Lost Round One to the Insurance Co.

[Craig P]

After having my sleep study earlier in the month, I contacted a local DME with my Dr's prescription for my new equipment. Unfortunately this is my fourth insurance company over the past ten years and they are requiring that I submit to a new diagnostic sleep study to confirm that I do indeed have OSA. Even if I were to obtain a copy of my original diagnostic sleep study they would not accept it. ????? Do they think you can get over OSA? To my knowledge no one has ever recovered from Sleep Apnea.

Anyway, I will submit to the sleep study and let them have their way. I will just make sure that I get the equipment that I want/need to continue my progress to a better nights sleep. After spending the last week reading over the posts and available information I will be well prepared to get what I want.

Thanks to everyone who has posted their knowledge on the subjects of masks, machines and how to make the system work for me.

[JohnBFisher]

Greetings and welcome to the forum!

Though it might seem frustrating to need to go through another sleep study, that policy helps protect you as much as it does the insurance company. Why? It sure seems as if it might be redundant. You already know you have OSA. Yes, they want to see if you "still have it". Or they might have said that. Remember the customer service reps don't put the policies in place so may not know the reasons the doctors at the insurance companies built the policies.

The fact is that as we age so do our bodies. And that might mean that you need a differing pressure range. Or it might mean you need to move to BiPAP. Or it might mean ... Shoot! There's just no way of knowing what you might now need. Nor will your doctors until they've look at the sleep study.

Your insurance company knows that if they give you a new machine based on the old setting, there's a good chance you will need something different. That can cost you and yes them more money than it is worth.

So, whatever machine you get, you probably want an auto-titrating unit (an APAP or a BiPAP Auto). You want one that is fully data capable. And you want one that can transport easily. You want a heated humidifier. And of course, you want a good night of sleep!

Once again, welcome and here's hoping your sleep test goes well.

[el_zorro]

The other option is to take your prescription and buy something new online or on auction. For around $200 you can buy a nice machine online (brand new) these days and for $300 an Auto machine. If you are feeling good and you dont have complex apneas there is very little risk. If your pressure has changed an APAP will take care of that for you, thats what the sleep lab uses to titrate you anyway.

[fidelfs]

They want to know "You" the insured are the one who is getting the supply and you are not buying it from somebody else using your insurance.

I love conspiracy in the morning

[SleepingUgly]

After having my sleep study earlier in the month...

You just had a sleep study earlier THIS MONTH and they want you to redo it?!

[nobody]

Depending what your deductible/co-pay is on a new study, it might be cheaper to buy a new or used machine online.

[Craig P]

As I said in my original post I had a sleep study earlier in the month to determine the current settings I need to treat my OSA, which gave my Dr the information needed for my prescription. The insurance company won't accept this information as proof that I have sleep apnea. They are requiring a completely new diagnostic sleep study.

As I said I do not object to actually doing a new diagnostic sleep study, it is the fact that I am not aware of anyone recovering from sleep apnea.

My co-pay is not very much and I have very good insurance at this time so that is not a problem. It just seems that they have too many non technical people making policies in a one size fits all mind set, when we all know that we are all individuals and what applies to one person won't necessarily work for another.

[Wulfman]

(repeating what's been said before in various ways)

As long as you HAVE your prescription (the physical document), screw the insurance provider and the hassles with the local DMEs.
Get one of your choice from CPAP.COM.


Den

[timbalionguy]

It seems weird to me that the insurance company wants to spend $2,500 for a new diagnostic sleep study to justify a $1,000 machine. These people must sleep with their head in the ground. By the very nature of the titration sleep study they just did, they demonstrate you have OSA because they had to determine a pressure at which your events stopped happening.

I agree as well. Buy online or at CPAP auction rather than through insurance. And if I were you, I would be looking for a new insurance company.

[fidelfs]

The things is we are charged 2500.00 if we don't have insurance. Insurance does not pay that amount.

[mdboze]

The things is we are charged 2500.00 if we don't have insurance. Insurance does not pay that amount.

only 2500.00 ? thats not bad.

My 3 sleep studies last year cost 4900.00 each:
1. Sleep Study: Do I have APNEA ? YES
2. CPAP Sleep Study: Will a CPAP work ? NO made it worse - discovered I had Central/Complex Apnea
3. VPAP Sleep Study: a BiPAP will work for my Central Apnea

I'm glad I have Insurance !

[nobody]

2. CPAP Sleep Study: Will a CPAP work ? NO made it worse - discovered I had Central/Complex Apnea

They can't tell that from the first sleep study?

[ecocyber]

I agree with fidelfs statement. Everyone here should be concerned with the "allowed" amount when talking about insurance and DME companies. It doesn't mean much to say....."my sleep study cost $5,300"; or......"my mask cost $390 from my DME". And, it is not very informative to newbies. In fact, it really causes for confusion and muddled discussions. Please.....everyone use the "allowed" amount when discussing costs.

Anyone can "bill" any amount they want when sending in an insurance claim. It is totally irrelevant except to the CPA of the billing company who has to write off the excess over the "allowed" amount.

[mdboze]

I agree with fidelfs statement. Everyone here should be concerned with the "allowed" amount when talking about insurance and DME companies. It doesn't mean much to say....."my sleep study cost $5,300"; or......"my mask cost $390 from my DME". And, it is not very informative to newbies. In fact, it really causes for confusion and muddled discussions. Please.....everyone use the "allowed" amount when discussing costs.

ecocyber,
You got me thinking about it, so I researched this to confirmed what I posted yesterday about the cost of my sleep studies:

09/27/2009 $4,500.00 Amount Allowed and Paid By Plan (my First Sleep Study to Assess if I had a sleep disorder)

10/02/2009 $4,900.00 Amount Allowed and Paid By Plan (my 2nd Sleep Study on a CPAP - which made it worse, because I had Central not OSA)

10/24/2009 $4,900.00 Amount Allowed and Paid By Plan (my 3rd Sleep Study on a VPAP)

All amounts are in US Dollars - in the Dallas Texas area.
From what I've seen other post, My these sleep studies may have been priced too high.

Anyone can "bill" any amount they want when sending in an insurance claim. It is totally irrelevant except to the CPA of the billing company who has to write off the excess over the "allowed" amount.

ecocyber,
You are right, they can BILL ANY AMOUNT they want; for example:
Last week my insurance company got billed for my BiPap AutoSV Advanced:
Amount Billed: $40,000 (I confirmed with my DME this was a Typo, and they meant to put $4000
Amount Allowed: $2977.52

[DreamOn]

Wow, mdboze! I've had two full-night sleep studies:

....................................Billing Code........................Amount Billed....................Insurance Allowed..................My Cost
Diagnostic Sleep Study............ 95810 ............................. $1,950 ............................. $635.77 .......................... 0
Titration Sleep Study.............. 95811 ............................. $2,300 ............................. $701.01 .......................... 0