, specify the exact name and model of machine desired, e.g., ResMed S9 Autoset with Hi5 humidifier and Climate line hose
JQLewis wrote:As far as the sleep doc goes, I have no idea what to think. He indicated that he was going to check on the leak data from my machine, even after I told him it was an Escape and had no leak data. I know he asked for the compliance data and received it from the DME, but apparently he did nothing after that.
Your new sleep doc may want to examine your data, but he may not know which machines provide it or how to get it. Most Doctors I've seen rely on the DME to send them reports and most DME's, IMO, only send compliance data or compliance and summary at the most. Of the 5 or so doctors I've seen, only the last had the capability and/or the desire to download data in their office. As far as DME's go, they don't care about much more than compliance data. I had to show my DME how to access detailed data in ResScan.

Maybe you should talk to your Doctor or his nurse to find out how he normally gets the data to review.

_________________
Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Additional Comments: S9 Auto, P10 mask, P=7.0, EPR3, ResScan 5.3, SleepyHead V1.B2, Windows 10, ZEO, CMS50F, Infrared Video

User avatar
bwexler
Posts: 1507
Joined: Mon Nov 08, 2010 11:52 pm
Location: San Marcos, Ca. USA

Re: More Madness

Post by bwexler » Sat Aug 23, 2014 10:13 am

Get a copy of your prescription.
If it doesn't say what you want it to say, have the doctor write a new on.
It should include the following words
Resmed S9 Autoset or Resmed Airsence 10 Autoset
With Climateline heated hose
Dispense only as written.

Se

_________________
Mask: SleepWeaver 3D Soft Cloth Nasal CPAP Mask with Headgear
Additional Comments: AurCurve 10 ASV Also using Sleaplyhead 1.1, ResScan 6 and CMS50i

User avatar
JQLewis
Posts: 180
Joined: Fri Apr 11, 2014 10:05 am
Location: New York City

Re: More Madness

Post by JQLewis » Sat Aug 23, 2014 4:02 pm

LSAT wrote:You obviously know the law...you posted it on another of your posts.

http://www.hhs.gov/news/press/2014pres/ ... 0203a.html

According to HPPAA law you are entitled to copies of ALL your lab tests and prescriptions. You need to write a letter to your doctor quoting the law. Then you need to find another doctor and DME.
I'm not in doubt as to my rights, I'm in doubt as to how to get what I want. Doctors do not take kindly to patients ordering them around. Then, when you want them to do you a favor, they tell you to take a hike. How does that help me? My goal is not to get a copy of a script, but to get a new machine.

As far as getting a new doctor, I'm on my third PCP and fourth sleep doctor in the last four months. By the rules of my insurance company I can't switch PCPs for the next two months. I'd considered making a special appeal after I received word that my request for a new machine had been approved. Now I'm glad I didn't. I might still need this guy. Until I have the new machine in my hands I'm not going to do anything to alienate any of these people. After that I can revert to my usual obnoxious, demanding self.

Krelvin wrote:If you saw your PCP and he wrote an RX for you why did you not have him/her give you a copy right then? Did you do this over the phone?
My doctor agreed to write the script for me, but he didn't do it on the spot. He did send me to his assistant, who call their DME, Apria, and got the ball rolling. That proved to be a waste of time and I had to then fax them and request they resubmit the script to the DME I've been dealing with, since I thought it was going to be easiest to exchange machines with them. Otherwise I would have to return the first machine before getting the replacement and probably have a gap where I had no machine. For reasons I won't bother going into, I thought my PCP hadn't resubmitted the script, but it turns out he did.

I'm going to go there on Monday and wait for a copy of the script. I shouldn't have to do this, but I see little choice.

As far as the new sleep doctor goes, I have no idea what to do about him. Maybe he did call about a new machine and was told a script was already under consideration.

_________________
Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Sleepyhead, Sleep Studies done 3/14, AHI 85.6
Sleep Study-Titration Study
Help find the undiagnosed. Send me a PM if you'd like to help (http://osaaction.org)

Wulfman...

