OT: Insurance companies suck

[TSSleepy]

** vent-mode on **

Over six months after my polysomnograph, my insurance company finally decides I'm not fully covered and bills me for $1656. Bill arrived today and is due in 9 weekdays.

It wouldn't irritate me so much, but they originally told me that it was covered, and since I hadn't been billed...I wasn't expecting this. It also irritates me because I didn't sleep during the polysomnograph, so it was a complete waste of time and money.

I ended up having to buy, out of my own pocket, a pulse oximeter and a used CPAP machine and show a doctor that I had a problem and that CPAP fixed the problem. So this $1656 is pretty insulting when I diagnosed my own problem, fixed my own problem, determined my own pressure settings, and demonstrated the problem/solution to a doctor.

So what did I get for all my time and money? Well, the doctor did finally hook me up with a new APAP and mask for only several hundred dollars. But they have repeatedly ignored my request to give me a written prescription, so I'll probably have to go through this all again some day.

** vent-mode off **

[Julie]

Can you not fight this, if they told you you were covered? Or did they then tell you you weren't and you still spent all the money on equipment? Even then I might try to fight it, after all you were very concerned about your health and weren't getting much help from anyone!

[sleepycarol]

I would appeal the decision. I don't know the process or how successful people are, but I would certainly check it out.

[CpapRRT]

appeal, appeal, appeal!

Do you have a confirmation number of the first time you called and they told you it was covered? That would help as most calls are recorded.
Then keep appealing the decision.

If you lose, it at least puts off how soon you have to pay, and you usually get up to 3 appeals.

[Tcamillemars]

Been there, done that, over and over! I agree, the system sucks, and I'm tired of having to fight for everything, too. I also believe that sometimes you just have to vent or you'll blow up. We pay a fortune for insurance coverage, only to have to fight to get what is in that "contract."

[jdm2857]

I'm convinced that the insurance companies routinely and randomly deny a certain percentage of legitimate claims on the theory that not all of them will be challenged. For the ones that are challenged they say "whoops, we made a mistake." For the others, they pocket the money.

If the insurance companies do it, it's a "mistake." But if you do something similar, it's insurance fraud, and you go to jail.

[TSSleepy]

Yeah. I'll call them and argue. But I actually think I owe them the money. I was sort of surprised when they said it was covered originally.

Mostly I just needed to vent last night. I have a bunch of anti-healthcare reform friends who are afraid of "giving the government too much power" or afraid of "being taxed to death". Most of them are in their 30's and 40's, have never lived without insurance, have never had serious medical issues.

Over the last several decades, insurance companies have grown into giant bloodsucking racketeering ticks that are a blight on society. I have a really hard time with the concept that people would rather trust their money to companies like AIG than to the government.

If the government screws up, we can vote them all out. But the insurance companies have gotten so large and powerful, that when they screw up...we're forced to bail them out to keep Wall Street from buckling.

Anyway. I'm irritated because my sleep apnea care was shoddy, slow and ineffective...so I had to do it myself. And then I get a big bill for their efforts six months after the fact. Whatever.

I shouldn't be surprised, "Kaiser Permanente NW" sent my mother a bill 2.5 years after she died in their care.

[Georgio]

SEE: https://www.youtube.com/watch?v=A0Su9lEHVA8

[Heavy Zs]

We have "health care" in Canada, and it doesn't cover CPAP machines or diagnostic sleep studies. If your lucky, you may get insurance coverage with Blue Cross, Sun Life, etc., that covers part of your costs.

My insurance paid 80% for my CPAP gear up to a limit they described as "normal cost". Naturally, that was a couple of hundred bucks less than what I was quoted at every location in the city that sells the gear, but it was better than nothing.

Strangely, they refused to pay for the sleep study, which I assumed would have been covered under medical diagnostic testing. How they pay $1600 for a machine that requires a prescription to buy, yet refuse to pay for the $150 overnight sleep study (never mind the overnight $800 test) required to diagnose the condition before you buy the machine is a study in insurance logic.

[Maple Leaf]

I've just finished dealing with my insurance company (Pacific Blue Cross) for the purchase of a new machine/mask. The very FIRST question I asked was, "will you send me a PREAUTHORIZATION LETTER TO PURCHASE"?. I received the letter 2 weeks later indicating the dollar amount I was covered for along with a 90 day validation. I would never accept a verbal confirmation by phone, something I too, learned the hard way.

Regards, Rick

[jdm2857]

I have a high deductible, so before my sleep study I called the insurance company to find out what it would cost me. They told me I would be billed their negotiated rate with the lab, but could not tell me what that would be, that it would only be determined when a claim was submitted. They suggested that a I call the lab.

The lab told me their full rate ($3000), but would not divulge what their rate to my insurance company was.

So their attitude was that I can't get a price until after I was committed to pay for the study I already had.

What a system.

[mattman]

Understand this is based soley on my experience and your results may or may not be different. Also, many insurance companies have different policies and yours may be different.

That being said -

One of the fundamental tenets of Medicare (And therefore most insurance companies since they more or less follow Medicare guidelines) is that once a company provides you with equipment you can no longer be held responsible for the full purchase price ASSUMING you did not sign a specific agreement stating otherwise (Usually called an Advanced Beneficiary Notice or ABN form). This form also requires the specific dollar amount you'd be responsible for to be listed on the form along with the possible reason for your denial. Not too many Insurance companies require the dollar amount as well but some do.

That's why you always see those wheelchair and diabetic companies advertising on TV about how your items are free if Medicare denies your claim. Big deal. Of course they are, it's the Law. They advertise it like it's a big deal though.

Most insurance companies have something to that effect in place. So I'd look through whatever paperwork you signed and see if there is something to the effect of an acknowledgement that your claim may be denied and that you agree to be financially responsible for the amount if that's the case.

Apart from that, I'd also ask to find out specifically why your claim was denied. The two biggest reasons I'd see where either a diagnosis that doesn't qualify (780.50 - unspecified apnea is often a denied code since it's a "catch-all") or an AHI that doesn't qualify (Some Insurance companies still use the old AHI>15 basis which rules out a lot of people). Either way, find out exactly what got the claim rejected. That will give you an idea of how to go about fighting it.

Once you get that in a row you are going to want to find out how to get a claim put before your insurance companies Medical Review board or whatever they call it and basically you'll have to establish why whatever got you rejected shouldn't matter.

Your DME provider should be able to help you with most of this. I'd definately start with them.

Good luck -

mattman

[TSSleepy]

an AHI that doesn't qualify (Some Insurance companies still use the old AHI>15 basis which rules out a lot of people)

Thanks mattman, maybe that's what happened. Even with 2 Ambien in me, I didn't sleep enough during the sleep study for them to get data to make a diagnosis. I think I dozed a couple hours, resulting in a 20-something% sleep efficiency and no stage 3/4 or REM sleep.

My doctor pretty much diagnosed me and prescribed APAP by looking at my pulse ox data with/without my ilegally-purchased used CPAP.

[TSSleepy]

Update:
I just got off the phone with them and they are dropping it to 10% co-pay, so I saved $1490.40 with a phone call. They didn't explain why it was billed the way it was or why they were changing it, but I was too grateful to ask.

I love insurance companies! Insurance companies rock!

[Arizona-Willie]

My government run insurance paid for my studies and machine and masks and continues to do so every time with no argument .. no hassle.

Oh that evil government health care.

Medicare rocks!!!