OT: Insurance companies suck

7 years ago I had neuro-psych testing done. My mental health coverage is different than my physical health coverage. The ordering doctor had both precertify the testing.

Testing was done, bills were sent. Neither would pay for it. Appeal was then made and both paid for it. I just walked away from all of that then and let the hospital it was done at deal with which money they wanted.

This kind of sounds like the process whichmany people go through in California to get a permit to exhibit exotic animals. First you apply for the permit. Even if your permit application is perfect, they will find 'something wrong' and categorically deny you. The only way you can get the permit, even though the law states that they must give you a permit if you are qualified, is to sue them. And of course, they have ridiculous requirements you have to meet to get the permit at all.

This continues to illustrate what is really wrong with health care here in the US: greed. No one has ever advanced a plan to reduce health care costs by ridding the system of rampant greed. If someone was willing to do this, we could reduce the greed, and increase the quality of healthcare, with little cost to the Government. In fact, the cost of doing this would be more than offset by the savings on healthcare for Government employees. Problem is the healthcare lobby will do any and everything to protect their cash cow. And if the plan before Congress ever gets enacted, it will be a systemization of the broken system we have today, with the added 'bonus' of the Government telling you how to manage your care....or else.

Call the Gov't Medicare office and ask them what THEY pay a lab for the sleep study. You'll be surprised. Here in Texas they get about $350 TOTAL for a split sleep study with titration - and you didn't even get that.

If you've got to pay cash for the study, only offer them the Gov't medicare fee.

Another trick is to claim to your insurance company that the lab is an outpatient facility. In that case you only pay your regular dr's visit co-pay. I know several folks how got their SS for $20.

Heavy Zs wrote:We have "health care" in Canada, and it doesn't cover CPAP machines or diagnostic sleep studies. If your lucky, you may get insurance coverage with Blue Cross, Sun Life, etc., that covers part of your costs.

My insurance paid 80% for my CPAP gear up to a limit they described as "normal cost". Naturally, that was a couple of hundred bucks less than what I was quoted at every location in the city that sells the gear, but it was better than nothing.

Strangely, they refused to pay for the sleep study, which I assumed would have been covered under medical diagnostic testing. How they pay $1600 for a machine that requires a prescription to buy, yet refuse to pay for the $150 overnight sleep study (never mind the overnight $800 test) required to diagnose the condition before you buy the machine is a study in insurance logic.

What province are you in? In Ontario the sleep study is covered, and the government kicks in 75% of the cost (up to $780 of the CPAP system - mask & machine & hose, etc.) every 5 years. By law, companies that sell CPAP machines in Ontario have to offer a start-up CPAP system for $1040 or under.

To: TSSleepy,

I work for a health insurance company and now that I've disclosed such will likely be kicked off this site. Based on your comment it appears that your insurance has denied the claim under the "not medically necessary" portion of your policy because you don't have a prescription from your doctor and the results of the sleep study test came out badly. You can write a letter of appeal but you'll need to supply documentation the company will accept showing you did need CPAP therapy. Unfortunately, it is likely the only documentation the insurance company will consider acceptable needs to come from your doctor, such as the results of the sleep study and his prescription. Since it appears you're not likely to get this documentation it is likely you'll not win the appeal. Sorry to give you this bad news. You need a new doctor. You might want to report your current doctor to the Medical Licensing bureau in your state.

The company sending you the bill wants to be paid and will likely let you make payments. Pick up the phone and call them.

Good Luck

Cat

TSSleepy wrote:

mattman wrote:an AHI that doesn't qualify (Some Insurance companies still use the old AHI>15 basis which rules out a lot of people)

Thanks mattman, maybe that's what happened. Even with 2 Ambien in me, I didn't sleep enough during the sleep study for them to get data to make a diagnosis. I think I dozed a couple hours, resulting in a 20-something% sleep efficiency and no stage 3/4 or REM sleep.

My doctor pretty much diagnosed me and prescribed APAP by looking at my pulse ox data with/without my ilegally-purchased used CPAP.

You know what - that might be it right there. It totally slipped my mind - but one of the other big denial reasons we would see is that most insurance companies (Medicare included) require a minimum of 2 hours of recorded sleep time during a study.

Now this is totally understandable since the purpose of a sleep study is to get a good picture of a patients sleep but it also has the curious side effect of causing problems for those with significantly screwed up sleep. Which is where the Medical Review board comes in.

