Insurance "watching" xPAP users

I had to buy all my cpap equipment out of pocket because my health plan doesn't cover DME, so for better or worse I haven't had to deal with insurance/compliance issues. But when I read people's stories about insurance companies monitoring compliance and taking their money back when patients are 'noncompliant' it makes me wonder -- is there any other area of health care where an insurance company can retroactively refuse coverage for treatment? I'm thinking, if your insurance covers your medication prescriptions, no one monitors your 'compliance' with taking the medication. If you decide not to take it, you don't lose the coverage. If your insurance covers physical therapy and you don't regularly practice the exercises the physical therapist gives you, your insurance can't/doesn't stop covering your PT appointments. I'm just wondering how it came to pass that if a doctor writes a prescription for xPAP the insurance company has the right to "watch" to make sure the patient is using it and to "take their money back" if the patient isn't using it to their satisfaction. Is it just because they can, because there's a technology that allows them to monitor hours of use? Just kinda curious...

In most cases of medication, people do not continue picking it up if they give up on treatment. With cpap treatment, a lot of people quit using it, often within the first couple months. Why should the insurance pay $2000 or more for equipment that will gather dust. It makes sense that they want to know we will actually use it.

The real problem is that DMEs and doctors often don't work to make sure that the treatment is working and the patient is able to use it. If somebody is struggling to use it feels no benefit, then it makes sense that they will quit. And the useless bricks make the problem worse. ALL machines should have full data. That alone helps people to use their machine consistently and feel the benefits. Then both the patient AND the insurance company benefits (fewer health problems later on).

zoocrewphoto wrote:In most cases of medication, people do not continue picking it up if they give up on treatment. With cpap treatment, a lot of people quit using it, often within the first couple months. Why should the insurance pay $2000 or more for equipment that will gather dust. It makes sense that they want to know we will actually use it.

The real problem is that DMEs and doctors often don't work to make sure that the treatment is working and the patient is able to use it. If somebody is struggling to use it feels no benefit, then it makes sense that they will quit. And the useless bricks make the problem worse. ALL machines should have full data. That alone helps people to use their machine consistently and feel the benefits. Then both the patient AND the insurance company benefits (fewer health problems later on).

Good point but insurance companies aren't exactly known for providing coverage because something is cheaper in all situations. Unfortunately, the specific situations I am thinking of don't come to mind. I have a vague recollection of hospital services being covered but equivalent type home services not being covered.
So if someone knows what I am talking about, please respond:)

Also, I am curious about how the coverage of other medical supplies and equipment is handled and what the rules are.

It just seems like this sets a very dangerous precedent. For example, I read about a company developing a tool for tracking whether people are taking meds.

So what if someone stops taking it due to horrific side effects and the insurance company then decides 6 months down the road, it wants reimbursement due to this compliance tracking tool? Their reasoning would be stopping the meds is going to lead to greater costs down the road due to evidenced based medicine guidelines which I think is questionable in some situations (another post).

Personally, as much I hate not having health insurance, this is one situation that makes me glad I don't have it. I find electronic monitoring very creepy but such is life in this technology era.

49er

oh man... if you think this is bad... wait until "Obama - care" kicks in. The "death-squads" will bump us off cpap coverage like there's no tomorrow.

Sheriff

My last employer insurance wouldn't cover hospitalization in non-network hospitals unless it was PREAPPROVED. One time when I was in the hospital after obtaining the necessary preapproval, my doctor told the 2nd day that the insurance company had REVOKED the PREAPPROVAL without specifying a reason. The hospital let me stay and I appealed afterwards showing the written PREAPPROVAL I had obtained before I was hospitalized. That's the only appeal I've ever won.

So yes. There are other situations where an insurance company came retroactively refuse to pay for health care.

Sheriff Buford wrote:oh man... if you think this is bad... wait until "Obama - care" kicks in. The "death-squads" will bump us off cpap coverage like there's no tomorrow.

Sheriff

Well the Affordable Care Act HAS kicked in as of two years ago and we are still, amazingly, alive. I like the fact children can't now be denied coverage because of preexisting conditions (and in 2014, all of us), young adults can stay on their parents' policies until age 26, that preventive care is covered 100% with no co-pays allowed, that businesses get tax credits to offer workers insurance, and that now insurance companies must pay back cash refunds to policyholders if the insurers dont spend at least 80% of annual premium dollars on actual medical care and not advertising, overhead, and CEO bonuses. Amongst hundreds of other new requirements that benefit people.

And, thank you very much, uninsured Americans suffering from sleep apnea will all soon be able to get the health insurance they need to affordably obtain xPAP machines and supplies.

The reason CPAP machine use is tracked is that because the private insurance companies follow Medicare's DME policies for most of their own rules, and for years Medicare started demanding proof of CPAP compliance info in order, very rightly, to save taxpayers' money. Is that a 'death panel?' Or a 'fairness panel'? Why give grandpa a $2,000 Bi-Pap machine if he's going to throw it into a closet in a week -- or worse, sell it to make some fast cash. Becaus that was exactly what was happening.

