Insurance Frustrations + CPAP purchase

[Fizzled]

Hi All. I just began the diagnostic process for sleep apnea. Unfortunately, my insurance is through Kaiser and there's just nothing good to say about them. I'm at my wits end with not being able to sleep and it'll be some time longer before Kaiser will do anything for me.

It started like this. I scheduled an appointment with my doctor and the earliest appointment was 2 weeks away. I got a call about 4 days before the appointment saying my insurance wasn't valid; if I showed up I'd have to pay out of pocket for any services. After a long back and forth battle, it came down to my work's insurance broker submitting a corrected enrollment that was... incorrect (I've only had the job for 7 months). However, Kaiser wasn't any help with rectifying this situation, all they kept saying was that someone at my work invalidated my enrollment, while everyone at work (it's a 6 person company) said it wasn't them.

I finally see the doctor who says, "There's a lot of reasons why you could be feeling fatigued, let's run some blood tests to make sure you're not anemic...." This involves another trip back to office for a blood draw as the tests require fasting. All come back normal. The doctor's assistant calls me about a week later to say "Call this number to schedule an appointment with the sleep clinic." I call the sleep clinic, who says that I have to do a 90 minute orientation. The earliest appointment I can make is 3 weeks away. That day comes around, and either a screw up on their part or mine I miss the appointment by a day (My office manager says these scheduling mixups are frequent with them). I reschedule, and this time I'm 4 weeks out from being able to attend.

I attend the orientation, which is in all honesty a colossal waste of time. Everything discussed there was information readily available online or via the pamphlet they distribute. At the end of the orientation I have to fill out a questionnaire and check the box indicating I'd like a sleep study. The presenter says that "They'll contact you by mail in 3-4 weeks to schedule the sleep study."

This is where I am now, waiting for some bureaucracy to catch up.

After they contact me, I have to go pick up a take home sleep study machine and bring it back the next day (2 trips). I then have to wait for them to analyze the data and determine if I actually have sleep apnea. Once they determine I have it, I have to go back to pick up a different machine, this one will apply CPAP treatment and measure efficacy and show results for different settings. Once they have this information, I have to bring the machine back at which point they'll prescribe and ORDER/program my machine. I then have to go back again to get it.

I can't wait that long and there's way too many hoops to jump through. The back of my throat is killing me as I snore all night according to my girlfriend. I kick/toss-turn and wake up all night. I'm in IT, my lack of sleep is trying my patience with my clients. I'm afraid to take my motorcycle to work as my wits aren't about me in the morning. It's likely to be 2+ months before Kaiser will get me my own CPAP, at which point my horrendous insurance will only do a 50% DME Coinsurance. Which, means I'll be paying more through insurance than just getting a used setup. It's not worth the time or money to suffer through this for that long.

I give up. I want to just get a CPAP on Craigslist and make it work. Unfortunately I have no idea what's a fair price to pay for between equipment, how to size/fit the mask, or what methodology to use to go about getting the correct settings in place. I still plan on completing the insurance's required processes(except for buying the machine through them), but I need SOME relief in the interim. I can't sleep on my stomach unfortunately.

Help?

[jdm2857]

There are trusted members of this forum that post new or almost new equipment at good prices.
One is STLMark and the other is papman857.

You could also try http://www.secondwindcpap.com. They're a reliable source of machines at good
prices, too. And most come with warranties.

[kaiasgram]

(jdm, OP can't use secondwind right now because he doesn't have a prescription yet)

Fizzled, no wonder you're fizzled -- you have Kaiser. Last year I went through what you're now going through with them -- their sleep medicine program is high volume and IMO woefully inadequate.

It's a bit of a risk to buy a machine without knowing your diagnosis and which machine you might end up needing. There are different types of machine and they function differently. On the other hand, you wouldn't be the first person to take matters into your own hands. Look up forum member "dos coyotes" -- he came onto the forum early this year with no insurance but knowing he snored and sure he had sleep apnea. He bought an Auto CPAP machine and mask from forum members and did his own titration to figure out what pressures he needed. He downloaded free software to help him determine his optimal pressure settings and to monitor his therapy and last I heard he was doing really well.

If you decide to go this route, let the forum help you with the process, and definitely with how to buy a decent machine and one that you can actually do an at-home titration with. It's possible that someone on the forum might have an auto pap machine to sell (look for an established forum member, not someone who's just posting for the first time to sell a machine).

