Medicare and Sleep Studies

For me, a new user (jan2007), I also had a split nite study - but I thought it was for another reason, to rule out that daytime sleep problem (forgot what it's called). The tech came out during the study and said "You're a candidate for this" and slapped some nasal pillows on my face. Those didn't work out, caused my sinuses to clog right up.

Anyway, I was eager to get my results and get things going; the tech gave me a number to call to set that up. Had to wait for them to compile the data & get it to the docs. Then, You have to go to another location to talk with their sleep docs. So I did that, they tell me I have severe OSA (62/hr) but unfortunately I have to go back because I didn't have enuff time on my back. Well, hey your guy didn't tell me to sleep on my back, I usu. sleep on my back but you can't with that mask on your face.

So I go back, that night again. The mask leaks keep waking you up, the tech is talking to you over the speaker - I rip the mask off to talk to him, then he says "You took the mask off". Before I left I told him I wouldn't wear that thing if you send me home with it today. On they way out I ask him if he has ever laid on that bed with ALL that stuff attached. He's been doing this 18 yrs. but NO he hasn't.

So I tell him, in case you want to know why I kept ripping that mask off? You absolutely cannot talk with the mask on an the wind whipping thru your mouth. And each time you keep bumping up the pressure, what are you trying to do? He says just following the docs orders. I said well it gets to the point where when you cannot exhale, you can't breath. That is another reason to rip the mask off. Well the other is I didn't know how to unsnap it.

Actually, I think we had this conversation the 1st night. And I really did like the tech. asking for him again the 2nd night.

Fast forward, couple of mask fits & follow ups with the doc (well PA.) and he asks how you feeling? I tell him I hoonestly cannot tell any difference. He orders an auto w/card reader for me, from Apria. That is another story in itself (don't get me started).

So the next follow-up w/PA I go in w/list of questions and what I want so I don't forget. 1st, I don't want anything to do w/Apria, OK. He agrees I need an auto, OK. I am gonna order you this, & this, & this (a real smooth talker). I want the script in my hand when I leave so I am waiting for it when he comes out with the mask fit tech (RT?) and she explains because I have Medicare, they only do business w/Apria <sigh>. I forgot the BS reason they told my why they couldn't give me the script right then. So I leave, Apria calls in a couple days, surprise.

Apria tells me because I have Medicare coverage they can't honor my script. Why?? Because Medicare requires you to have a min. of 2 hrs. in diagnostic (w/o mask). So what is the prob?
Well, it seems I only had 1.9 hrs. <sigh>, so we can't order ANY supplies for you.

So for .1 hrs. they want to pay $1800 for the study, I have to have 130 more apneas and risk another stroke? Really? Yes!

This ladies and gentlemen is why health care co$t$ sooo much.

So I call the sleep lab to find out how much is out of pocket for this additional sleep test, 3rd in ten months. $350, wow.

I call the sleep lab to tell them, the PA I left the message for has the snotty mask fit lady call me and she blaps on & on about how they set me up for another study, so what is the prob? I explain the two previous tests, tell her that was not my fault the tech didn't tell me to sleep w/o the mask, but in fact I was, the tech. came out and told me it was time for me to try this (nasal pillows).

I tell her it's gonna cost me $350 co-pay for this test and this is NOT my fault either. She says well you had different insurance at that time, you shouldn't have switched. Oh really?

I don't know if 3 sleep studies in 10-11 months is the norm, but I am looking for a another lab for my next study.

Can anyone recommend a good sleep lab in the Waterbury or New Haven area of CT?
Thanks,
GumbyCT

Even though we read so many stories like this on this forum, it still never ceases to amaze me that our health care system is so shoddily run. These places just blatantly lie to get your money.

I'd seriously question the assertion that Medicare will only pay for Apria. For one thing, I know that cpapforseniors.com accepts medicare, though there may be some details I'm not aware of. Why not contact them and see if you are covered through them. You should also call your insurance provider and see what DME's are covered.

Then, when you get a better sleep lab, you may have a very different story to tell. I had a subpar sleep lab, too, but no where near as bad as yours. At least they did ok with the initial study.

Okay, Gumby, I assume you do not have secondary insurance or your secondary insurance doesn't cover DME equipment?

I am on Medicare but I have good secondary insurance as well, thank goodness.

It would be worth your while to call the various DME suppliers in your area and ask them directly if they accept Medicare. My understanding is that MOST DME supplier not only accept Medicare but that the bulk of the DME business is paid for by Medicare. In my case, due to my secondary insurance, I only had the option of 3 local DME suppliers IF I wanted my Medicare co-pay paid for by the secondary insurance. I could have gone to other local DME suppliers IF I wanted to pay the co-pay myself (which I didn't, of course).

It is true that Medicare does require 2 hours of sleep out of 6 hours bedtime in order to qualify for payment. Since your sleep lab tech is the one who screwed up and didn't let you sleep the full 2 hours the lab should "swallow" the cost of the needed second study. It is THEIR responsibility, not yours, to see to it that you meet the criteria for payment, if at all possible.

I slept all right for the sleep evaluation, they didn't try to do a split night, but then my apnea was in the "mild" category. BUT I didn't sleep for beans during my titration (42 minutes out of 6 hours) so I had to go back in for a second titration at which I also slept lousy (98 minutes out of 6 hours), however, Medicare "did" pay for the second titration as well as the evaluation and first titration. The difference between yours and mine was that it wasn't anyone's fault I didn't sleep the full 2 hours (the two titrations together did qualify for 2 hours of sleep).

Frankly, I've found that wearing the CPAP mask and all those wires and the hose ENCOURAGES you to sleep on your back. Maybe because I started out on my back due to the "exercises" they do to check contacts of the equipment before telling you you can try to sleep. Being unused to everything you are almost afraid to move at first.

I doubt that Medicare is going to pay for another study at another lab when they don't want to pay for this one due to insufficient sleep time. I think you are going to have to negotiate w/this sleep lab pointing out that it is THEIR FAULT you didn't sleep long enough for Medicare payment. But it would be worth your while to call Medicare and explain the situation.

The only other option is to refuse to pay for the study since it was their fault it didn't qualify for payment but that could hurt your credit for awhile. They should at the very least accept only your copay and nothing more. I think that you could ease the hit on your credit once you explain things in writing to the "credit bureau" but no guarantees on that. You would have to be sure to prove Medicare's refusal to pay and why.

Good luck!!