Follow Up Sleep Studies

[MaskingtheNightAway]

Hello Everyone:

I am very troubled about my recent experiences with Doctors and DME suppliers. I have successfully used CPAP since 2004. The treatment has changed my nightly sleep experience in a very positive way. I was always a very loud snorer, but I had started to awake frequently gasping for air and sometimes my airway was full of stomach acid. It was terrifying and it took me several minutes to calm down and clear my airway. CPAP treatment ended those episodes. I feel fortunate that I have never fought using the machine or masks. Others in my family just cannot stand using the machines and fight having the mask on. I feel lucky.

My insurance would not pay for supplies or a new CPAP machine without a new or current RX from a doctor. MY primary care doc (PCP) is part of a large physician group. My PCP refused to give me an RX or letter for a new machine and supplies. Instead, she offered me a referral to one of her associates in the large physicians group. This makes me feel like a piece of meat being passed around for everyone in the club to bill out some extra charges on my insurance.

I currently use a five year old auto CPAP machine I obtained after a relative passed away. My first machine (S7) became very noisy (squealing) after 7 years. I bought a used (S7) from a DME for $200.00 and got 2 more years out of that. The Phillips 550 Auto FLEX machine from my passed relative was a huge upgrade from the S7. It had a smart card, I could view the data in Sleepy Head, I could monitor my AHI and usage hours, and it adjusted my pressure as needed. I have four years of data on the SD card.

It seems to me, the treatment data I have on that SD Card should end the need for further sleep testing.

I refused to do another study, overnight in the hospital lab, and allow them to charge my insurance over $3000.00. I found a home sleep test doctor. Took my machine with me to the first appointment. He never even pulled the SD card out of the machine. He wanted me to do a home sleep test (HST). I told him I cannot sleep without my machine. He insisted I try the HST and just get him four hours of data. I had a horrible night trying to sleep without CPAP. I moved from my bed to a recliner for a few hours, slept fitfully, did not rest much at all. Finally about 3am I end the HST test and tried to get a few hours of rest with my machine. I felt like crap for several days after not using my CPAP for the first time in 11 years. What was the point of all this????

To the HST back to the DR. He agreed is still have sleep apnea. They submitted to my insurance for a new machine and supplies with costs of about $1300.00. DENIED. UHC denial letter states that I have a working machine. After having two prior devices fail, I know I must be proactive and obtain a new device before my present one bites the dust. Also, insurance has only ever paid for one CPAP for me in 2004. I cannot sleep without a machine. I have experienced a machine failing and I know I need to have a backup plan.

I bought a new machine with my own funds. Got a great deal as well. NEW, Phillips DS560HS, AUTO w/humidifier and SD Card for $462.00. So, my UHC Insurance dodges the bullet. HST doctor did bill for HST and office visits. I paid two copays of $40 bucks each time, $80 total. UHC paid him about $300.00 for the HST.

I truly do not need the doctors, sleep labs, or DME's. The machines now have the technology to monitor and adjust my treatment as needed. I feel abused by greedy doctors and DME suppliers, EXCEPT for the place that sold me the NEW DS560HS at such a great price. (ONLINE Store!). However, even paying for my own machines and masks, I need the RX from a doctor. This is all bogus, IMO.

This entire industry needs to change very soon. Yes we do have a healthcare crisis.

Greedy doctors, greedy insurance companies, and greedy DME's in collusion with some of them. (some of them, not all of them).

Your thoughts????

The Masked Man

[metsfan302]

I could be wrong, but I thought some insurances pay for a new machine every 5 years?

However, even paying for my own machines and masks, I need the RX from a doctor.

For ? You can find most things online, without a script- I assume to order thru your local DME or to get insurance to pay?

I agree the system is pretty messed up. I am going thru somethings now with my insurance, turns out in the end its going to cost them more as the home tests well for my case arent too reliable and they even said I will prob need a lab study done - but in order for them to pay, I need the home test 1st. - sort of ass backwards and well yea.

Welcome to the Forum
Eric

[MaskingtheNightAway]

Yes, I was lucky to find my new machine online and they shipped without an RX.

Many online DME's state policies requiring an RX for a machine or masks. The local DME's are very jealous of the online stores and throw a fit if they find out you can get things without the RX. The HST doctors office advised me to "BE VERY CAREFUL" buying online. I just don't get it. If online suppliers can operate cheaper and sell at an attractive price, the local DME's are going to lose that business.

Also, I thought once THE FDA approves a device for sale in the USA, they could sell it to anyone, but some say you need the RX for machines and masks.

The HST doctor told UHC I got my current machine in 2012. No explanation about it being a second hand machine from a relative. So, they denied my request. They should only be allowed to consider equipment they paid for, not something I obtained on my own.

Insurance requires the RX just as another hoop to make you jump thru. I may try to submit my bill for the new machine just to see if they will go along.