Re: More Madness

Post by Wulfman... » Sat Aug 23, 2014 5:05 pm

Doctors do not take kindly to patients ordering them around.
They work for YOU.

My wife and I started with a new doctor last Fall. Near the end of the year, I asked her (yes, I've now got a lady doctor )if she would sign a new CPAP prescription for me. No problem. I have had mine on file with CPAP-dot-COM since April of 2005, but my original sleep doctor wrote it in a haphazard way and with a pressure of 18 cm. I came to find out my optimum pressure was 12 cm. I never was pleased with it, but it worked for filling my orders with them. I may never have to use this new one, but I now have it written the way I want it.

Practically ANY doctor (even a dentist) can write a prescription for you.


Den

.

User avatar
JQLewis
Posts: 180
Joined: Fri Apr 11, 2014 10:05 am
Location: New York City

Re: More Madness

Post by JQLewis » Sat Aug 23, 2014 6:06 pm

Wulfman... wrote:
Doctors do not take kindly to patients ordering them around.
They work for YOU.
That's been my experience until recently. Then I got involved with sleep medicine. Four sleep doctors in four months. Do you really think I accept less than adequate service? I think it's absurd that I'm jumping through hoops the way I am. I also think it's absurd that a board certified pulmonologist, a member in good standing of the AASM, stuck me with a brick. In fact I have yet to experience anything with regards to my OSA treatment that I didn't think was ridiculous, except for the initial sleep studies.

My PCP is actually a really nice guy who seems to be very knowledgeable, but his office is a nightmare to deal with. It's like McMedicine. They use a call center to deal with all phone calls and they never do anything without multiple phone calls. I do plan to get rid of them once I have the new machine in my hands. Until then I'm taking no chances.
Wulfman... wrote:Practically ANY doctor (even a dentist) can write a prescription for you.
In my case I think the script mattered a bit less than the "letter of medical necessity". The insurance company has to have a compelling reason to override the original script, which called specifically for a Resmed Escape. Apparently my PCP did a pretty good job in that regard, since his script was approved.

All that having been said, doctors really don't take kindly to patients ordering them around. They're generally an arrogant breed, and do need to be handled with a certain level of finesse, especially if you want them to do you a favor.

_________________
Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Sleepyhead, Sleep Studies done 3/14, AHI 85.6
Sleep Study-Titration Study
Help find the undiagnosed. Send me a PM if you'd like to help (http://osaaction.org)

User avatar
Krelvin
Posts: 1977
Joined: Tue Jun 06, 2006 5:23 pm
Location: Metro Phx Area - Dry Heat!

Re: More Madness

Post by Krelvin » Sat Aug 23, 2014 6:21 pm

The last time I got a new machine (6 years ago), the Dr gave me the RX form... and I faxed a copy to the DME (was Apria). It was exactly what I asked her to write on it. The Insurance company didn't have anything to do with the RX since I was already approved for a machine.

Note that the Insurance company didn't care what machine was ordered other than it had to be valid. For example, my study clearly stated a Bi-Level was needed so any Bi-Level was acceptable. I just made sure it included auto and had data I could use to monitor it.

This time round, I needed a new study because the Insurance company wanted a new one and the original was more than 8 years ago, but I will do the same thing. When I see the Sleep Dr to go over it, I will tell him what machine I want and that is what he will put on the RX and give it to me. We already talked about it. I will then give a copy of it to the DME which most likely will again be Apria, but again, it will say exactly what I want on it. The new sleep Dr was quite content with how I had been using my machine, the reports I had, now clean the machine was and the fact that I used it every day.

If he didn't agree with it, I wouldn't use him. My PCP is also very into XPap therapy and supportive of what I use and want. I seriously doubt I will deal with the Sleep Dr after I get the machine. Only the PCP from that point on.
Current Settings PS 4.0 over 10.6-18.0 (cmH2O) - Resmed S9 VPAP Auto w/h5i Humidifier - Quattro Air FFM
TNET Sleep Resource Pages - CPAP Machine Database
Put your equip in your Signature - SleepyHead v1.0.0-beta-1
Kevin... alias Krelvin

Wulfman...

