I recently posted a success story about using this forum to get an APAP instead of what the DME told me Id be getting. Thanks again to those who helped and also those who replied.
Was expecting my new unit to ship this morning and hopefully receive it tomorrow as my nights are getting much worse, last night being just awful and feeling like I was run over by a truck repeatedly. Frankly, I dont feel like I can
The call came from Claudia at Billmyinsurance.com and instead of the "it's on the way" conversation, we had the you cant get your equipment talk instead.
Apparently, the sleep lab not being aware of Blue Cross's new more strict policies on approving equipment for sleep disorders, didnt know that I must be recorded for 120 mins of actual sleep time before switching me to the CPAP machine. I had a total of something like 225 mins of actual recorded sleep time over the entire test, but only 75 mins of recorded sleeptime prior to the mask going on.
According to Claudia, my results show a severe problem and theres no question that I need the equipment, however, billmyinsurance has been getting so many denials due to not enough pre mask (sorry dont know exact terminology) time that they won't risk it and send me the equipment without me paying the full "insurance company" price. Which is of course more than twice the price I can get it from CPAP.COM.
Now of course it gets interesting. Will Blue Cross cover a second diagnostic sleep test? Will the sleep lab take any responsibility for not knowing my insurance companies requirements? Did I just spend $1000 deductable for this entire process only to have to pay for my equipment and supplies out of pocket, for as long as I need them. When, oh when, will I get my equipment and get a nights sleep?
Im not kidding when I say that I didnt even know how I was going to make it until tomorrow without treatment. Was told by Claudia that calling Blue Cross was futile as the person would probably say, no problem, but 30 days later when the claim hits, it would most likely be denied.
Like I said, a true waking nightmare.
Small success turns to a waking nightmare
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brackstone
- Posts: 168
- Joined: Sun Jul 16, 2006 5:42 pm
Wow I'm really sorry to hear about that.
Unfortunately it's the situation of the insurance company wants money or doctors prescribing CPAP machines willy nilly. Whichever side of the argument you look at you are suffering for others mistakes and that should never happen.
I hope you get the device you need soon.
Unfortunately it's the situation of the insurance company wants money or doctors prescribing CPAP machines willy nilly. Whichever side of the argument you look at you are suffering for others mistakes and that should never happen.
I hope you get the device you need soon.
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girlsaylor
- Posts: 140
- Joined: Tue Dec 19, 2006 12:00 pm
try and negotiate your copay amount with the facility
I don't know if this will help, but, if it were me, I'd do a couple of things.
First off, create an audit trail. Send a written communication to the insurance company, giving dates of studies, dates you spoke with insurance and with Claudia, as well as what was discussed. Recreate the conversations as closely as you can as to who you spoke with, date, problems noted, and solutions offered. Request they consider this as a complaint for review and ask to be notified of the particulars of the complaint process, the method of notification they will use when they review this, and what steps can be taken by you and the DME provider, such as precertification request for benefits, or another sleep study (I'd be negotiating that sleep study copay with the lab that did the study, if it were me, as it's their responsibility to get the precertification requirements initially before doing the sleep study).
If you engage in any e-mail contact with either the insurance company or the DME provider, keep copies of those, even if it means blind cc-ing yourself so you have those, as they are date and time stamped and will serve as part of your audit trail.
You can get the name of the medical director to go over the heads of customer service, directing your correspondence to that person rather than a generic customer service person.
Don't get undone if they ask for medical records and engage in other delay tactics. Just keep the records and keep creating your own audit trail. If they do not respond to your requests, the next communication can be cc'd to your state board of insurance. That often gets results, as if the board is any good at all, they will call the insurance company to find out how the complaint process is progressing. I am currently at that stage in my complaint process with my own insurance company. Sad, but they have blockages in place in some companies to deny coverage, or to make access very difficult.
Please keep the faith and keep on keeping on. We're here to support you.
girlsaylor
First off, create an audit trail. Send a written communication to the insurance company, giving dates of studies, dates you spoke with insurance and with Claudia, as well as what was discussed. Recreate the conversations as closely as you can as to who you spoke with, date, problems noted, and solutions offered. Request they consider this as a complaint for review and ask to be notified of the particulars of the complaint process, the method of notification they will use when they review this, and what steps can be taken by you and the DME provider, such as precertification request for benefits, or another sleep study (I'd be negotiating that sleep study copay with the lab that did the study, if it were me, as it's their responsibility to get the precertification requirements initially before doing the sleep study).
If you engage in any e-mail contact with either the insurance company or the DME provider, keep copies of those, even if it means blind cc-ing yourself so you have those, as they are date and time stamped and will serve as part of your audit trail.