If you check your insurance policy other DME equipment is rental only, like hospital beds, oxygen systems, etc. It accomplishes the same thing -- allowing use, but not allowing one to sell off a DME item on the sly.

Kaiser is like an electronic Big Brother. If you have a chronic condition like asthma or diabetes and you aren't filling prescriptions regularly, you get contacted. They don't cut off insurance coverage, but they want to hook you up with a patient educator or a respiratory therapist ( in the case of asthma) for "case management". In the asthma situation I stopped taking meds because I had no symptoms for a few years, but when I got sick with a respiratory illness it was very, very bad. I finally worked with the RT (weekly consults at first!) and it was a really good thing because I now have the asthma under good enough control to weather colds without triggering severe bronchitis. They are on me like flies to get an overdue mammogram and pap smear--to the point of annoyance.

But I have to say its inconsistent. My father died of colon cancer and it took me FOUR years of fighting with them to finally get a colonoscopy instead of an occult stool screening.

As for pap, since they purchase rather then rent and they auto titrate at home on their machines, they have a pretty good idea of compliance before you are authorized to get a machine, so they don't check after the first month (probably only then because of Medicare rules).

BCBS of NE does not monitor.

They told me they have better things to do than play big brother.

They also authorized me to do an outright purchase of my APAP.

I have BCBS and I haven't been able to find in the plan documents that they monitor. I did talk to my doc about it because my usage has been sporadic at best and he said even if they did, he could contact them and get it overriden because I have my issues with PAP 'on record' with him.

I guess that would be the take-away from this - if you are having problems, call your doc and get them into your file. It is likely your doc won't or can't do anything to fix your problems, but it might save you from having your machine taken away.

Insurance companies are putting the short leash on patients these days. My insurance company has a program that provides me with insulin, test strips, and other diabetes supplies at 100% coverage. The catch is that I have to demonstrate compliance by allowing the insurer's "nurse" to call me up at least once every eight weeks and ask me all sorts of questions about my health and what I am doing to stay healthy. That should really be my doctor's job, but I play along with the game to save money.

I also learned long ago to get ALL major procedures pre-approved IN WRITING.

So far CIGNA has been great about not bothering me regarding CPAP compliance, but I'm sure the day is coming.

In the US, former members of the US military, and those disabled while in the service use the VA. For those readers outside the US, the VA means the Veterans Administration, medical care for the veterans. Like any public health care system it has a lot of overworked doctors, such as those who are forced to work for the VA as part of their training, while also working full time at University hospital. VA has a lot of ordinary employees who having passed their probationary period, are full time employees and can not be fired, so they do no work except to lose patient files, ignore patients, gossip with one another. The VA is filled with regulations.

Health care regulations of the future, on display today at the US VA system. While I was in southern Oregon I used to eat at a homeless shelter, where I met an individual who told me his story with the VA. He was not eating because he was in end stage stomach cancer. He had been through four surgeries, multiple rounds of chemo, radiation therapy. He had once received VA disability payments. It had been stopped because he was "non-compliant," with getting VA treatment. His VA hospital was in Portland. He did not want to live in Portland, because at that time (in the late 1980's) the lower sections of town were violent, and even more dangerous to the disabled who had problems with defending themselves. He also preferred the small town with a river running though it, than the concrete. His last three trips to the VA had been triggered by a demand by the VA to go to a medical appointment.

Each time the cancer doc told him, "I did not ask to have you scheduled to come in here, the administrators did. As I have said before, there is nothing more we can do for you. I am really sorry. We have applied to have you placed in a hospice, but the waiting list for hospice care is much longer than you are likely to live.'

Several times this Vet did pay to ride a bus from southern Oregon to Portland, spend hours waiting to see a doc. The administrators, knowing that the Vet was not physically in Portland, kept rescheduling appointments until they got their desire. He missed an appointment. The VA stopped his disability payment, with the result he will die homeless.

Recently a Vet told me that the VA has a policy that any failure to meet the VA system of compliance, for any treatment, would mean the Vet would lose his disability payments, and the VA system would make it very hard to get any appointment to be seen in a VA facility. By compliance meaning missing any medical appointment, not taking any drug or treatment prescribed. If the doc said I think you are depressed, and writes a prescription, then it is tracked as to whether he picks up the pills at the pharmacy (yes, more hours waiting, and the VA has a co-pay system) When the vet sees a doc, the doc will ask are you taking these pills, if the patient does not explicitly say, "Yes, or give a doctor approved reason for not taking them, then that is not being in compliance. The system gives not just the doctor near godlike powers, but also the administrators, who are trying to cut costs, all kinds of tools to stop disability payments, or make health care to be delayed. Health care for other issues than the one the patient is "Not in Compliance" for.