[OkyDoky]

Get your Rx from the Dr who did your sleep study to have for future purchases. There are other options to get your equipment but the study should provide something for the money they were paid.

[Pugsy]

I could be wrong, but I thought some insurances pay for a new machine every 5 years?

Not necessarily. It depends on the insurance plan. More and more insurance plans are going for the "only replace if it is broken and costs more to fix it than new would cost."
It used to be that everyone sort of used the 5 year rule but not anymore.

[Guest]

I am sleep tech in NC and a CPAP user. Usually after 5 years, the insurance company will cover the cost minus deductibles and any other thing they can deny. If you have proved compliant with data uploads, they will usually only require a "Periodic Titration" study to make sure the pressure is correct. If they can not prove you have been CPAP compliant, they will require the process to start over from the diagnostic study. I myself went the HST and auto pap direction to save on money. CPAP machines and mask are prescription based, but tubing, cushions and filters are not. If you do not have comorbidities (obese, high blood pressure) to go along with your sleep complaints most insurances will only pay for a HST before an in lab titration study. BCBS of NC will be requiring this starting in 2016.

[RPSGTryan]

I am sleep tech in NC and a CPAP user. Usually after 5 years, the insurance company will cover the cost minus deductibles and any other thing they can deny. If you have proved compliant with data uploads, they will usually only require a "Periodic Titration" study to make sure the pressure is correct. If they can not prove you have been CPAP compliant, they will require the process to start over from the diagnostic study. I myself went the HST and auto pap direction to save on money. CPAP machines and mask are prescription based, but tubing, cushions and filters are not. If you do not have comorbidities (obese, high blood pressure) to go along with your sleep complaints most insurances will only pay for a HST before an in lab titration study. BCBS of NC will be requiring this starting in 2016.

Sorry, I forgot to sign in before posting this.

[Anon2003]

Our thoughts: We too had predatory experiences with MDs and DME. Over long period of time, "insurance-preferred" DME offered us (husband) only the oldest and least desirable CPAP machines. We got a good machine only when we went rogue, did our own research and picked out what we felt was the best available/affordable and that met the Rx and sleep study specs. We threw in the towel and paid out of pocket because we were so worn out with the DME and MDs that we just did not have the energy to fight for insurance reimbursement for the machine that worked for us.

Currently trying to sort out some sinus problems and we have the sleep doc tossing us to an ENT and the ENT tossing us back to the sleep MD. Sooner or later our insurance company will question why we are paying them both for consult re the same issue . . . So we share your pain.

In the mean time, like you we are grateful for a piece of the pie: that we now have a machine which has significantly improved my husband's quality of life, (even though we had to call the machine his Christmas and birthday present in the year we bought it).

If your insurance requires current MD Rx, does the MD have to be a sleep specialist? In our plan, any MD can write a CPAP scrip. If you have a good and sympathetic MD within reach, and if insurance plan doesn't require scrip writer to be a sleep or PC MD, you can ask the sympathetic MD to write your scrip with input supplied by you. I am certain some would suggest that this is a dangerous way to go, but it worked for us . . . You have already indicated that you feel confident you have the info you need if you can find a willing MD (or in some states and plans, even a DDS).

We know there are DMEs and MDs with integrity out there . . . We just did not find 'em, nor did you. I wish I believed that approaches like ours will effect market-driven change . . . If it is coming, it is moving at the speed of a glacier emerging. The hearing aide industry is similar . . . lots of greedy bottom feeders mucking up the system for everyone.

Does your insurance company have an appeals process? There are some decent books out now on how to aggressively pursue insurance coverage appeals. I consider myself to be an old hand at fighting for coverage, but but I am always learning something new because the industry is in disarray. Your state insurance regulatory board might be a resource for you. There is a forum section on this site that is focused on DMEs and other system "players." Good info there.

All of this takes time and energy and the bean counters running the insurance companies know this. They hope you will give up. Don't.

[Pesser]

It looks like the entire medical system surrounding CPAP revolves around an effort by the insurance companies to save money. But how exactly are they doing this. Most conditions of OSA are detectible by a spouse, friend, or a tape recording. Over time this “witness” method should be more reliable than any sleep study. That’s because a sleep study will tell you what happens in one night. When you consider how much money you are paying for the Dr., Study, DME…..exactly how much money is actually going to the manufacturer? This is where we want the money to go. We want these people to earn a lot so that they can manufacturer and research. The insurance company would save a lot of money by getting rid of all this middle stuff. Of course the more serious cases need intervention. But when you consider that good machines can get you to your optimum pressure….what else is needed. I bet an S9 or S10 only brings $200 to the manufacturer.

[chunkyfrog]

UHC, if there have not been dramatic changes in the past few years,
is a collection of greedy twits; to be avoided by any means possible!
Medicare paid for my new machine, even though my S9 Autoset
(for which I paid 100% out of pocket) was only 3.5 years old.