MD writes RX for CPAP without sleep study results

[VikingGnome]

I met a woman that talked her shrink into writing an Rx for CPAP just because she wanted it. She previously went to the sleep center where I had my study and she said they told her there wasn't anything wrong with her (no OSA, hyponeas, centrals, or even desats). She was very unhappy so she asked her shrink to write an RX for one without revealing the results of her sleep study. And guess what? She's on SSI and Medicaid so you know who paid for the needless machine. The shrink doesn't know a thing about CPAP therapy. She told me he told her to set the pressure at whatever setting she wants. The ResMed S9 Elite doesn't go above 20 but neither she nor her shrink know that.

I can't imagine anybody WANTING to use a CPAP at night if they didn't need it (unless they are crazy).

Something is really wrong when doctors can write scripts for CPAP with government money paying for it when there is actually evidence the patient DOESN'T need it.

[BlackSpinner]

I met a woman that talked her shrink into writing an Rx for CPAP just because she wanted it. She previously went to the sleep center where I had my study and she said they told her there wasn't anything wrong with her (no OSA, hyponeas, centrals, or even desats). She was very unhappy so she asked her shrink to write an RX for one without revealing the results of her sleep study. And guess what? She's on SSI and Medicaid so you know who paid for the needless machine. The shrink doesn't know a thing about CPAP therapy. She told me he told her to set the pressure at whatever setting she wants. The ResMed S9 Elite doesn't go above 20 but neither she nor her shrink know that.

I can't imagine anybody WANTING to use a CPAP at night if they didn't need it (unless they are crazy).

Something is really wrong when doctors can write scripts for CPAP with government money paying for it when there is actually evidence the patient DOESN'T need it.

No it won't pay for it without a sleep study meeting "medicare" guidelines, an Rx is not enough.

[NateS]

I met a woman that talked her shrink into writing an Rx for CPAP just because she wanted it. She previously went to the sleep center where I had my study and she said they told her there wasn't anything wrong with her (no OSA, hyponeas, centrals, or even desats). She was very unhappy so she asked her shrink to write an RX for one without revealing the results of her sleep study. And guess what? She's on SSI and Medicaid so you know who paid for the needless machine. The shrink doesn't know a thing about CPAP therapy. She told me he told her to set the pressure at whatever setting she wants. The ResMed S9 Elite doesn't go above 20 but neither she nor her shrink know that.

I can't imagine anybody WANTING to use a CPAP at night if they didn't need it (unless they are crazy).

Something is really wrong when doctors can write scripts for CPAP with government money paying for it when there is actually evidence the patient DOESN'T need it.

Have you seen the machine?

More importantly, have you seen the Medicaid paperwork allegedly approving payment for the machine?

Especially with the personality of the woman you describe, I would not be inclined to take her word for any part of the story. Ask to see the corroboration for yourself.

Nate

[Pugsy]

BlackSpinner is correct. There's more to it than someone writing a RX and expecting whatever insurance a person has to pay for it. Documentation of diagnosis and need must also be met.
Medicare has some specific requirements and I would assume state level Medicaid would have something similar.
She can write the RX and the DME could sell it outright to her based on the RX but to bill any insurance the RX alone isn't enough.

Here's part of it..there are also specific post initial cpap follow up criteria...so many days of compliance and face to face before 90 days rental, etc. Even if the criteria below is met they can quit paying rental if follow up criteria is not met.

"In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.

An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:

The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.
The patient has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
Hypertension, ischemic heart disease, or history of stroke.
The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary."

[archangle]

I think most private insurance won't pay without a sleep study either.

I guess CPAP is a lot less potentially harmful than other unnecessary medication. Maybe she can become fixated on her CPAP, reading the results all the time, spend a lot of time cleaning the equipment, etc. Maybe it will keep her busy and away from less destructive forms of behavior.

[Denial Dave]

My 72 year old mother in law suddenly had a Devilbis brand CPAP machine with nasal mask and never had a sleep study analysis done.

The ladies in her "semi-assisted" living apartment building all go to lunch and compare ailments & then recommend treatments based upon each others conditions.

We have a hunch she got her CPAP from one of her "friends" in her semi-assisted living apartment building.

Somehow, Medicare agreed to pay for all of her supply needs.

[VikingGnome]

Yes, I've seen her machine and she has nasal pillows (actually she was quite proud of that). When she said she could set it at 40 if she wanted, I told I have the same machine and it won't go above 20 and that having pressure too high could cause central apnea. And yes, she got it on Medicaid (not medicare). She has about 20 doctors she goes to every month. None of them know she sees others. One to get pain killers and another to help her with pain killer addiction. She's a mess. I deliver food to her apartment once as month but the Bishop told everyone at church to NOT be close friends with her. She has a way of manipulating people into doing just about anything.

When I first met her, she had totalled her old pickup in an accident. She was driving within our state without a valid driver's license, no insurance, and not registering the vehicle for over two years. When she first told me she was CPAP I didn't believe her. But then I saw the machine in her house by the TV with nasal pillows and everything. I don't think she actually uses it at night but keeps out in the open so others can see how pitiful her life is and oh, BTW, she has to sleep with CPAP every night. I wasn't very sympathetic AT ALL.

