Ok, sorry to vent, but it seems that no one in my life (when I'm not on this computer) seems to get it.
I called Gentiva this morning to check on the status of my request for APAP machine. Apparently, when my doctor sent the prescription, they didn't write it generically, but wrote it quite specifically for the Remstar Auto Pap w/ C flex (which is at the top of my wish list). My copy of the sleep study report fails to mention ANYWHERE the difficulty I had with CPAP after the chinstrap was applied, and doesn't even mention the chinstrap except for in the recommendation section re: mask w/ chinstrap. I asked for the APAP based off of what I have gleaned from the forum re: lower costs in the long run (decreased need for future sleep studies, able to adjust pressure, the debate about is the pressure at the study always being the right pressure given all the different factors that change daily) and requested the C flex because I read that it would help with not swallowing air (which was a HUGE problem after the chinstrap was put on during the sleep study). I didn't go back to sleep during the sleep study once the chinstrap was put on, I had major leaks and swallowed a ton of air (I think, heavy sarcasm, that I didn't tolerate it well).
So, here's the problem. I was told this a.m. by a lovely person at Gentiva that my prescription has been sent to Cigna's "medical review board" because of the machine I requested and that it "could take weeks and still might then be denied". She also said "if you had just asked for a CPAP, you'd have your equipment." (twist the knife, go ahead)
So, while they are busy reading an incomplete report (in my last job, if it's not in the report, it didn't happen), making decisions about if they grant me my wish (which was based on sound reasoning, but nobody there cares because they just want me to take their CPAP and Comfortgel mask and be quiet), my deductible will expire at the end of December AND I am not getting treatment.
I understand that in the great big scheme of things, I have probably had SA for at least 8 years, what's a couple more weeks, anyhow? However, I am so at the end of my rope, and I am so very tired.
So, I'm "white knuckling" it for now, just trying to hang on.
So very frustrating....
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sleepyinsunnyvale
- Posts: 121
- Joined: Mon Feb 28, 2005 5:42 pm
I ran into a similar situation with Gentiva/CIGNA.
In my case Gentiva was changing DMEs. CIGNA/Gentiva had been renting my machine for 4 years but Gentiva was changing DME to CARECENTRIX.
Without boring you with the details, it became apparent to me that dealing with Gentiva would be a nightmare. I called CIGNA and they said it would be OK for me to buy the machine on my own and submit a claim to them. The only issue was that it would be an out of network DME so they would only cover 60% rather than the 80% for in network DME. I felt it was well worth the few extra out of pocket dollars so I bought my APAP from cpap.com.
If you take this route make sure you are given explicit pre-approval from CIGNA before ordering or benefits will be reduced.
In my case Gentiva was changing DMEs. CIGNA/Gentiva had been renting my machine for 4 years but Gentiva was changing DME to CARECENTRIX.
Without boring you with the details, it became apparent to me that dealing with Gentiva would be a nightmare. I called CIGNA and they said it would be OK for me to buy the machine on my own and submit a claim to them. The only issue was that it would be an out of network DME so they would only cover 60% rather than the 80% for in network DME. I felt it was well worth the few extra out of pocket dollars so I bought my APAP from cpap.com.
If you take this route make sure you are given explicit pre-approval from CIGNA before ordering or benefits will be reduced.
only a suggestion. there are many online DME who will jump over tall building to get your business. I don't know how responsive the "billmyinsurance" listed here is. I have previously talked to another online DME who said to send them a copy of prescription. I went through a similar hassle with the DME that did sleep study and tried to push the CPAP on me. When the online company called for the prescription transfer, the local DME became very eager to do business and had my AUTO with C-flex delivered the very next day FEDEX. I thinking your DME is not used to much competition.
THE GRINCH STOLE MY AVATAR !!!
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Guest
Ok, I called Gentiva to discuss the transfer of the prescription, the person I spoke to was more helpful (imagine that) and suggested that even if I order it from a different DME, that because the report doesn't discuss my difficulties with CPAP after the chinstrap was applied, that insurance will still deny APAP (regardless of who I order it from). He then gave me a fax number and suggested I type up the information about the difficulties I had with CPAP after the chinstrap was applied, as, in his opinion, that showed my inability to tolerate CPAP. The number I am faxing it to is Gentiva's medical review board, and they will (supposedly) forward it to Cigna. I also obtained a fax number for Cigna's medical review department. I will fax my letter to both departments tonight. Don't know if it will help or not, but I feel better that hopefully decisions will be made with all of the information, and not just partial information.
Thanks for the feedback and support. I feel better now
Thanks for the feedback and support. I feel better now
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Colorado Jan
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sleepyinsunnyvale
- Posts: 121
- Joined: Mon Feb 28, 2005 5:42 pm
Newgal
I have had CIGNA for 4 years and am extremely pleased with them. The best part is that when you call you get to speak to someone who is very knowledgable. I am frankly surprised they are dealing with a seemingly second rate outfit like GENTIVA.
Anyway, I don't know about your chin strap situation but in my case the Dr's Rx said APAP (Respironics) and that was all CIGNA needed. This review board stuff sounds like you are heading down a dark hole from which you will hopefully emerge triumphant some day, but when?.
If your problem is that GENTIVA has your Rx, I wouldn't waste time asking them to transfer it I would just call the Dr and ask for another copy. That's what I had to do because my original DME had the only copy of mine and they said they would "try to locate it" since it was 4 years old.