Re: More Madness

Post by Wulfman... » Sat Aug 23, 2014 6:37 pm

JQLewis wrote:
Wulfman... wrote:
Doctors do not take kindly to patients ordering them around.
They work for YOU.
That's been my experience until recently. Then I got involved with sleep medicine. Four sleep doctors in four months. Do you really think I accept less than adequate service? I think it's absurd that I'm jumping through hoops the way I am. I also think it's absurd that a board certified pulmonologist, a member in good standing of the AASM, stuck me with a brick. In fact I have yet to experience anything with regards to my OSA treatment that I didn't think was ridiculous, except for the initial sleep studies.

My PCP is actually a really nice guy who seems to be very knowledgeable, but his office is a nightmare to deal with. It's like McMedicine. They use a call center to deal with all phone calls and they never do anything without multiple phone calls. I do plan to get rid of them once I have the new machine in my hands. Until then I'm taking no chances.
Wulfman... wrote:Practically ANY doctor (even a dentist) can write a prescription for you.
In my case I think the script mattered a bit less than the "letter of medical necessity". The insurance company has to have a compelling reason to override the original script, which called specifically for a Resmed Escape. Apparently my PCP did a pretty good job in that regard, since his script was approved.

All that having been said, doctors really don't take kindly to patients ordering them around. They're generally an arrogant breed, and do need to be handled with a certain level of finesse, especially if you want them to do you a favor.
You could always bypass the insurance provider (for the equipment) and go out-of-pocket. When I did the math, it would have been about even on what I'd have paid to go through a DME using insurance or going straight out-of-pocket. Fortunately, my insurance provider reimbursed me for 80% of the purchase of the equipment I bought out-of-pocket from CPAP-dot-COM. I billed my insurance provider using the information from the invoice from CPAP-dot-COM as it had all the proper billing codes. My insurance provider considered me to be in-network and I made up an invoice with me as the billing party and them as the party being billed. I did discuss this with them beforehand, but they had no problem with it. Everybody saved money. However, if they hadn't agreed to do it, I was prepared to pay the whole amount rather than go through a local brick and mortar DME.


Den

.

User avatar
JQLewis
Posts: 180
Joined: Fri Apr 11, 2014 10:05 am
Location: New York City

Re: More Madness

Post by JQLewis » Sat Aug 23, 2014 9:26 pm

Wulfman... wrote:
JQLewis wrote:
Wulfman... wrote:
Doctors do not take kindly to patients ordering them around.
They work for YOU.
That's been my experience until recently. Then I got involved with sleep medicine. Four sleep doctors in four months. Do you really think I accept less than adequate service? I think it's absurd that I'm jumping through hoops the way I am. I also think it's absurd that a board certified pulmonologist, a member in good standing of the AASM, stuck me with a brick. In fact I have yet to experience anything with regards to my OSA treatment that I didn't think was ridiculous, except for the initial sleep studies.

My PCP is actually a really nice guy who seems to be very knowledgeable, but his office is a nightmare to deal with. It's like McMedicine. They use a call center to deal with all phone calls and they never do anything without multiple phone calls. I do plan to get rid of them once I have the new machine in my hands. Until then I'm taking no chances.
Wulfman... wrote:Practically ANY doctor (even a dentist) can write a prescription for you.
In my case I think the script mattered a bit less than the "letter of medical necessity". The insurance company has to have a compelling reason to override the original script, which called specifically for a Resmed Escape. Apparently my PCP did a pretty good job in that regard, since his script was approved.