[49er]

Hi Fizzled,

Two forum members are selling machines:

viewtopic/t88566/For-Sale--PR-S1-Series ... e-485.html

As an example of Shawn's character, when a former member was selling a very similar type machine who was an absolute jerk, without asking, Shawn showed him how to better present the data to increase the chances of a sale.

viewtopic/t90549/RESPIRONICS-760HS-bIPA ... -Mask.html

I am mentioning this thread for two reasons even normally, a new member would not start with a bipap machine. Even though Shawn is offering a fantastic price, the deal papman is offering is a steal since it is an auto bipap machine which is usually alot more expensive than a regular apap machine. And he is including a mask which you need.

As an FYI, Papman has several satisfied customers. But even though I don't think Shawn has done any previous sales on this forum, I would have no reservations about purchasing something from him.

With either purchase, it will be possible to obtain the manual that will show you how to change the pressures. You will also be able to use free Sleepyhead software that will enable you to access data that will guide you in what pressure to use. Forum members can help you with this process.

49er

PS - This thread gives you an idea as to the differences between a bipap and an apap machine.

viewtopic/t81886/Dumb-Question--APAP-vs-BiPap.html

Hi All. I just began the diagnostic process for sleep apnea. Unfortunately, my insurance is through Kaiser and there's just nothing good to say about them. I'm at my wits end with not being able to sleep and it'll be some time longer before Kaiser will do anything for me.

It started like this. I scheduled an appointment with my doctor and the earliest appointment was 2 weeks away. I got a call about 4 days before the appointment saying my insurance wasn't valid; if I showed up I'd have to pay out of pocket for any services. After a long back and forth battle, it came down to my work's insurance broker submitting a corrected enrollment that was... incorrect (I've only had the job for 7 months). However, Kaiser wasn't any help with rectifying this situation, all they kept saying was that someone at my work invalidated my enrollment, while everyone at work (it's a 6 person company) said it wasn't them.

I finally see the doctor who says, "There's a lot of reasons why you could be feeling fatigued, let's run some blood tests to make sure you're not anemic...." This involves another trip back to office for a blood draw as the tests require fasting. All come back normal. The doctor's assistant calls me about a week later to say "Call this number to schedule an appointment with the sleep clinic." I call the sleep clinic, who says that I have to do a 90 minute orientation. The earliest appointment I can make is 3 weeks away. That day comes around, and either a screw up on their part or mine I miss the appointment by a day (My office manager says these scheduling mixups are frequent with them). I reschedule, and this time I'm 4 weeks out from being able to attend.

I attend the orientation, which is in all honesty a colossal waste of time. Everything discussed there was information readily available online or via the pamphlet they distribute. At the end of the orientation I have to fill out a questionnaire and check the box indicating I'd like a sleep study. The presenter says that "They'll contact you by mail in 3-4 weeks to schedule the sleep study."

This is where I am now, waiting for some bureaucracy to catch up.

After they contact me, I have to go pick up a take home sleep study machine and bring it back the next day (2 trips). I then have to wait for them to analyze the data and determine if I actually have sleep apnea. Once they determine I have it, I have to go back to pick up a different machine, this one will apply CPAP treatment and measure efficacy and show results for different settings. Once they have this information, I have to bring the machine back at which point they'll prescribe and ORDER/program my machine. I then have to go back again to get it.

I can't wait that long and there's way too many hoops to jump through. The back of my throat is killing me as I snore all night according to my girlfriend. I kick/toss-turn and wake up all night. I'm in IT, my lack of sleep is trying my patience with my clients. I'm afraid to take my motorcycle to work as my wits aren't about me in the morning. It's likely to be 2+ months before Kaiser will get me my own CPAP, at which point my horrendous insurance will only do a 50% DME Coinsurance. Which, means I'll be paying more through insurance than just getting a used setup. It's not worth the time or money to suffer through this for that long.

I give up. I want to just get a CPAP on Craigslist and make it work. Unfortunately I have no idea what's a fair price to pay for between equipment, how to size/fit the mask, or what methodology to use to go about getting the correct settings in place. I still plan on completing the insurance's required processes(except for buying the machine through them), but I need SOME relief in the interim. I can't sleep on my stomach unfortunately.

Help?

[zoocrewphoto]

You will definitely want a machine with full data, and preferably an auto machine.

I would also recommend going to cpap.com and going through the pages of masks. Think about what you might consider the most comfortable. Do you need to breathe through your mouth or not? Look at the photos. It will still be trial and error, but you will have a better shot at picking a good one for you.

[mgaggie]

Is there any way you can speed up the sleep study?

I would be really loathe to just buy a machine and start using it. Far to many variables.

