Complains problems with insurance

[W7SOT]

OK - so my wife got a letter from the insurance Co. today saying that they where not going to pay for her CPAP machine, becouse she did not use the minimum amount required, which is the standard 4 hours a night 70% of the night during a 30-day period -- they said that she only used the machine for 4 hours a night, 61% of the time during the 30-day period - I knew this was wrong when we read it - because I have been thier every night helping her get it on, and that fun stuff - they said she had wore it long enough each night - so that was not the issue.

This evening, I went and read the card with Rescan - and found some interesting numbers their - nothing like what the Insurance is claiming - in Rescan, in the review data screen, with the viewing range 30-day complaince period, between the dates of 4/3/2012 (when she got the machine) and 5/2/2012 she used the machine a total of 29 days, 25 of those where over 4-hours a night - and they gave a % of days used over 4 hrs. a night at 83%!! -- a lot different than the 61% the insurance is claiming. If i am reading this wrong - someone please tell me now, so I sound like a fool when I go and start making phone calls tomorrow.



They gave us a bunch of forms and stuff to fill out to file an appeal, basically they are wanting details of why she did not wear the mask like she was supposed to, and if her reason is good enough - they will pay for it - the only issue is, she did wear the mask enough - something got messed up someplace - we just need to figure out what happened, and get the right numbers to someone.

Not sure how that all works though - we took the card into the DME for them to do the download (took them almost 1 1/2 months to get the card back to us) - and then I would assume they reported that data to the insurance Co - so need to get this figure out before they decide they want their machine back - at least to the point where the Insurance Co will pay for things, and then the DME is getting the machine back anyway - and going to see about getting her an S9 autoset - something that we can some data out of, and that involves going to a different DME - but for now, just need get the number right.

Anyone know the best way on how to make this happen without a big hassle with it?

Scott

[dragonflybeach]

Hopefully, one of the long time posters will have a better answer, but in the meantime,...

In my opinion, you are well on your way there. Print out the screen shot you have posted - it has a name and dates and/or date range of use.
Another option, print out each individual day, staple it together and send out with your appeal.

Also, verify with the insurance company which date range they are interested in and go back to the DME and get copies of what they sent to the insurance company.

Good luck.

[W7SOT]

yup - my first stop on monday is going to be at the DME - just down the road, and will get everything they have - will also take the card in if they want to "re-read" it - but not after making a back-up on the computer.

[W7SOT]

yup - my first stop on monday is going to be at the DME - just down the road, and will get everything they have - will also take the card in if they want to "re-read" it - but not after making a back-up on the computer.

So went into the DME office, with the card and print-out from ReScan - and they would not even look at it - they said I needed to talk to one of they respiratory therapists about it - and they did not have any in today - so have an appointment with them tomorrow, so sit down and explain to me how when I read the card, I get 81%, and when they read the card, it shows 61%, so will see what happens tomorrow with them - I do now when we get this figure out, I am having my wife change her DME to the one that I am using.

[BlackSpinner]

Print off your rescan reports and bring them with you too.

[chunkyfrog]

Somebody could have hit a wrong key transcribing numbers to the form;
or were reading off someone else's data.
It happens all the time.
I think they get bonuses for it.

[archangle]

Somebody could have hit a wrong key transcribing numbers to the form;
or were reading off someone else's data.
It happens all the time.
I think they get bonuses for it.

Or some crappy computer display, bad font, handwriting, and 81 looked like 61.

[GumbyCT]

Somebody could have hit a wrong key transcribing numbers to the form;
or were reading off someone else's data.
It happens all the time.
I think they get bonuses for it.

Have to agree and sometimes the numbers 6 & 8 do look close. Could be a mistake on the insurance end too.

Plus keep in mind that unless you have a release from your wife they may refuse to even speak to you about her medical info. They certainly don't have to, unless she is there with you.