All that having been said, doctors really don't take kindly to patients ordering them around. They're generally an arrogant breed, and do need to be handled with a certain level of finesse, especially if you want them to do you a favor.
You could always bypass the insurance provider (for the equipment) and go out-of-pocket. When I did the math, it would have been about even on what I'd have paid to go through a DME using insurance or going straight out-of-pocket. Fortunately, my insurance provider reimbursed me for 80% of the purchase of the equipment I bought out-of-pocket from CPAP-dot-COM. I billed my insurance provider using the information from the invoice from CPAP-dot-COM as it had all the proper billing codes. My insurance provider considered me to be in-network and I made up an invoice with me as the billing party and them as the party being billed. I did discuss this with them beforehand, but they had no problem with it. Everybody saved money. However, if they hadn't agreed to do it, I was prepared to pay the whole amount rather than go through a local brick and mortar DME.
I don't think it will be necessary for me to do that, though before I got the approval two weeks ago I did think I'd have to go out-of-pocket. The insurance company approved a new machine, and I have to assume they did so out of a recognition of medical necessity. I don't know the specific language of the script, and obviously I need to find that out, but if my current DME is unwilling to offer an acceptable machine I'll take the script elsewhere. The exchange will be more difficult, but I'll do what's necessary.

None of this is really my problem right now. The main problem is I have no idea what to do. The sleep doc I saw told me he wasn't sure what kind of machine he was going to script for, possibly a Bi-PAP. I was assuming that the script that was approved, whatever it was, was the machine he decided was best for me. I thought that he was going to call me before submitting it, but I was sure that whatever I got would be vastly better than the brick I have. Now it turns out to be the script from my PCP. I'll find out what it says, but is that going to be what's best for me? I'm not sure what this new sleep doc did. He got the compliance info from the DME and then appears to have done nothing. Did he screw up? If so, do I want to go back to him? I was surprised when he mentioned a Bi-Pap. No one has suggested to me before that I might have COPD or some other obstructive condition which would require a Bi_Pap. Unless I'm misunderstanding what a Bi-Pap is for?

_________________
Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Sleepyhead, Sleep Studies done 3/14, AHI 85.6
Sleep Study-Titration Study
Help find the undiagnosed. Send me a PM if you'd like to help (http://osaaction.org)

Wulfman...

Re: More Madness

Post by Wulfman... » Sat Aug 23, 2014 9:32 pm

OK. Good luck.

Please let us know how all this turns out.


Den

.

User avatar
JQLewis
Posts: 180
Joined: Fri Apr 11, 2014 10:05 am
Location: New York City

Re: More Madness

Post by JQLewis » Wed Aug 27, 2014 4:30 pm

Well, amazingly, it all turns out to have been crazier than I thought. I called my insurance company after I received approval for the machine in order to confirm that 1- I had gotten an extension on the rental period of my old machine and that 2- This approval was for a new machine, not my old brick. I called a total of six times. I was assured over and over that indeed I had an extension and that indeed the approval was for a new machine, not my brick. I spoke with a supervisor at my insurance company, not just a standard customer service rep. After all that, it turns out to have been nothing but a huge pile of lies. No extension on my rental period, no approval of a new machine, in fact neither of the two doctors who were supposed to be helping me ever submitted a script. I was told the script which had been approved was written by my PCP, and it wasn't true. So now I'm told it was the approval for the purchase of my brick that I received and that now I am the proud owner of said brick.

I just ordered a used S9 autoset from secondwind. Since I at least have a humidifier from the original machine I didn't have to buy that, and I guess I can use the Escape as a backup if I ever need it. At least I get filters, hoses and masks this way. Only a one year warranty on the used machine, but I hope it lasts for the next 4 1/2 years. Otherwise, for the time being, I'm done with all these people. I see no reason to ever go back to my PCP or the sleep doctor who promised to help me and then turned his back on me. I'm going to try to make an appointment to see Dr. Park in the Bronx, since he seems to be the only rational person in the world of sleep medicine in the city of New York.

I intend to file complaints against my insurance company with every relevant agency I can find, but I doubt I'll get much benefit from it.

_________________
Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: Sleepyhead, Sleep Studies done 3/14, AHI 85.6
Sleep Study-Titration Study
Help find the undiagnosed. Send me a PM if you'd like to help (http://osaaction.org)

Wulfman...

Re: More Madness

Post by Wulfman... » Wed Aug 27, 2014 5:20 pm

Thanks for that update.
Unfortunately, similar stories have been told on the forum many times over the years. It's sad, but true.

But, at least you're getting a data-capable machine......albeit from another source.


Den

.