kaiser...

hi, my girlfriend waited months to be able to get the equipment to test for sleep apnea. when we returned the equipment they told her that she would hear from them in 2 weeks, she didn't, so she called her doctor who said; "you have moderate sleep apnea and your perscription has been filled, wait for a phone call." yesterday she gets a letter in the mail saying she doesn't have sleep apnea, and she was denied... wtf? anyone else have bs probs with kaiser like this?

--thanks

roob

I'd say that is PAR for the course for Kaiser, it is how they got to become this huge medical conglomerate.

Taking your money in higher premiums and giving you sub-standard treatment in return is their motto.

yeah, i figured... what should i do? how should i fight it? ask for the results or something? any advice?
thanks

If it were ME and I was experiencing the effects of OSA, I'd ask the doctor for the prescription and buy the equipment online (like from CPAP.COM).

It could be in the stages where it's progressing and could/will get worse. Better to head it off before it has too many adverse effects on the body.

It's her health that's at stake.

Good luck.

Den

Okay-

I have had Kaiser my entire life and have had a myriad of medical conditions. I have finally figured out how to deal with Kaiser. It is possible that you have mild to moderate apnea and I've been told that Kaiser won't give you a machine unless you are moderate to severe.

1. You are legally entitled to access your medical records. I'd get a copy of the sleep study.

2. talk to your GP. See if he can get a copy of your sleep study, or if he'll go to bat for you. Sometimes this works, but I wouldn't count on it. I've discovered doing it by e-mail is the best b/c they don't "misunderstand" you and it creates a paper trail.

3. Contact Member services. Believe it or not, but they are usually really helpful, especially if you phrase it in a pre-litigation way. For instance, I contacted them about the fact that the Kaiser near me won't do polysomnograms at the hospital, and mentioned that it seemed odd since all the sleep disorder associations state that an at home test is only good for diagnosing apnea provided that a follow up overnight study is done....magically, I have one scheduled in a few weeks.

4. Now, if none of those works, play the system against itself. Since none of the docs actually talk to each other, contact your sleep study doc and say that one of yours says you have it, another says you don't, but that a third NEEDS to know for risk reasons. For me, my shrink thinks I have some sleep disorder other than apnea. the neurologists thinks it's just depression and won't refer me for tests. However, I'm having gastric bypass and the surgeon wants he question answered one way or the other. All of the sudden I'm getting a MSLT, MRI, and a whole bunch of other tests that Kaiser refused to run for the last 8 years. The system is soooo funny. Since my sleep doc is the only one able to agree to run the tests, I just had to tell her another doc wanted them. Now they're getting done no questions asked. If one doc thinks another thinks something needs to be done then they'll do it (and never actually ask the 1st doc).

Hope that helps. Good luck with Kaiser.


Sarah

lawdognellie wrote:Okay-

I have had Kaiser my entire life and have had a myriad of medical conditions. I have finally figured out how to deal with Kaiser. It is possible that you have mild to moderate apnea and I've been told that Kaiser won't give you a machine unless you are moderate to severe.

1. You are legally entitled to access your medical records. I'd get a copy of the sleep study.

2. talk to your GP. See if he can get a copy of your sleep study, or if he'll go to bat for you. Sometimes this works, but I wouldn't count on it. I've discovered doing it by e-mail is the best b/c they don't "misunderstand" you and it creates a paper trail.

3. Contact Member services. Believe it or not, but they are usually really helpful, especially if you phrase it in a pre-litigation way. For instance, I contacted them about the fact that the Kaiser near me won't do polysomnograms at the hospital, and mentioned that it seemed odd since all the sleep disorder associations state that an at home test is only good for diagnosing apnea provided that a follow up overnight study is done....magically, I have one scheduled in a few weeks.

4. Now, if none of those works, play the system against itself. Since none of the docs actually talk to each other, contact your sleep study doc and say that one of yours says you have it, another says you don't, but that a third NEEDS to know for risk reasons. For me, my shrink thinks I have some sleep disorder other than apnea. the neurologists thinks it's just depression and won't refer me for tests. However, I'm having gastric bypass and the surgeon wants he question answered one way or the other. All of the sudden I'm getting a MSLT, MRI, and a whole bunch of other tests that Kaiser refused to run for the last 8 years. The system is soooo funny. Since my sleep doc is the only one able to agree to run the tests, I just had to tell her another doc wanted them. Now they're getting done no questions asked. If one doc thinks another thinks something needs to be done then they'll do it (and never actually ask the 1st doc).

Hope that helps. Good luck with Kaiser.


Sarah

they are in a bigger mess than I thought they were.

Lawdognellie, You are absolutely right. My Wife and I, have Kaiser for about twenty years now and you really do have to learn the ends and outs, otherwise you will fall through the cracks and I mean large cracks.

