Newly Diagnosed rant. BCBS MA denying titration study

[sonnet]

No, you don't need PCP referrals for studies. IYou only need them for specialist visits. For studies you need authorizations, I'm assuming that's what they really mean, but who knows. BCBS apparently told the doctors office an auth wasn't necessary. We'll see how far that gets me.

I will call BCBS tomorrow. And it's a good idea to ask them for their CPAP policies in writint - thanks for the suggestion.

[bwexler]

If you get stuck with the sleep lab bill, it will be time to hone your negotiating skills.
Start with you told me BCBS authorized the study so go collect from them.
Then, my copayment is 20% so my share is $660 and I won't pay a dime more.

I know it can be tough fighting the system but it really helps to have a positive attitude. If you go in expecting to win you are half way there, if you expect to loose well you are half way there too, and no one is going to fight your expectations.

[Cardsfan]

Did you have a referral from your PCP to the sleep specialist dr.?

[sonnet]

Cardsfan - I don't know - I hope so. The initial appointment was made last year, but I only got to see him this March. So I really don't remember. BCBS paid for it though, so I think there must have been a referral.

Bwexler - I know, you're right - My attitude's horrible right now - and I need to be more positive. But right now I am just so angry and frustrated. I know people go through much worse than this dealing with the healthcare system, so I should probably count my blessings.

[Cardsfan]

Definately contact your PCP and get a paper copy of the original referral to the sleep specialist. You can use this to prove to the insurance co. you did have a proper referral. You may have to mail a copy of the referral to your insurance co. yourself.

Also, get in writing copies of your cpap prescription, and the results of your sleep report. If you are uncomfortable doing this on the phone, write a letter to the Dr. office with the request. You do not have to explain why you want them. It is your right to have them.

And I would not count on the Dr. office to deal with your ins. Co. on your behalf. I know it is all overwhelming, but only when you don't know the best way to proceed. You need to keep a paper trail of everything to protect yourself.
Good luck.

[Cardsfan]

Also, do not pay that sleep center bill until you know exactly why it has been denied. It sounds like there is some kind of paperwork mistake along the way.
There are lots of good folks here who have been thru this, and will help.

[sonnet]

Thanks cardsfan. For the advice and encouragement.

[tan]

I would call my insurance co and have them mail me a written explanation of what is covered, what needs pre approval, what you are responsible for, etc. concerning DME and anything to do with diagnosing and treating sleep apnea. Did you know you needed a referral from the primary care dr?

I did just that - no use. I initially rejected the idea, but home-based titration is not as bad, except probably for UARS, when there should be something more advanced than just an APAP.

[49er]

When my former insurance company kept erroneously processing a claim for my cardiologist as out of network, I googled the email address of the CEO and sent a complaint to him. To make a long short, it was finally processed the same week.

Emailing the CEO hasn't always worked for me but it might be worth a shot in this case. Nothing to lose and everything to gain.

49er

[purple]

Sonnet, about the insurance company and you. Now we all know why doctors hate insurance companies. They make unreasonable rules that one can only argue with them about within their own system.

[Demerit]

Not trying to add to your troubles, just giving you a heads up, I'd there wasn't an authorization done for the sleep study then the dme may not be able to obtain autf for the cpap. If auth is able to be obtained you must meet compliance >4hrs per night 21/30 days within a 90 day period every 90 days for the first year and every year thereafter. Yes bcbs policies that utilize aim guidelines are worse than Medicare when it comes to compliance guidelines. This is where having an auto machine will greatly benefit you and aid you in this compliance.