One thing you'll see as you scan the various posts on this forum is that us patients need to take charge of our treatment and assert ourselves (nicely)with insurance companies, DMEs and (yes even) doctors.
I have had CIGNA for 4 years and am extremely pleased with them. The best part is that when you call you get to speak to someone who is very knowledgable. I am frankly surprised they are dealing with a seemingly second rate outfit like GENTIVA.
Anyway, I don't know about your chin strap situation but in my case the Dr's Rx said APAP (Respironics) and that was all CIGNA needed. This review board stuff sounds like you are heading down a dark hole from which you will hopefully emerge triumphant some day, but when?.
If your problem is that GENTIVA has your Rx, I wouldn't waste time asking them to transfer it I would just call the Dr and ask for another copy. That's what I had to do because my original DME had the only copy of mine and they said they would "try to locate it" since it was 4 years old.
One thing you'll see as you scan the various posts on this forum is that us patients need to take charge of our treatment and assert ourselves (nicely)with insurance companies, DMEs and (yes even) doctors.
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rested gal
- Posts: 12881
- Joined: Thu Sep 09, 2004 10:14 pm
- Location: Tennessee
Newgal, sorry to hear you're getting such a run-around by your DME. No matter how it gets resolved, I'm a big believer in having a copy of your own prescription in your own hands. That will give you the power to shop where you wish if it ever comes to that and if you can get the money together to buy something you need.
You may have already done this, but if not...check with billmyinsurance.com (a division of cpap.com), as Shimari suggested, to see if your insurance will work with them. If so, you can choose the machine/mask/etc., YOU want, instead of being at the mercy of a DME that wants you to have only what they can make the most profit on.
You may have already done this, but if not...check with billmyinsurance.com (a division of cpap.com), as Shimari suggested, to see if your insurance will work with them. If so, you can choose the machine/mask/etc., YOU want, instead of being at the mercy of a DME that wants you to have only what they can make the most profit on.
DME=Frustration
New Gal,
I jut had the exact same experience with Gentiva/CareCentrix. When I called them I was told The "medical review board" denied my APAP request and responded that my sleep study was "expired" (3 years old!).
I asked them why would I need a sleep study if my prescription calls out for a APAP....
They transferred my call to a supervisor who agreed with me and "approved" the APAP. They told me to expect the APAP by XMASS. I'm not holding my breath. I'm sure they figure out that our insurance ends 12/31/05 and they simply "string" you along until the end of the year. I plan to keep calling every few days to check the status of my APAP.
My advice is to keep calling until they raise your issue to a higher level.
Good Luck!
I jut had the exact same experience with Gentiva/CareCentrix. When I called them I was told The "medical review board" denied my APAP request and responded that my sleep study was "expired" (3 years old!).
I asked them why would I need a sleep study if my prescription calls out for a APAP....
They transferred my call to a supervisor who agreed with me and "approved" the APAP. They told me to expect the APAP by XMASS. I'm not holding my breath. I'm sure they figure out that our insurance ends 12/31/05 and they simply "string" you along until the end of the year. I plan to keep calling every few days to check the status of my APAP.
My advice is to keep calling until they raise your issue to a higher level.
Good Luck!
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ProfessorSleep
- Posts: 338
- Joined: Sat Sep 10, 2005 7:42 pm
- Location: Wisconsin
Good luck, Newgal! Personally (just my opinion) I wouldn't count on the DME being particularly supportive/knowledgeable/helpful, and would not make a purchasing decision or accept a big delay just to have that personal backup. My RT through my DME admitted he was a non-compliant sleep apneic. And he's supposed to support me? He knew nothing about a particular machine I mentioned, had no suggestions regarding condensation in the hose, and never heard of a particular mask. Some folks have been very, very lucky and got good personal support and assistance, which is how it should be. but with this kind of runaround about the machine? I wouldn't count on them being too helpful after they have the $ either. Shop around - online and otherwise. There ARE some good ones out there. Let the know what you want, and don't be afraid to be assertive (in a polite/professional/knowledgeable sort of way, of course).
Beware of the EVIL DME
Get YOUR Rx in Your hands . Shop around . They just want to sell you a cheapo cpap that they have on the shelf . The money is the same to them either way so why would they provide an auto and cut their profit .
Beware of the copay. You may be better off paying out of pocket to an online provider.
Ask for an itemised price. Notice they bill for the mask, headgear, hose, humidifier tank, humidifier.
Notice that the mask comes with the headgear. The tank with the humidifier and the hose with the cpap if you purchase online. And don't forget the clinician manual. You will not get this with a DME. They take it out of the box and sell it on Ebay.
:twist ed:
Get YOUR Rx in Your hands . Shop around . They just want to sell you a cheapo cpap that they have on the shelf . The money is the same to them either way so why would they provide an auto and cut their profit .
Beware of the copay. You may be better off paying out of pocket to an online provider.
Ask for an itemised price. Notice they bill for the mask, headgear, hose, humidifier tank, humidifier.
Notice that the mask comes with the headgear. The tank with the humidifier and the hose with the cpap if you purchase online. And don't forget the clinician manual. You will not get this with a DME. They take it out of the box and sell it on Ebay.
:twist ed: