Two week lurker, first time poster...

CheezWiz · Post by **CheezWiz** » Wed Mar 08, 2006 9:03 pm

Hi all,
I have been experiencing strange heart issues since early January and as a diagnostic I went through a sleep study. I was monitored at 35 events per hour and my doctor said that my events are severe. So he ordered service for me from a local company. They were to set me up with a Respironics Auto BiFlex and related equipment..
(Begin Vent)
I am an Employee of the State of Tennessee and we just switched over to CIGNA as the provider for our POS plan. Turns out that my doctor's trusted provider is out of network for CIGNA. After calling around town, turns out that only one company based out of Nashville is the sole contractual provider for CIGNA and their nearest location is nearly 100 miles away!

So I contact them and am told that Cigna's response time to get this started has been up to 12 weeks! and that they may require that I be put on a CPAP first and will only get a bipap after they verify that a CPAP is not good enough for my condition.

Needless to say, I feel like I am now part of an HMO. The state insurance office touted that Cigna would be providing identical service as our previous BCBS plan. Well, every local provider would have had me setup next day had I been on BCBS and I would have gotten whatever equipment my doctor ordered.
(End Vent)

Now my request for input:
Any of you out there on a CIGNA POS plan?

My options are, wait on CIGNA (still not sure how much they will even cover with an in-network provider and I will have to miss work and drive to them regularly) or go with a local at 70% CIGNA - 30% Me.

Now the stickler, I am looking at $4000 from the local company over 13 months! Seeing that the machine can be bought at cpap.com for $1500, that is a big difference! I understand that the insurance company will not help pay for one, but only rent-to-own? Plus the local provider will collect usage data for me and provide support service? So I guess I am wondering, is this all worth the extra $2500 ?

I suppose I have no choice.
My doctor and the cardiologist are making it clear that I need to begin treatment ASAP..

Any advice on such a situation? I am considering calling the state insurance office and lodging a formal complaint against CIGNA if they do not reply by Friday..

At 34 years old, I really feel let down by my body right now. Guess it is paying me back for college!

Guest · Post by **Guest** » Wed Mar 08, 2006 9:16 pm

CIGNA does have a policy (your actual coverage may vary but this is their position paper) that can be found online if you search CIGNA CPAP in google (or at least I did) - they spell out criteria for providing APAP, BIPAP etc - arm yourself with that - first few pages of the long pdf document might be all you need to read - you might need to take that to your doc

second, check billmyinsurance.com

third, ask CIGNA for preferred providers in your area - you might find a list online for your area too as I know they have one in my area (which isn't Tennessee - sorry)

I have a CIGNA plan and just feel that you should be able to find something closer than 100 miles

NightHawkeye · Post by **NightHawkeye** » Wed Mar 08, 2006 10:12 pm

Don't now if this applies, but my BC/BS plan would have been the same if I'd gone through a local provider. I'd have had to rent the machine as well for a period of ten months.

However, when I started questioning about buying online, at first they didn't want to do this, but when pressed, they indicated that I could buy direct online and then submit the bill to them and would get reimbursed at the out-of-network rate. I opted to do that and ended up getting reimbursed 100% for the equipment, and completely avoided compliance tracking issues and inflated DME prices.

Don't know if this might be an option for you or not, but if it is then it would probably be a good option. You can even get next day delivery of the equipment.

Regards,
Bill

CheezWiz · Post by **CheezWiz** » Wed Mar 08, 2006 10:26 pm

By not using a local DME, I guess that you give up such things as trying out masks until you find one you like. Is that all that you give up?

BillMyInsurance does not deal with my plan, but buying from cpap.com @ approx $2000 would mean $600 for me verses $1200+ from a local DME.

The 1200 was just for the machine from the local DME, then they want more for hose, mask etc...

Linda3032 · Post by **Linda3032** » Wed Mar 08, 2006 10:36 pm

I don't believe "billmyinsurance" deals with CIGNA.

Your percent of the $4000 is $1200 as compared to $1500 at cpap.com.

If you bypassed the DME, and take control of your own therapy, then you should also purchase your own card reader and software. Another couple of hundred.

I think it just depends on if you can afford the outlay of $1700 now instead of spreading the payments over 13 months.

But, what happens at the end of 13 months? Do you own the equipment or do you start a new rental agreement?

Also, you have to consider your time off work plus gas, and the hassle.

Therapy is a hassle - but obviously nobody is going to care about all the inconvenience to you - except you (and us here).

If you can afford it, deal with cpap.com right off the bat. You can get plenty of excellent help right here. Plus, your doctor will always be there to give you professional advice. And he will probably be really impressed by how much you know (very possibly more than he does unless he is a hose-head).

Alot to think about. Good Luck. We are here to help regardless.

Guest · Post by **Guest** » Wed Mar 08, 2006 10:48 pm

I am the previous guest in this thread

I chose to get a mask from cpap.com that came in several sizes in the package and it is now the only mask I use - I got one from local DME also and now replacement from the local DME for what I bought at cpap.com

I got my machine from a local DME and they did all the dealing with CIGNA which was great. The bill was higher yes but I didn't have to worry about coming up with all the money up front and getting it approved after the fact. I also went into it knowing how much I would have to pay using the local DME versus possible full payment at cpap.com

The whole idea of auto-bipap CIGNA might balk at but it has all the bells and whistles and can be run in various modes. That is why I suggested earlier you find the CIGNA stand on this.

For me, CIGNA wanted a letter from my doc (I took to him encore pro output) for complaince to convert a rental to purchase. The local DME never read my card.

As Linda suggest check your finances and check the actual out of pocket you will have to pay at a local DME. Their prices will be 3 times cpap.com's ones at least.