You can get the name of the medical director to go over the heads of customer service, directing your correspondence to that person rather than a generic customer service person.
Don't get undone if they ask for medical records and engage in other delay tactics. Just keep the records and keep creating your own audit trail. If they do not respond to your requests, the next communication can be cc'd to your state board of insurance. That often gets results, as if the board is any good at all, they will call the insurance company to find out how the complaint process is progressing. I am currently at that stage in my complaint process with my own insurance company. Sad, but they have blockages in place in some companies to deny coverage, or to make access very difficult.
Please keep the faith and keep on keeping on. We're here to support you.
girlsaylor
I would "get on the sleep lab's back". Medicare requires a minimum of 2 hours sleep out of a minimum of 6 hours bed time (lights out, in bed, trying to sleep) and most insurance companies follow that guideline. Different BC/BS policies provide different benefits but I would be very surprised if any of the "Blues" didn't follow the Medicare requirement for CPAP qualification. In our area, BC/BS was THE predominant insurer for years and years. For someone in our area to NOT know BC/BS policy for their services would be virtually unheard of and unthinkable. Your sleep lab "should" do a second study and if insurance refuses to pay or pays a reduced rate the lab "should" just swallow the cost. Their mistake, their responsibility.
_________________
| Mask: Quattro™ FX Full Face CPAP Mask with Headgear |
| Additional Comments: PR SystemOne BPAP Auto w/Bi-Flex & Humidifier - EncorePro 2.2 Software - Contec CMS-50D+ Oximeter - Respironics EverFlo Q Concentrator |
Women are Angels. And when someone breaks our wings, we simply continue to fly.....on a broomstick. We are flexible like that.
My computer says I need to upgrade my brain to be compatible with its new software.
My computer says I need to upgrade my brain to be compatible with its new software.
I just had a dispute with BCBS of Mississippi over out of network vs in network technologist who billed me.
The CSR I spoke with told me to write a letter appealing the Est. of Benefits and to BE SURE to state
"that I didn't have a choice" with the selection of "service provider". She said there was also a second appeals process if that fails.
Just thought that tactic might help in your situation as well.
The CSR I spoke with told me to write a letter appealing the Est. of Benefits and to BE SURE to state
"that I didn't have a choice" with the selection of "service provider". She said there was also a second appeals process if that fails.
Just thought that tactic might help in your situation as well.
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christinequilts
- Posts: 489
- Joined: Sun Jan 23, 2005 12:06 pm
I agree with Slinky- your first call needs to be to the lab that did your test and demand some answers, not your insurance company or DME. The 120 minute sleep time, pretreatment is a standard many insurance companies adhere to, based on Medicare requirements. Most sleep labs automatically do all studies as if every person has Medicare, because there is less chance for problems like this to occur. We as consumers have a hard enough time keeping up with what our insurance company requires, how can a lab possibly keep track of all the various insurance companies of every patient? Very few, if any, insurance companies have stricter requirements then Medicare regarding sleep studies and apnea events are defined; some may not be as a strict, but why take the chance?- the requirements could have changed, the wrong insurance could be mistakenly listed, the person could have recently changed insurance, etc.
And two hours sleep time isn't that much, if you really think about it. If someone had a lot of sleep onset centrals, which are a fairly common and typically normal occurrence, they could potentially be wrongfully diagnosed with Central Sleep Apnea instead of Obstructive Sleep Apnea if numbers were projected from to little sleep. If your entire sleep time was only 225 minutes, that only left 2 1/2 hours for the titration. Was that really enough time to find the right pressure? How much REM could you have in that time frame? Did you have problems falling asleep to start with or something? Or was the tech trying to rush you out the door as fast as possible? If you had problems falling asleep, then they should have postponed the titration for a second study.
I'd be on the phone with the lab ASAP, asking why they didn't provide an adequate test and how they are going to fix the situation, noting you or your insurance company should not be expected to pay additional money for a repeat test. And in the mean time, they should provide you with a loaner machine, free of charge, as you are certain the doctor doesn't want you to go without treatment.
Good luck!
And two hours sleep time isn't that much, if you really think about it. If someone had a lot of sleep onset centrals, which are a fairly common and typically normal occurrence, they could potentially be wrongfully diagnosed with Central Sleep Apnea instead of Obstructive Sleep Apnea if numbers were projected from to little sleep. If your entire sleep time was only 225 minutes, that only left 2 1/2 hours for the titration. Was that really enough time to find the right pressure? How much REM could you have in that time frame? Did you have problems falling asleep to start with or something? Or was the tech trying to rush you out the door as fast as possible? If you had problems falling asleep, then they should have postponed the titration for a second study.
