insurance route or not be insurance route - that is the question

[Tawaki]

For me...

It look a LONG time because of the sleep physician cabal in my area. There are three huge practices, and it is literally impossible to get a sleep study without going through them.

Anyway...

1 year ago in home study showed nothing.

Last October suggested I see a sleep specialist.

First available appointment was in early December.

Saw doctor.

Schedule sleep study 1/4.

Heard from office two weeks after to come in for a fitting. Got bumped up to 1/20 because I called every day for the cancel list.

Horrific fitting trial.

Heard nothing until 2/20 when I called to raise hell. From 2/20-3/16 bounced through three DME and still no machine. Usual excuses were no order, lost fax whatever...

3/16 got my machine. Love my current DME. Will be going back because I want to try nasal pillows. Have to pay out of pocket for that.

Total wait time from being to end a little over 5 months. That is total utter BS, but every other sleep doctor a lateral move. My GP wrote for order for the nasal mask/pillows.

I only have to stay with this doctor until the insurance obligation is over. Can't stand her or her cruddy techs. Will be going to the big deal university clinic, which I'm sure is a hot mess, but all pulmonary doctor works out of there. Getting this wench to send anything to him takes an act of God.
I want him to have easy access to my records.

My insurance pays for everything, so that is the sole reason I barely tolerated the whole situation.

[PollCat]

Man have things changed (for the worse) since I got my first machine in 1995! At the time of my titration, the sleep center gave me my first cpap machine and they billed my insurance company directly. Since that time, I've bought machines either directly out of my pocket, used insurance, or a combination of the two; the next purchase is going to involved Medicare.

[bronty]

Well - I have had a not so pleasant experience with my high deductible insurance plan. I have struggled with sleep issues for many years, but never was diagnosed with OSA. I am currently being treated for anxiety, panic disorder, obesity, high cholesterol and now higher levels of glucose (pre-diabetes). I happened to mention to my primary care physician that my wife noticed that I snored a lot and she ordered an overnight oximetry. I did that and.got a call back to see a sleep specialist.

So, here's my timeline and costs (my deductible is $3000)

Primary care physician visit 3/9 $72
Overnight Oximetry 3/11 $21
Initial Sleep Doctor Visit 3/25 $140
Sleep Study 4/2 $700 - ended up being a split night study
Sleep Doctor Followup 4/7 $70 - AHI 72.4 wanted me to start on cpap but said I would likely need bipap - asked for bipap - said needed to see me on auto bi pap as I didn't have enough sleep during study on bipap
Referred to DME who took 2 weeks to tell me they didn't take insurance
Called insurance company and found 1 DME that was in network that was not very far
DME Respironics System One CPAP and Wisp Mask 4/16 $980
DME called me and said Sleep Doctor wanted me to due BiPap auto titration 4/20 $unknown
Using auto bipap and love it - called sleep dr and asked for script
Said needed numbers - offered to read off from SleepyHead (that was stupid of me)
Called DME - they can't access modem on device so I downloaded Encore basic and faxed report over to sleep doctor (didn't want to bring SD to DME - I travel a lot for work)

In the end, I think I would have been better off just getting the bipap auto which I likely will end up with (but I think I will be stuck with a CPAP that I can't use)

[trailrider]

Why would the DME not rent you one for 1-6 months while you get settled in and get data for BiPAP? On the otherhand, I'm sure there are people who will happily purchase a low hour, nearly new machine. From the various posts on this board, there seem to be many looking for such machines.

(Aside, reading these insurance headache threads makes me glad I'm in a place with publicly funded healthcare.)

[Sleeprider]

Why would the DME not rent you one for 1-6 months while you get settled in and get data for BiPAP? On the otherhand, I'm sure there are people who will happily purchase a low hour, nearly new machine. From the various posts on this board, there seem to be many looking for such machines.

(Aside, reading these insurance headache threads makes me glad I'm in a place with publicly funded healthcare.)

And yet you don't have to look far to find where the wonderful Canadian system breaks down. http://www.apneaboard.com/forums/Thread-...ink-a-rant . You are an exception to the normal patient in Canada that is routinely issued the lowest level CPAP with no data, only after going through all the diagnostic hoops.

In addition to that sad story, countless threads of Canadians being unable to obtain auto machines and medically necessary bilevel and ASV, and being charged extra fees to get care are posted here weekly. The high cost of obtaining equipment in Canada and long delays for treatment and equipment is such a persistent topic, that your satisfaction is actually an anomaly exceeded only by the unavailability of a secondary (used) market to get equipment if one chooses not to go through the government insurance.

The Resmed S10 Autoset For Her is an exceptional issuance from what I have seen. You should start a thread coaching others in Canada on how to pull it off.

[trailrider]

I'm not trying to start a health policy debate. I did make a thread two months ago about experiences in Canada and walked through my experience in Ontario. http://www.apneaboard.com/forums/Thread-...rification

I know across the spectrum of health care models our two countries are polar opposites. Personally I like the Euro models better. I do not understand the US system at all: it is confusing and has considerations like in and out of network, very large ($3k) deductibles, etc. I truly find it opaque and mysterious.