Insurance rules and regulations are in constant flux. As those of us who have Medicare know, the dollar costs for the patient are not "what we can afford" if we actually have health problems, like I have. I must conclude the dollar amounts for Medicare Premiums, Deductibles, Co-Pays are meant for us to choose not to seek health care. Simultaneously we have long ignored the best way for a person to have better health is for them to eat a quality diet. Not living most of the month on starchy fillers like, Ramen, Mac and Cheese, peanut butter. Also keeping in mind that pro-active health care is likely to be the least expensive health care for the system to accomplish, maintaing the life functionality highest for the patient. That is these dollar restrictions of placing such high costs of health care on those in Medicare are actually causing people to not go to see doctors.

Soon. The payments to providers are to be one third less than they were. Frankly, a lot of private doctors, clinics would not accept new Medicare/Medicaid before those cuts.

If one understands the consequences of the current Medicare policies, without the addition of what happens to non-compliant patients, then I say it is obvious that the system of Social Security Payments and medical costs will cause the reduction of the functionality of the life of recipients, premature death, while increasing the dollar costs for the system by delaying medical care, and reducing the quality of the diet of recipients. Penny wise and pound foolish policies that are pointed at containing short term costs, while increasing costs within a year or two. May I also say, an example of book keepers making medical decisions. I feel the US government's unannounced, secret goal is to get rid of those on 'earned benefit' programs by causing their premature death.

Viking Gnome - Wow, what a a frightening experience. I am glad you won your appeal.

Guest, great point about the cpap and the fact that people were selling them.

Jan, I understand the issue with asthma meds. But I am thinking more along the lines of cholesterol issues which you have discussed in paleo threads. It would be quite annoying to have Kaiser want me to follow up with a patient educator if I didn't think my cholesterol was an issue.

Brucifer, all I can say is wow about that insurance nurse calling you.

Purple, I find the situation you described horrifying. So if a service person has a traumatic brain injury and refuses psych meds that have a good chance of making the TBI worse, he/she will get kick off of disability for being non compliant? Wow!

That is horrible about the homeless vet.

49er

My father died of colon cancer and it took me FOUR years of fighting with them to finally get a colonoscopy

With Obamacare, that doesn't happen anymore. Every insurer now must provide free preventative screenings. Part of the reason for Obamacare is to make insurers pay for the preventative tests that identify problems early, both to reduce cost and improve outcomes.

Jan, I understand the issue with asthma meds. But I am thinking more along the lines of cholesterol issues which you have discussed in paleo threads. It would be quite annoying to have Kaiser want me to follow up with a patient educator if I didn't think my cholesterol was an issue.

Like I said, it's kind of inconsistent. Last time I had a fasting BG, it was 99, but it's often over 100 because of severe insulin resistance. (Nevertheless, I've brought my A1c down to 5.4 on my low carb paleo diet). DH has an A1c of about 5.2, a reasonably healthy diet (still eats carbs, but he exercises hard and has like 17% body fat), but his FBG was 100 on a recent test (probably because of stress from the blood test--he's terrified of needles). So now they are bugging him to get "dietary counseling" so they can tell him to eat 6 servings of carbs a day and swap out margarine for butter They bug him, not me.

And, BTW, I saw a cardiologist this week--regular check up for my congenital heart disorder. He started in on me about my LDL-C (145 Friedenwald calculation), but when I pointed out my HDL (79) and Triglycerides (71) he stopped. That was that. And nobody has bugged me yet from Kaiser about it.

Guest wrote:

Sheriff Buford wrote:oh man... if you think this is bad... wait until "Obama - care" kicks in. The "death-squads" will bump us off cpap coverage like there's no tomorrow.

Sheriff

Well the Affordable Care Act HAS kicked in as of two years ago and we are still, amazingly, alive. I like the fact children can't now be denied coverage because of preexisting conditions (and in 2014, all of us), young adults can stay on their parents' policies until age 26, that preventive care is covered 100% with no co-pays allowed, that businesses get tax credits to offer workers insurance, and that now insurance companies must pay back cash refunds to policyholders if the insurers dont spend at least 80% of annual premium dollars on actual medical care and not advertising, overhead, and CEO bonuses. Amongst hundreds of other new requirements that benefit people.

And, thank you very much, uninsured Americans suffering from sleep apnea will all soon be able to get the health insurance they need to affordably obtain xPAP machines and supplies.

The reason CPAP machine use is tracked is that because the private insurance companies follow Medicare's DME policies for most of their own rules, and for years Medicare started demanding proof of CPAP compliance info in order, very rightly, to save taxpayers' money. Is that a 'death panel?' Or a 'fairness panel'? Why give grandpa a $2,000 Bi-Pap machine if he's going to throw it into a closet in a week -- or worse, sell it to make some fast cash. Becaus that was exactly what was happening.

If you check your insurance policy other DME equipment is rental only, like hospital beds, oxygen systems, etc. It accomplishes the same thing -- allowing use, but not allowing one to sell off a DME item on the sly.

"Guest": nobody will get "coverage" unless the death squads approve of it. Allowing access to to medical treatment doesn't mean the goverment should take over one fifth of the economy.

Come to think of it... I'd better shut up or the death squads will deny my next order of cpap supplies! Sorry Obama Hussain, I love your idea of socialism and to heck with the 22 million people that don't have jobs... I'm voting you back in!!