She's a very smart cookie and knows the government programs very well. She knows exactly how to do to get what she wants without raising red flags. She gets SSI and food stamps and is supposed to report whenever she gets help from someone in the way of money or groceries. She gets a month's worth of grocery from my church every month and I just bit my lip so I don't say anything to offend her. You definitely don't want to be the brunt of her rage.

[lazer]

....She's a very smart cookie and knows the government programs very well. She knows exactly how to do to get what she wants without raising red flags. She gets SSI and food stamps and is supposed to report whenever she gets help from someone in the way of money or groceries. She gets a month's worth of grocery from my church every month and I just bit my lip so I don't say anything to offend her. You definitely don't want to be the brunt of her rage.

I'll bet she's a democrat.

[49er]

....She's a very smart cookie and knows the government programs very well. She knows exactly how to do to get what she wants without raising red flags. She gets SSI and food stamps and is supposed to report whenever she gets help from someone in the way of money or groceries. She gets a month's worth of grocery from my church every month and I just bit my lip so I don't say anything to offend her. You definitely don't want to be the brunt of her rage.

I'll bet she's a democrat.

Republican-Heavy Counties Eat Up Most Food-Stamp Growth

http://www.bloomberg.com/news/2012-11-0 ... rowth.html

49er

[2Tim215]

Sad situation indeed. Sometimes people have ways to get past medical requirements or guidelines but unfortunately it can be their own undoing, such as you mentioned, addiction. Sounds like she may need a wake-up call, no pun intended. Hopefully her addiction therapy will be successful and she will be clear minded enough to make better choices.

[lazer]

....She's a very smart cookie and knows the government programs very well. She knows exactly how to do to get what she wants without raising red flags. She gets SSI and food stamps and is supposed to report whenever she gets help from someone in the way of money or groceries. She gets a month's worth of grocery from my church every month and I just bit my lip so I don't say anything to offend her. You definitely don't want to be the brunt of her rage.

I'll bet she's a democrat.

Republican-Heavy Counties Eat Up Most Food-Stamp Growth

http://www.bloomberg.com/news/2012-11-0 ... rowth.html

49er

Well I'll be damned. Makes no sense. What's this world coming to?

Just for the record. I don't identify myself as a "Republican" but more as a "Conservative". I wish there was a "Conservative" party left to vote for.

[greatunclebill]

this is the internet where anything can appear to happen for any reason. when i stick my real life hat on i don't believe a word of it.

[VikingGnome]

Well believe it. There ARE people in this country that have learned to live without working. She gets SSI, all free medical care, section 8 housing, Food stamps, free cell phone, free pet food for her cat & dog, free neuter and spaying, free vaccinations for her pets. If something is available out there for free, she knows about it. At first I couldn't figure out how medicaid would possibly pay for all those doctor visits. All the women at church were rotating to drive her to her appointments. Finally the Bishop said, NO MORE. Let her find her own rides. She can call and ask but nobody is obligated to take her anywhere. The sense of entitlement this woman has is astounding.

I strongly suspect the way she gets away with multiple doctor visits and prescriptions is that she is using multiple identities. Otherwise, the system would have caught her by now. She probably told her shrink she had excessive daytime sleepiness to get CPAP without telling him about all the narcotics she's taking. Then she tells another doctor she can't sleep at all because of all her pain. And she openly admitted to me that the "Dollar Store" down the road will take her food stamps to buy ANYTHING.

So she is an example of people who have learned how to work "the system" and get everything they want at expense of taxpayers. At least in my state, medicaid and welfare fraud is rampant. For too many generations people have depended on the welfare system. Now that welfare has been limited, they've learned other ways to get something for nothing.

When Phen-Fen was withdrawn from the market, thousands of people claimed injury from taking it. The paper said a local pastor and his secretary at a church were arrested for fraud. They collected over $30,000 dollars in damages from Phen-Fen manufacturers when they never actually took the drug. They just got somebody to write a phoney doctor's report for their claim.

When a train with cars caring dangerous chemicals derailed, a neighborhood was evacuated for 2 days for safety. The railroad company said they would reimburse expenses for hotels and eating out for those couple of days if they provided receipts. So people went to stay with family across town, got phoney receipts, and collected thousands of dollars. Later, more than 100 people were prosecuted for fraud. Fraud is the livelihood of those that won't do an honest day's work.

An attorney had an ad on TV yesterday with a guy saying he'd had a heart attack and now social security wouldn't give him disability benefits. So he hired "Big Shot Attorney" and got what he deserved. Thousands of people have heart attacks and are not disabled by it. The message was basically, have any kind of ailment, this attorney can get you disability benefits and you won't have to ever work again. That's the mentality around here.

[chunkyfrog]

If there was a bounty for turning these cheats in, there would be a lot fewer of them.

[zoocrewphoto]

If there was a bounty for turning these cheats in, there would be a lot fewer of them.

There is, sort of, but they make it very difficult. If you report somebody, and they go after them for fraud, you can earn a reward. I tried to turn somebody in a few years ago. I didn't care about the reward. I just thought it was wrong that somebody could get disability, brag about it paying the mortgage on her farm, while she bred and trained horses. Her website had photos of her riding the horses. And she was active on an email list for several hours a day. Clearly, she could do work at a computer and do physical labor. But I couldn't file the report against it because it wanted to know how much she was receiving in benefits, and I had no idea. I don't know why they couldn't accept a name, address, and website url proving she didn't need assistance.