We have had to apply the very same tactics that you have and it works great, but it can become very frustrating at times. A person thinks that sense they pay their premium's they deserve to get good quality care, but it just doesn't work that way with most HMO's. We do get good care, but it comes with a great deal of prodding and congealing and there are lot of good Doctors at Kaiser, a person has to look hard and find them and keeping a good Doc, sometimes is very hard. They, Kaiser, have a pretty good turn over rate. We have at least 10 to 12 Doctors come and go as our PC providers, some we were very sad to see go, while others, happy to see go.

So do as Lawdognellie says and you will succeed in getting your XPAP machine.

Dan

Kaiser is really sad. Most of my docs sit there and say they'd run a test if it were up to them, but Kaiser won't allow them too. It becomes a real pain in the butt. Gastric Bypass has been worth it because if for no other reason Kaiser is now running tests that they should have done years ago. I swear, I'm at the point where I do research on my conditions, figure out what tests should have been run and then tell my GP the bariatric dept needs me to have them done. I've done this for 5 different tests, including an abdominal CT, MRI, MSLT, etc. and it's the 1st time I've had them agree.

What's also funny is that some of the people who are in the process of undergoing gastric bypass are having major problems because of sleep apnea. When you go in, they basically say that if you haven't been tested, you must before you can get approved for surgery. Also, the surgeon told us that anyone with apnea MUST have a CPAP machine or they can't have surgery. However, some of the people in my classes were told (previously) that because their apnea is mild they can't have a machine. Now they are being told they must. I know one person had to appeal denial of coverage for a machine and had to have the surgeon write a letter saying it is required. Ha ha. Doc said must have, and insurance says don't need. Anyone see what's wrong with this situation?

Sarah

Before you stress too hard about Kaiser, you might want to look at the financials.

What is your benefit really worth if you bother pushing Kaiser?

If you have to go through a Brick and Morter DME (with Kaiser) they will charge a lot more for the machine than purchasing cash online.

If your deductable hasn't been met or your copay is high, the benefit may not be worth anything anyway.

Check this out and get your prescription from the doc and copy of your sleep study (which you won't need online but it is good to have) and visit Cpap.com and pick out your stuff. Nice auto machine is about $700 with heated humidifier, and mask $100 to $150. So $850 and you are set.

Snoregirl--

They're gonna have to push Kaiser b/c you can't get a machine w/o a prescription, which they haven't gotten yet. Not to mention, they would still need to do a titration study to know what pressure to set it at.

I tried to have a sleep study done outside of kaiser at it is $5800...therefore, can't just do it independently.

sarah

[quote="snoregirl"]

Check this out and get your prescription from the doc and copy of your sleep study (which you won't need online but it is good to have) and visit Cpap.com and pick out your stuff. Nice auto machine is about $700 with heated humidifier, and mask $100 to $150. So $850 and you are set.

For cpap.com you have to have the script before they will fill an order.

I am well aware that you need a prescription to purchase online.

I also know that ANY doctor can write one. The primary care physician can and given what the original poster said that the doc called her and said she indeed had sleep apnea and that her prescription would be filled, I assumed that some doc agreed that she had apena and that that doc would write the script. It looked to me that the only issue was Kaiser deciding she didn't qualify. The insurance company deciding you don't qualify doesn't stop one from getting a script from a doc who says you have apnea. It just stops insurance benefits which may not be worth all that much anyway.

At the very least, if this doc that is being referred to is not her primary care physician or won't provide her with the script, I would make a visit to my PCP and explain t,he situation and see if I could get the script there.

Once I got the script I would order an auto from CPAP.com and forgo the titration study and the insurance company if at all possible.

roob wrote:hi, my girlfriend waited months to be able to get the equipment to test for sleep apnea. when we returned the equipment they told her that she would hear from them in 2 weeks, she didn't, so she called her doctor who said; "you have moderate sleep apnea and your perscription has been filled, wait for a phone call." yesterday she gets a letter in the mail saying she doesn't have sleep apnea, and she was denied... wtf? anyone else have bs probs with kaiser like this?

--thanks

roob

I think this is what snoregirl and I were both seeing. The doctor said she had "moderate sleep apnea and your prescription has been filled".
Apparently, there's a prescription floating around out there for her.
See if you can grab hold of it.
As snoregirl indicated, Kaiser/insurance payment rules don't preclude you from treatment.

How much is her health worth?

Den

Wulfman said it very well.

To the original poster. Call the doc that said your girlfriend had apnea, or better yet have her go to the office. Tell them that you want her prescription. Offer to wait until they can get it to you, sit in the waiting room and check with the receptionist on the 1/2 hour. It is like a prescription for antibiotics, takes 2 minutes for the doc to scribble a new one.

I wouldn't take the answer you got about "wait for a phone call" if I had strep throat, I would want the prescription in hand when I left the office. Same here.

Doctors dictate the treatment, not where you get your prescription filled who pays.

Then you have what you need for online purchasing.

Hey, Roob,

PM me for some help on getting around Kaiser.