In Canada you get whatever coverage your province decides to go with. Each one is different, but they also tax you differently. You can get topped up by a group (private) insurance. The Autos may be relatively new (i.e. under 5 years) at a price deemed acceptable, and you only get one machine every 5 years, which may affect why many patients don't have them (yet.) My province pays the first $750 towards any machine Rx by the doc. But the DME will only issue the Rx. So the patient and doc have a conversation about cost considerations and supplemental insurance coverage.

But ALL the diagnosis steps were paid by the province. So that part seems odd for me for US patients. Do you pay for your own ECGs and Xrays and blood tests as well? We see the doc; the doc says you need xxx test or whatever, here is the form. Go to the local private lab or facility as required, present the appropriate body part, walk out and await the results from the doc. I've never known any other way of doing this, even when I lived in the UK for a while.

So, from reading the threads on here, it appears to me that the US insurance system is convoluted and frustratingly difficult to navigate. I do not understand it.

[me50]

I'm not trying to start a health policy debate. I did make a thread two months ago about experiences in Canada and walked through my experience in Ontario. http://www.apneaboard.com/forums/Thread-...rification

I know across the spectrum of health care models our two countries are polar opposites. Personally I like the Euro models better. I do not understand the US system at all: it is confusing and has considerations like in and out of network, very large ($3k) deductibles, etc. I truly find it opaque and mysterious.

In Canada you get whatever coverage your province decides to go with. Each one is different, but they also tax you differently. You can get topped up by a group (private) insurance. The Autos may be relatively new (i.e. under 5 years) at a price deemed acceptable, and you only get one machine every 5 years, which may affect why many patients don't have them (yet.) My province pays the first $750 towards any machine Rx by the doc. But the DME will only issue the Rx. So the patient and doc have a conversation about cost considerations and supplemental insurance coverage.

But ALL the diagnosis steps were paid by the province. So that part seems odd for me for US patients. Do you pay for your own ECGs and Xrays and blood tests as well? We see the doc; the doc says you need xxx test or whatever, here is the form. Go to the local private lab or facility as required, present the appropriate body part, walk out and await the results from the doc. I've never known any other way of doing this, even when I lived in the UK for a while.

So, from reading the threads on here, it appears to me that the US insurance system is convoluted and frustratingly difficult to navigate. I do not understand it.

I think it is what we are used to. Not everyone has huge deductibles. I don't have any deductibles for my machine/supplies. With my insurance, my machine/humidifier cost less than a total of $500 where I was only responsible for less than $250 over 13 months. The year before, my machine and supplies were paid at 100% by my insurance company.

I am a little confused about Canadian ways. I had a friend that told me that if it was an emergency (like heart attack, cancer, etc.) you get in fast but if it isn't deemed an emergency, the wait can be long.

[Mark Douglas]

I'm trying to avoid a political discussions but seems where it is going and since it is my thread
.
The reason our health is an absolute mess and getting messier everyday simple - gvt interference.
Why else would a box with a little blower and a few cents worth of electronics cost a thousand dollars?
It is easy to document how and when this started.
If gvt is going to ration healthcare why not gvt ctl of everything? Mark just be quiet!

[Doc J]

I saw my regular Doc and set up a full on sleep test for a month away. Three days before that I got a bad cold so I couldn't take test, so they set up for another month. Finally test was taken with same results as my video recording had shown. A week later got my auto machine (but is was 3B medical non recording brick for the same price as a good one would have cost). Full face mask was my nightmare but I kept up treatment. I was out $1400 after deductible and copay.
Since then I have bought Resmed S9 autoset used (low hours) and bought my own P10 pillows that I love. I have boycott my DME out of spite I think. I use my equipment every night and monitor on cpu and adjust accordingly. I wish I would have done my homework during those two months of agony. Given that knowledge I would have gone it alone in a second. Every case is different so I can't say how you should go, but good luck as long as you do something. Therapy is rough on some people you may have to try several masks and tough it out in the beginning but it is worth it. I hope your sleep improves soon.

[Sleeprider]

....
So, from reading the threads on here, it appears to me that the US insurance system is convoluted and frustratingly difficult to navigate. I do not understand it.

I think our medical care is pretty straight-forward until we get into the CPAP related DME stuff. If you're critically sick or injured, you go to an emergency room and will be treated. The amount that is paid in deductible and copay is part of your contract for insurance, and should be no surprise. Most people can see their doctor for a wellness physical or routine care and costs are pretty reasonable. Prescription drugs are usually able to be purchased at reasonable cost and a co-pay may apply.

So when it comes to sleep disordered breathing we get into a complex arena where there are more confusing relationships and a lot of mechanisms that restrict access to equipment and seem to make getting CPAP therapy much more expensive than it should be. DMEs are incentivized to dispense the cheapest equipment possible, even though the cost of much better equipment is not a lot more.

It's not so confusing, but it is loaded with uncertainty because the diagnosis, prescription and dispensing of equipment is handled between doctors, clinicians and DMEs, and the patient has relatively little power unless they are very well informed and very assertive. I think it is the effort to educate new CPAP patients and give them some control that may make our system seem confusing or adversarial.