[123.Shawn T.W.]

Thanks 49'er!

I have done a few masks transactions here, but the "extra" APAP machine is because like the OP I got tired of waiting for everybody else ... And just bought a slightly used machine off Craig's list! Now I have this new one just sitting that I got at 20% (my portion of ins) of the DME's inflated price!

One thing the OP also could try is to get a Oximeter and see if, or how much they are dropping in O2 while they sleep ... Check out http://www.pulseoxstore.com/Downloadable-Pulse-Ox.html I bought from them!

[123.Shawn T.W.]

One more thing Fizzled ... If you go to cpap.com (our generous hosts) and look at the masks ... Alot of the masks have a sizing guide ... You can print out and then cut out and apply to your face to check for size ... The real test is hooking it up to a machine and putting it on your face, and laying down in your sleep position.

I had collected 5-6 masks before I got a machine for my wife and myself (2 machines off Craig's list!) my wife picked the one she wanted and is still using that same mask, it works and she has no desire to try anything else ... Me on the other hand have gone through 12-15 masks in the last year! My wife has never had a sleep study, but I used my oximeter on her, and she was down in the low 80's, now no more snoring and she feels more rested, thanks to the help we got here on the forum!

Cpap.com can not sell you a whole complete mask ... Since a prescription is required for a complete mask (same as ebay) But they can sell you the parts to make up a whole one! Or once you decide what style you want to try, and the size ... Post here a "looking for ...thread." Quite a few of us have rejects that did not work for us just sitting around ... I never worried about a "used mask" that was cleaned by me ... No real difference than washing silverware that a guest used ... Sometimes you will see a mask for sale here, sometimes just postage to mail it to you!

Stick around as there is lots to learn, and lots of good folks here that have been down the same road that you are starting on!

[ChicagoGranny]

The back of my throat is killing me as I snore all night according to my girlfriend. I kick/toss-turn and wake up all night.

Know that sleeping on your back is often the worse position for apnea - gravity pulls your tongue and soft palate directly into your airway. Until you can get your CPAP, make 100% sure you don't sleep on your back. One person wore a small backpack with some hard objects in it that prevented him from rolling onto his back during sleep. This will not cure sleep apnea but it might make it less severe.

Can you not call the people that schedule appointments and ask to be put on a cancellation list?

[Stormynights]

I have been dealing with the doctor blames the insurance the insurance blames the doctor and the DME drops my case for months. For me I think it is finally all settled down now. It is very frustrating and makes you feel like you are trying to herd a flock of cats but eventually they get it figured out. If you go ahead with another source you will have a backup.

[sleeplessinaz]

Dear FIZZLED:

Can you call sleep study places to see how much a a split sleep study would cost if you paid out of pocket for it? A split study is they monitor you and determine if you have sleep apnea then come in and place a mask on you after a few hours and they will "titrate" you at that point with the mask on. Then you can buy a machine and know what your numbers are?

It might be worth paying out of pocket for it to save your sanity!
Hope this helps,
Carrie

[Janknitz]

Welcome to Kaiser, that's how they work.

It's all done for Kaiser's convenience, not yours. Everything is done in a group. If you are diagnosed with apnea through their home testing procedure, you will have to attend yet another group before getting a titration machine and fitting for a mask to use for about a week before they will take more time to determine your prescription from the SD card. Then you must make co-payment arrangements and wait for their vendor (Crapria in most cases for Kaiser) to drop ship your machine. Many weeks will pass.

You will have absolutely NO choice in machines. Kaiser prescribes one brand (Respironics in most areas) and THEY decide what model. Kaiser is your DME, Crapria is merely the supplier, so you cannot negotiate with Crapria, it doesn't work that way for Kaiser. And Kaiser does pay different amounts depending on the model--the usual one price fits all does not apply with Kaiser.

OK, so that's the bad, but a few things you should also consider:

Kaiser's system is a PITA, but eventually you will get a machine, LOTS of help with masks, and support. These things ARE worthwhile.

Consider that your 50% co-pay is 50% of Kaiser's cost. As a HUGE player, Kaiser is able to negotiate really good prices, so your 50% co-pay is usually very low. Your out of pocket expenses may not be terrible with 50% covered. Possibly better than you can do through other channels. It's worth looking into.

