Sleep Doc - Medicare/Insurance Question

About a year ago the sleep doc that oversaw my sleep study tests retired. I've been sort of on a search for another and I found one that is local to where I live and he seems to tick the right boxes for reviews/ratings from a few websites. The only snag I've come across is that information I've found about his practice is that he does not accept Medicare (non-participating). From what I've gleaned from Google searches I would likely pay up front for visits and then I think I can fill out and submit a Medicare form to try and recoup most of what I paid which will likely be more than what Medicare allows. My Medicare supplemental insurance usually picks the remaining 20% of what Medicare doesn't pay from my doctors that do accept Medicare, so I suspect I'd also need to make a claim to the supplemental insurance as well after Medicare does their thing.
Does anyone have experience with a Medicare 'non-participating' sleep doc (or other types of doctors) and the Medicare/insurance claims side of things Or maybe I simply should look elsewhere for a sleep doc that accepts Medicare and avoid the hassle and possible extra cost? Looking around at a few other physicians sites, it seems to be a trend of 'non-participating' for Medicare(?)

I do use OSCAR and peruse this site for hints and tricks for therapy improvement, but I do want to have a doctor on tap if the need should come about.

My husband just got a replacement machine (AirSense 11 AutoSet) on his Medicare. His PCP wrote the Rx. He went on Medicare 3/1, had to have a new appt with the doctor after 3/1 (he'd had one in Oct and dr wrote Rx), who sent visit notes, Rx, and compliance info (that hubby was a CPAP user who used his machine every night), to DME. He received a call within a couple of weeks that his machine was approved and ready for pick up. No need for sleep doc.

This was actually a Medicare Advantage plan, don't know if traditional Medicare might be different. And of course, YMMV.

booksfan wrote: ↑

Fri Apr 28, 2023 2:06 pm

My husband just got a replacement machine (AirSense 11 AutoSet) on his Medicare. His PCP wrote the Rx. He went on Medicare 3/1, had to have a new appt with the doctor after 3/1 (he'd had one in Oct and dr wrote Rx), who sent visit notes, Rx, and compliance info (that hubby was a CPAP user who used his machine every night), to DME. He received a call within a couple of weeks that his machine was approved and ready for pick up. No need for sleep doc.

This was actually a Medicare Advantage plan, don't know if traditional Medicare might be different. And of course, YMMV.

So your husband's PCP doesn't participate in Medicare, but his Medicare Advantage plan paid the fees for the visit with the PCP? Did your husband need to submit the bills to his Advantage Plan for reimbursement?
It was my PCP that gave the referral to the now retired sleep doc when I started the CPAP adventure. My PCP knows enough about sleep disorders to answer simple questions, but also knows enough when to give a referral to a specialist. My PCP did write the script for my CPAP, but it was notated verbatim from the report from the sleep doc.

Grumpy48 wrote: ↑

Fri Apr 28, 2023 12:36 pm

sleep doc

Why do you need a sleep doc? Your PCP can write a prescription for machines and supplies.

Grumpy48 wrote: ↑

Fri Apr 28, 2023 12:36 pm

About a year ago the sleep doc that oversaw my sleep study tests retired.

Did you get copies of your study and prescription?

booksfan wrote: ↑

Fri Apr 28, 2023 2:06 pm

This was actually a Medicare Advantage plan, don't know if traditional Medicare might be different.

They are very different.

ChicagoGranny wrote: ↑

Fri Apr 28, 2023 4:11 pm

Grumpy48 wrote: ↑

Fri Apr 28, 2023 12:36 pm

sleep doc

Why do you need a sleep doc? Your PCP can write a prescription for machines and supplies.

Grumpy48 wrote: ↑

Fri Apr 28, 2023 12:36 pm

About a year ago the sleep doc that oversaw my sleep study tests retired.

Did you get copies of your study and prescription?

booksfan wrote: ↑

Fri Apr 28, 2023 2:06 pm

This was actually a Medicare Advantage plan, don't know if traditional Medicare might be different.

They are very different.

Never said I needed a prescription and myself and my PCP do have copies of the study with the prescript.

My original question was how Medicare and insurance handles a patient claim on a bill if the sleep doc (or any doctor) is 'non-participating' in Medicare.

For the most part I don't 'need' a sleep doc and while good information can be found on this forum and the other forum, but there are sometimes health concerns that may warrant seeing a physician for a consult versus taking advice from some anonymous individual on a forum that doesn't know my health history.

I once had an Advantage plan, now a Medicare supplement plan. Each has its merits, but yes, very different.

Dental college for dental care.
Costco for glasses and hearing aids.
Just because Uncle Sam doesn't care if we can't see, hear, or chew,
is no reason to suffer.

chunkyfrog wrote: ↑

Fri Apr 28, 2023 5:41 pm

Dental college for dental care.
Costco for glasses and hearing aids.
Just because Uncle Sam doesn't care if we can't see, hear, or chew,
is no reason to suffer.

Zenni for glasses and don't need hearing aids (wife thinks otherwise).
No suffering..............

Mail order is OK for single vision--I need multifocal rx.
My hearing aid helps with the tinnitus.
Got to take care of my teeth--bone growth on jaw precludes dentures.

I think you are going to have to talk to your supplemental insurance provider about how to submit the bill for their share of the Medicare amount.

Grumpy48 wrote: ↑

Fri Apr 28, 2023 5:31 pm

Never said I needed a prescription

I never said you said you needed a prescription.

Grumpy48 wrote: ↑

Fri Apr 28, 2023 2:37 pm

booksfan wrote: ↑

Fri Apr 28, 2023 2:06 pm

My husband just got a replacement machine (AirSense 11 AutoSet) on his Medicare. His PCP wrote the Rx. He went on Medicare 3/1, had to have a new appt with the doctor after 3/1 (he'd had one in Oct and dr wrote Rx), who sent visit notes, Rx, and compliance info (that hubby was a CPAP user who used his machine every night), to DME. He received a call within a couple of weeks that his machine was approved and ready for pick up. No need for sleep doc.

This was actually a Medicare Advantage plan, don't know if traditional Medicare might be different. And of course, YMMV.

So your husband's PCP doesn't participate in Medicare, but his Medicare Advantage plan paid the fees for the visit with the PCP? Did your husband need to submit the bills to his Advantage Plan for reimbursement?
It was my PCP that gave the referral to the now retired sleep doc when I started the CPAP adventure. My PCP knows enough about sleep disorders to answer simple questions, but also knows enough when to give a referral to a specialist. My PCP did write the script for my CPAP, but it was notated verbatim from the report from the sleep doc.

Sorry if I was less than clear. I was suggesting that perhaps instead of a non-participating sleep doc, perhaps you could see your participating doctor if your apnea is under control (for lack of a better term) and you just need to meet Medicare's requirements to see a physician regularly for follow-up.

As far as hubby's experience, his PCP does participate in Medicare so they filed everything (Medicare Advantage and secondary insurance) as did the DME. We paid nothing to PCP and just copay to DME for the machine. He will have 2 more monthly ("rental" for 3 months) copays, then a final ("purchase") copay after 90 days after everyone sees compliance.