I'd be on the phone with the lab ASAP, asking why they didn't provide an adequate test and how they are going to fix the situation, noting you or your insurance company should not be expected to pay additional money for a repeat test. And in the mean time, they should provide you with a loaner machine, free of charge, as you are certain the doctor doesn't want you to go without treatment.
Good luck!
This is why insurance needs less control over our health care decisions. Time and time again, people have to fight with everything they have just to get approval for something simple, because they try and pull out the technicalities to get out of paying anything.
I agree with the above that you should hold the lab at fault for not following the required procedures for your insurance. It is their job to know what the requirements are, not yours.
I'd also keep pushing the insurance to stop practicing willful ignorance, and begin practicing positive health care.
I agree with the above that you should hold the lab at fault for not following the required procedures for your insurance. It is their job to know what the requirements are, not yours.
I'd also keep pushing the insurance to stop practicing willful ignorance, and begin practicing positive health care.
Great advice again all.
Finally got a call back from my sleep lab (which is the same office as my sleep Dr) and used many of the arguments that you all listed. I managed to be very soft spoken and tried to make my points intelligently and not let my emotions rule the conversation. Tuff to do knowing that if I couldnt convince them, I could be facing more expenses, legal hassles and a gosh knows how long wait for my equipment.
Fortunately, it never got ugly at all. They agreed to do a second study and I will be out of pocket no expense even if BC doesnt cover it. Im speaking to the lab manager tomorrow morning to get more details and talk about a loaner unit to get me through until my equipment is here.
On a side note, it was mentioned that I might not need to stay for the full study as all I need is the pre CPAP sleep time. Is this a good idea? I would hate to find out later that the two can't be combined and have to do a third. YIKES!!
In answer to your question Christine, yes I had trouble falling asleep as they started me at 10:30pm and I NEVER go to bed before 2am. The tech was actually extremely helpful and patient and made the entire process as bearable as I think it could be. I was out the door around 7am, which was right around the time they said I would be done. I get the feeling that the reason I was put on the mask so soon was, and I think they actually told me this, was that my symptoms are so apparent that they had sufficient data. That point was confirmed by Claudia at Billmyinsurance.com, but BC still is apparently "CRACKING DOWN" and insisting on the full 120 minutes.
I will update as new and fun info becomes available.
Thanks again to you good folk for giving me the ammo I needed to speak with some intelligence about my situation.
Finally got a call back from my sleep lab (which is the same office as my sleep Dr) and used many of the arguments that you all listed. I managed to be very soft spoken and tried to make my points intelligently and not let my emotions rule the conversation. Tuff to do knowing that if I couldnt convince them, I could be facing more expenses, legal hassles and a gosh knows how long wait for my equipment.
Fortunately, it never got ugly at all. They agreed to do a second study and I will be out of pocket no expense even if BC doesnt cover it. Im speaking to the lab manager tomorrow morning to get more details and talk about a loaner unit to get me through until my equipment is here.
On a side note, it was mentioned that I might not need to stay for the full study as all I need is the pre CPAP sleep time. Is this a good idea? I would hate to find out later that the two can't be combined and have to do a third. YIKES!!
In answer to your question Christine, yes I had trouble falling asleep as they started me at 10:30pm and I NEVER go to bed before 2am. The tech was actually extremely helpful and patient and made the entire process as bearable as I think it could be. I was out the door around 7am, which was right around the time they said I would be done. I get the feeling that the reason I was put on the mask so soon was, and I think they actually told me this, was that my symptoms are so apparent that they had sufficient data. That point was confirmed by Claudia at Billmyinsurance.com, but BC still is apparently "CRACKING DOWN" and insisting on the full 120 minutes.
I will update as new and fun info becomes available.
Thanks again to you good folk for giving me the ammo I needed to speak with some intelligence about my situation.
Well, good on your sleep lab for agreeing to a second sleep study at no expense to you regardless. I don't think it is a good idea, nor much of a savings, to cut the study short and/or not do the titration. I'd play dumb if the tech tries to boot you out early and insist on the full night sleep.
Good luck!
Good luck!
_________________
| Mask: Quattro™ FX Full Face CPAP Mask with Headgear |
| Additional Comments: PR SystemOne BPAP Auto w/Bi-Flex & Humidifier - EncorePro 2.2 Software - Contec CMS-50D+ Oximeter - Respironics EverFlo Q Concentrator |
Women are Angels. And when someone breaks our wings, we simply continue to fly.....on a broomstick. We are flexible like that.
My computer says I need to upgrade my brain to be compatible with its new software.