I had a max out of pocket for the year I considered in my decision as well at the %age I would have to pay in versus out of network. The DME I used has contract with CIGNA for 80 % of billed cost not 100% so even though they billed too high they didn't get quite all of that.

CheezWiz · Post by **CheezWiz** » Thu Mar 09, 2006 12:06 pm

Well,

I logged into CIGNA's web site and found that they will pay 100% of the DME with an in-network provider. That is hard to beat, but the "average 12 week waiting period" is not acceptable.

This is from the CIGNA site and is what has me concerned:
"CIGNA HealthCare covers APAP as medically necessary for the treatment of OSA in patients who meet the criteria for CPAP but prove intolerant of standard CPAP despite the use of heated humidification and an oral facial mask or nasal pillow, for at least three weeks.
CIGNA HealthCare covers BIPAP as medically necessary for the treatment of OSA as a second measure when the patient does not respond to or is intolerant to APAP/CPAP."

This sounds like they force you to use a CPAP first and then cycle up to the others....

Linda3032 · Post by **Linda3032** » Thu Mar 09, 2006 12:24 pm

Okay, if I understand all that right, then I would work with CIGNA's provider.

But, have your Doctor request immediate action in getting you on therapy. Sleep Apnea can be life threatening - is CIGNA really going to threaten your life for 12 weeks ... I don't think so. Both you and your doctor need to let them know that 12 weeks is unacceptable. Keep on them until they provide for you (that's what they are getting paid for). What if you told them they wouldn't get their premium payment for 12 weeks?

The Respironics Remstar Pro 2 with cflex is a very nice machine. So unless your doctor has specified Bi-level, then you should be okay to start there.

Also, these long drives to the DME for equipment and fittings should be able to count as "sick time" from work because it is related.

I would think that once you get started, then the DME should be able to mail additional masks, etc. Just make sure they measure you for them and let you try them on when you are there the first visit. Also, they might let you take 3 home and return the two that won't work. It never hurts to ask.

Later, you can get the card reader and software on your own. I might still have a free software site I know of, so when you get ready to purchase, please PM me.

Good Luck and keep us informed.

CheezWiz · Post by **CheezWiz** » Thu Mar 09, 2006 2:59 pm

Another hiccup in the OSA adventure.
The sole in-network provider for my area is APRIA!

From what I can tell so far, they are not held in very high regard around here. Or anywhere else I have found.

I would imagine that incompetence could have an office-to-office variance so I will not judge them outright. The guy I have been speaking with is certainly very nice and willing to share information about the machines they have and such...

Linda3032 · Post by **Linda3032** » Thu Mar 09, 2006 3:04 pm

Another thing would be to check with CIGNA if they would consider you as an "in network provider" (I'm not sure if that's what its called or not).

Many here act as their own provider. They purchase their own equipment, pay for it in full, file a claim, and let their insurance company reimburse them. One fairly new member got reimbursed 100% because his reimbursement was below the allowed amount. (was that you Nighthawk?).

Wulfman · Post by **Wulfman** » Thu Mar 09, 2006 4:06 pm

Linda3032 wrote:Another thing would be to check with CIGNA if they would consider you as an "in network provider" (I'm not sure if that's what its called or not).

Many here act as their own provider. They purchase their own equipment, pay for it in full, file a claim, and let their insurance company reimburse them. One fairly new member got reimbursed 100% because his reimbursement was below the allowed amount. (was that you Nighthawk?).

That's right, Linda.

YUP!
Too many people either don't know about or overlook this option to save themselves BIG BUCKS. Most insurance providers WILL reimburse you for out-of-pocket purchases (including this equipment).
Many times, by the time you add up your co-pay (of the amount that a storefront DME would charge) that comes out of YOUR pocket, it's usually about the equivalent to what the same equipment would cost from CPAP.COM. So, the storefront DME gets a HUGE profit from your insurance provider.

Den

TerryB · Post by **TerryB** » Thu Mar 09, 2006 5:32 pm

CheezWiz,
I am with Cigna HMO and my provider is Apria. I had quite an adventure getting a working machine, I had four units in my hands within 8 days. One CPAP (Respironics plus) which did not meet my MDs requirement for downloadable. I was told there was a Pro on the way but it turned into an Auto with c-flex. I had two duff autos one min pressure and one 20 cm all the time before I got the last one which works great. I got a letter from CIGNA noting that it was covered 100% up $3500.

I had it within 7 days of the script being sent by the MD.

Good Luck,

TerryB

NightHawkeye · Post by **NightHawkeye** » Thu Mar 09, 2006 7:37 pm

Linda3032 wrote:One fairly new member got reimbursed 100% because his reimbursement was below the allowed amount. (was that you Nighthawk?).

Yep! All $1600+.

I thought I was getting to be a fairly old member here though. .

Regards,
Bill

Linda3032 · Post by **Linda3032** » Thu Mar 09, 2006 11:11 pm

Time flies for the elderly ...........

CheezWiz · Post by **CheezWiz** » Sat Mar 11, 2006 11:55 pm

TerryB,

Looks like the 12 week thing was an exaggeration. Apria called today to confirm my information so that a "local" RT can contact me. That is good news because I assume that means Cigna has replied to their query.

Now comes the fun part. I get to find out what they are offering to me. I will not accept anything other than the Auto or Pro 2 BiPap from respironics. I have no clue how to go on masks, I am guessing that they will let me try on different ones and make a decision?

When my doctor told me about the results, he mentioned 12 and 7 and a ramp. I understand the first two but I am looking for the definition of ramp on the forum now.

Thanks for all the input everyone, it is much appreciated. I will hopefully (with some dread too) be joining the ranks of the hose-head corps soon!