Anyone ever beat Kaiser?

Hi everyone.

First, a little background. I got my current machine about a year and a half ago, used from Craigslist for $250. I got it after doing a home sleep study. I was diagnosed with severe complex apnea- over 60 apneas per hour. After about a year, I complained to my Dr. that I still wasn't getting a good night's sleep, and I took my machine in so they could read the card. Based on the card readings, they said I still was having about 20 apneas an hour. That's when I got them to start the stay-over sleep studies (I've now had three). So the machine I have now been prescribed is the ResMed ASV, which brought my AHI down to 7.4 in a sleep study.

It really burns me that Kaiser is telling me that I have this very serious condition, and they refuse to treat it because the treatment happens to be a machine. It's especially stupid because, if the apnea goes untreated, I will start having a lot of other health issues which they WILL have to treat. But that's OK as long as the treatment doesn't require a machine.

So my question to the group here is, has anyone here ever appealed the DME denial and won? If so, how did you do it? And if not, what did you do to try to get them to reverse their decision?

Thanks

Never worked with Kaiser myself. I suspect that the issue with Kaiser is a bit different than what you think. They must have you go through some hoops to prove you need an ASV. It is now typical of insurers to make people do various things to prove there is not a cheaper solution.

Like for me to get a Bi Level machine, I had to have a sleep study which said, Patient can not tolerate APAP, or CPAP. or some such nonsense. One would think that if the doc prescribed a particular class of machine, he has a good reason, and the insurer does not have try to discourage one from getting the treatment one needs by - this - time wasting - push to make us do more qualifications.

Perhaps speak with Kaiser or Docs office about this issue.

Better still, if someone who has worked with Kaiser, or Janknitz can come along and help with this.

Of course, if you have the buckitos, then maybe STLmark or someone can find a ASV but less-expensive machine for you.

with hope someone else came come along and explain what you need to do. BUMP.

You can appeal a Kaiser care decision. What state are you in, and is your health plan provided by an employer? Really that question is intended to understand if kaiser or your employer bears the risk for your care, which impacts the regulator in some states.

Do you have something in writing that says you need an ASV?

One unanswered question about your situation -- Do you have a Kaiser plan that does not cover DME? Or is it that your plan includes DME but Kaiser is giving you a hard time about providing the machine? An appeal/complaint would be worth a try if your plan does cover DME. If like me you have a plan (I'm self-employed with an individual Kaiser plan) that does not include DME, I don't think you can do anything about it. I've had to buy everything myself.

kaiasgram

Does that mean you have one of those inferior plans Mr Obama keeps talking about?

About a week ago there was a Resmed ASV machine offered here for $1750. I was tempted to buy it but I have a one month old PRS 1 ASV machine already. If I had that amount of cash laying around and didn't know what to do with it I would buy that machine.

Kaiser wants to treat apnea, because NOT treating it is much more expensive for them in the long run. But if you don't have DME coverage, they are not going to buy you a machine PERIOD. So your first step is to find out if you have DME coverage. Request (in writing!) the Evidence of Coverage (EOC) book from Kaiser. You've never seen this document unless you've specifically requested it, but it's the contract between you and Kaiser. Read that to find out IF you have DME coverage and how Kaiser covers DME in your contract.

Even if your plan doesn't cover DME, you may still be able to get Kaiser's heavily discounted price from Crapria.

I apologize. I did some cutting and pasting in my post, and a line got lost- I have an employer-provided plan that does not include DME.

However, I have never seen the EOC for my plan, that's a good idea.

Yeah, without DME coverage you're out of luck.

A lot of people have tired of the DME dance, and are getting their machines second-hand and their supplies on e-bay or other online sources. Check Craigslist, secondwindcpap.com, and STLMark and McDover on this forum for great deals without all the hoops to jump through.

The way I beat Kaiser was to drop them for CIGNA. I was lucky my employer offered 3 different plans.

It was more money, but everyone I knew that had Kaiser had nothing but problems. While I didn't have any issues with them I felt
I prevented a problem from happening. Reputation means something.

Bill44133 wrote:The way I beat Kaiser was to drop them for CIGNA. I was lucky my employer offered 3 different plans.

It was more money, but everyone I knew that had Kaiser had nothing but problems. While I didn't have any issues with them I felt
I prevented a problem from happening. Reputation means something.

Actually Kaiser has an excellent reputation. Five out of five stars on customer satisfaction as well. When people hear bad news about Kaiser, they don't take into consideration that the name Kaiser represents the doctor, the hospital, the pharmacy, the lab, any specialists, etc. Contrast that with someone complaining about Dr. Smith, Providence Hospital, Walgreens pharmacy, ABC lab, etc. Since those are not related, for example Dr. Smith isn't affected by someone's complaint about Walgreens.

ughwhatname wrote:

Bill44133 wrote:The way I beat Kaiser was to drop them for CIGNA. I was lucky my employer offered 3 different plans.

It was more money, but everyone I knew that had Kaiser had nothing but problems. While I didn't have any issues with them I felt
I prevented a problem from happening. Reputation means something.

Actually Kaiser has an excellent reputation. Five out of five stars on customer satisfaction as well. When people hear bad news about Kaiser, they don't take into consideration that the name Kaiser represents the doctor, the hospital, the pharmacy, the lab, any specialists, etc. Contrast that with someone complaining about Dr. Smith, Providence Hospital, Walgreens pharmacy, ABC lab, etc. Since those are not related, for example Dr. Smith isn't affected by someone's complaint about Walgreens.

I've never had any good experiences with an HMO. Like you said, there's just too much red tape with all of these entities baked in. In the end, everything was purchased OOP instead.

Without DME coverage, you don't have any ammo. It's tragic.

That said, I've had Kaiser for about 10 years now. For the most part, I am a very happy user. Docs are great. I get to see specialists within a week or less.
I too don't have DME, so it's a real drag. But thanks to Obama, I will now be paying 1/3 less for an equivalent policy. I am grateful to President Obama, and the voters who came out in droves to support this important issue. The next step: single payer health care.

ps My prior experience with a major health insurance company was deplorable.

Ive overruled a major insurance company. It was about ten years ago. They denied payment on a sleep study. I had it appealed by the company that hired the major insurance company. The insurance company was overruled and they were forced to pay. I should mention the company that overruled them was and still is, self insured and that made a big difference.

Never used kaiser, Ive heard a lot of bad stuff about them. Arent they out West a lot? Kind of like one of the original HMO health insurance companies? one of the originals that started all this managed care stupidity that has led to the demand to obamacare?

I admit I hate health insurance. And admit I enjoy spending their money and sometimes, screwing with them and giving them a hard time. The reason I am like that is I feel like they are screwing around with my doctor's decisions or desires sometimes and thus, screwing with MY health. Therefore, I dont care for health insurance much.

If they all went out of business, I'd be happy.

Eric

araminta wrote: But thanks to Obama, I will now be paying 1/3 less for an equivalent policy. I am grateful to President Obama, and the voters who came out in droves to support this important issue. The next step: single payer health care.

This may get interesting.