My computer says I need to upgrade my brain to be compatible with its new software.
another sleep study
Wow, nice that they will redo it for you. Since you are already there, all wired up, why not stay for the whole thing if you are willing to do it? More data could be helpful in making your diagnosis more accurate.
_________________
| Machine: DreamStation BiPAP® Auto Machine |
| Mask: AirFit™ P10 For Her Nasal Pillow CPAP Mask with Headgear |
| Humidifier: DreamStation Heated Humidifier |
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Guest
Small success turns to a waking nightmare
Yawnin NC,
If you have difficulty falling asleep, perhaps taking Ambien CR just before the sleep study would be wise to do. Wait until after you get hooked up for the sleep study. Also if you could try the sleep medication before the sleep study might also be a good idea.
Good luck!
If you have difficulty falling asleep, perhaps taking Ambien CR just before the sleep study would be wise to do. Wait until after you get hooked up for the sleep study. Also if you could try the sleep medication before the sleep study might also be a good idea.
Good luck!
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Guest
Small success turns to a yawning nightmare
Yawnin NC,
If you have difficulty falling asleep, perhaps taking Ambien CR just before the sleep study would be wise to do. Wait until after you get hooked up for the sleep study. Also if you could try the sleep medication before the sleep study might also be a good idea.
Good luck!
If you have difficulty falling asleep, perhaps taking Ambien CR just before the sleep study would be wise to do. Wait until after you get hooked up for the sleep study. Also if you could try the sleep medication before the sleep study might also be a good idea.
Good luck!
Greetings all,
Thought Id post a quick update since so many of you were kind to offer advice.
Well, today was very interesting. First off, I had my wife pick up some Breath Rite strips and Breath Rite snore spray as per my sleep docs recommendation. He had said on Monday, before all this bruhaha began, that it might offer some relief until I received my equipment. Strangely enough, I had the best nights sleep Ive had in weeks. Can't say I slept well, but I sure was much more rested than I have been in quite a while. Is it a good idea to combine the spray with the Apap or will it work against the equipment? Just a thought.
Anywho, I got the call from the sleep lab this morning expecting it to be about scheduling my free sleep study. It was actually the office manager calling to let me know that Billmyinsurance.com had actually gotten it wrong. Not their fault really, I assume since they are IN-NETWORK with BC/BS in Illinois, that they weren't fully aware of BC/BS NC's standards and requirements. According to the manager, after thoroughly researching it with the DME's and BC/BS, if the results are so conclusive, as mine were (and she listed the requirements) then the tech can and will go to the mask before the full 120 mins is up. She said I had really thrown them for a loop with what BMI.com had said because 90% of their patients have BC/BS and they've never had a claim denied for that reason. Guess things are a little diff here in NC.
So, I went to the local DME, who is ordering me a brand new Remstar Auto w/Cflex and HH, mask of my choice with all the fixins at no upcharge to me. And since it wont be in until next week they brought over a loaner, same unit just no HH for me to use until then.
Well here I lay, typing this and getting ready for my first night with treatment. Im excited and nervous, but looking forward to many nights of improved sleep.
Thanks to everyone on this board for the info and support.
Thought Id post a quick update since so many of you were kind to offer advice.
Well, today was very interesting. First off, I had my wife pick up some Breath Rite strips and Breath Rite snore spray as per my sleep docs recommendation. He had said on Monday, before all this bruhaha began, that it might offer some relief until I received my equipment. Strangely enough, I had the best nights sleep Ive had in weeks. Can't say I slept well, but I sure was much more rested than I have been in quite a while. Is it a good idea to combine the spray with the Apap or will it work against the equipment? Just a thought.
Anywho, I got the call from the sleep lab this morning expecting it to be about scheduling my free sleep study. It was actually the office manager calling to let me know that Billmyinsurance.com had actually gotten it wrong. Not their fault really, I assume since they are IN-NETWORK with BC/BS in Illinois, that they weren't fully aware of BC/BS NC's standards and requirements. According to the manager, after thoroughly researching it with the DME's and BC/BS, if the results are so conclusive, as mine were (and she listed the requirements) then the tech can and will go to the mask before the full 120 mins is up. She said I had really thrown them for a loop with what BMI.com had said because 90% of their patients have BC/BS and they've never had a claim denied for that reason. Guess things are a little diff here in NC.
So, I went to the local DME, who is ordering me a brand new Remstar Auto w/Cflex and HH, mask of my choice with all the fixins at no upcharge to me. And since it wont be in until next week they brought over a loaner, same unit just no HH for me to use until then.
Well here I lay, typing this and getting ready for my first night with treatment. Im excited and nervous, but looking forward to many nights of improved sleep.
Thanks to everyone on this board for the info and support.