However, since it was so quickly resolved I'm betting the previous posters suggestion that it was simply a paperwork issue (No Rx, Rx not signed, full sleep study not sent over, etc) and I'm glad to hear that it was so easily resolved!

mattman

I've heard some sleep doctors are sending patients home with a machine for home testing and then they bring the outfit back and the doc checks the data.

Of course, they don't have all the ekg and other info they get in the lab but it certainly shows if the person is having a lot of sleep interruptions.

Home studies are usually better for the patient because they are in known surroundings and comfortable.

Can't beat being in your own bed.

I agree that insurance companies suck.
I am yet to see them officially approve the CPAP I just received.
My RRT told me that I could not choose my CPAP and that my insurance only approved one type of basic machine, at least it comes with a humidifier.
I wanted another one but they said no. It's ok because I'm in the middle of switching and the other carrier covers the one I wanted.
I also found out they don't buy them, they lease them until they feel like Okay-ing the purchase. I also have a huge deductible so either way it's out of my pocket.
I was asked to bring a check for $800 to the sleep lab the night of my study. That was the agreed price between my insurance and the sleep lab. I think the actual cost a little over 2K. Even though it came out of my pocket the $800 were applied to my deductible. First year with a high deductible and first year I'm actually using it this much. AS long as it helps!!!!

mattman wrote:..most insurance companies (Medicare included) require a minimum of 2 hours of recorded sleep time during a study...Now this is totally understandable since the purpose of a sleep study is to get a good picture of a patients sleep but it also has the curious side effect of causing problems for those with significantly screwed up sleep.

Wow! I just snuck in at 130 mins for my split study with really messed up sleep like TSSleepy, mostly just dozed, 3-4 mins of S3&4 sleep & no REM, they would't even rate my sleep architecture just said "poor." Interesting little hiccup for those of us whose sleep was really deranged. Thanks for the info.

redbear wrote:I agree that insurance companies suck.
I am yet to see them officially approve the CPAP I just received.
My RRT told me that I could not choose my CPAP and that my insurance only approved one type of basic machine, at least it comes with a humidifier.
I wanted another one but they said no. It's ok because I'm in the middle of switching and the other carrier covers the one I wanted.
I also found out they don't buy them, they lease them until they feel like Okay-ing the purchase. I also have a huge deductible so either way it's out of my pocket.
I was asked to bring a check for $800 to the sleep lab the night of my study. That was the agreed price between my insurance and the sleep lab. I think the actual cost a little over 2K. Even though it came out of my pocket the $800 were applied to my deductible. First year with a high deductible and first year I'm actually using it this much. AS long as it helps!!!!

Your RRT is lying to you. Your DME just wants to give you a cheap machine so they make more money off you.
Cpaps and autopaps are all billed under E0601, same negotiated insurance rate for all of them.
Demand the machine that you want. Any DECENT DME will comply.

Seliina wrote:What province are you in? In Ontario the sleep study is covered, and the government kicks in 75% of the cost (up to $780 of the CPAP system - mask & machine & hose, etc.) every 5 years. By law, companies that sell CPAP machines in Ontario have to offer a start-up CPAP system for $1040 or under.

I live in Alberta, and yes, it is the province that takes care of health care, not the federal governmetn. Different provinces cover different things. Here they cover nothing related to sleep apnea unless you are a senior, but pretty much any employer health plan will cover CPAP equipment. My Sun Life capped normal cost at $2000 and paid 80% so I am out of pocket $400 on the total cost of $2200 for all my equipment. That includes the Resmed Autoset II with full kit/humidifier and whatever mask I end up keeping. That seems high compared to the US/online prices, but I got one of the top rated machines with no hassle in one day, changed my mask type on a follow-up a few days later, exchanged my new CPAP unit with no hassle when it emitted a high pitched whine, and got reimbursed by the insurer within a week.

That doesn't give me a lot to complain about compared to some of the stories here. From the sounds of it the provincial medicare coverage elsewhere in Canada is very restrictive, whereas here in Alberta medicare does not cover CPAP, but I can get whatever equipment I want (within prescription) and my private insurance covers up to $1600.

TSSleepy wrote:Update:
I just got off the phone with them and they are dropping it to 10% co-pay, so I saved $1490.40 with a phone call. They didn't explain why it was billed the way it was or why they were changing it, but I was too grateful to ask.

I love insurance companies! Insurance companies rock!

Care to share who *them* is?