One of the reasons Kaiser prescribes only one brand of CPAP is that they have the software to read your card and support your treatment (that and the fact that they get their huge volume discounts). So that also means they use data capable machines. If you get another brand machine, you won't have the option of going in for help from their sleep lab if you need advice and assistance. So if you plan on buying your own machine that's a worthy consideration. In my area they use Philips Respironics, but you'll have to find out what they prescribe in your own region. The sleep lab staff here is pretty good with helping out when I have a problem, and at least that's one on one.

Kaiser has a limited formulary for masks but they stock samples and will let you try everything on, and they will give you samples to take home until your next covered order. If you want to change mask styles you can go in for a fitting and bring home masks to try--NO CHARGE! This is worth a lot. Finding the right mask is 80% of the battle and if you have to do it all in pieces and parts you're going to find it crazy making.

In your shoes, I'd suggest the following:
1. You can call the sleep lab to ask what brand machine they use. If you stick to that brand, you'll have the option of getting some support from Kaiser if you need it.

2. Kaiser can tell you what your out of pocket costs will be for each machine they might prescribe. I was given a range of $100 to $135 as my 20% co-pay (depending on model prescribed) for the initial setup--machine, humidifier, mask, hose. (If 20% was only $135 at most for everything, you can see that Kaiser's negotiated prices are very low--and this is for purchase, not rental). Then you can decide if it makes sense to get your machine through Kaiser or not. It may at least make sense for mask fittings and replacements, because even parting out masks can be costly. Until you settle on a mask it's hard to buy without an RX.

3. Do the home sleep study even if you already have your machine on your own (test WITHOUT the machine). You can get a lot of valuable info about your apnea there. Yes, it's a PITA jumping through Kaiser hoops. But it can be valuable to know what you're treating if you choose the self-treatment route. And they will at least give you an RX for masks, hoses, etc, even a machine if you decide to buy your own later.

4. Use Kaiser at least for the masks, though they may require you to let them read your card and adjust your machine so that they think they can monitor your compliance and prescribe your treatment (they can think that ). This will save you money because they have samples for you to try as needed. Once you settle on a mask, 50% co-pay for cushion replacements and hose replacements at their negotiated prices is very low.

Kaiser is not perfect, but privately insured people also wait weeks and weeks for sleep study appointments, follow up appointments, getting the RX prescribed, fighting with insurance and DME's, etc. Given all that I concluded (AFTER the fact) that Kaiser wasn't all bad. But I was pretty angry and frustrated at first, too.

[RandyJ]

Shawn's zero hours machine (Philips Respironics System One Series 60 APAP model 560) is a great deal and would most likely be the best machine choice for you. People here can help you find interim settings you can use until you get the results of your study and prescription.

[123.Shawn T.W.]

Randy, actually it has 0.1 hours on it! Less than 6 minutes ... I used it at the DME to try on two masks!

But Basiclly new!

[forthguy]

Welcome to Kaiser, that's how they work.

It's all done for Kaiser's convenience, not yours. Everything is done in a group. If you are diagnosed with apnea through their home testing procedure, you will have to attend yet another group before getting a titration machine and fitting for a mask to use for about a week before they will take more time to determine your prescription from the SD card. Then you must make co-payment arrangements and wait for their vendor (Crapria in most cases for Kaiser) to drop ship your machine. Many weeks will pass.

Been lurking on this board for a while, and I was dreading what I was going to experience from Kaiser Northern CA after reading some of Janknitz's posts, and in no way does it help the OP, who seems to be experiencing things similarly...

But just as another Kaiser datapoint, and more evidence that they do things differently in different offices and regions, my experience has been very different. I just reviewed my appointments online to remind myself. On May 30, I was referred to the sleep clinic. On June 3, I went and picked up my WatchPAT. No group was involved, but that was only because one other person was coming to the information session, and I was on-time, so they dispensed with their usual slide deck/movie and just gave me personal instruction on using the WatchPAT. On June 5, the pulmonologist called me to inform me that I had severe sleep apnea (AHI around 98) and that he wanted me in for the earliest appointment on June 14. (I should add, the next appointment wasn't until early July, so there would have been a delay if I could not make that appointment. However, he was insistent that I _must_ make that date.) On June 14, again with no group, I was issued my titration machine and fitted for a mask (and while just talking to me, the RT identified me as a mouth breather -- removing a perfectly good insult from my vocabulary -- and gave me a FF mask.) On June 24, she had me do another WatchPAT night with the titration machine, and on June 25 -- again, with no group -- she reviewed my results and issued me my permanent machine, a brand new PR S1 760P, which I walked out with that day. (On my Kaiser plan, I have no copay/coinsurance on DME, so the RT decided to send me home with the BiPAP, due to my high peak pressure.)