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

[Mark Douglas]

This morning awoke feeling like I had done several rounds with Sugar Ray. Made coffee and packed momma a lunch and sent her to work and I crashed on the couch until 11am. Feeling ate up with guilt as she goes off to work and I'm a couch potato...

So here I sit in the parking lot of a walk-in cash sales PAP shop that is also on the supplier list. I can do their home study for $195 Monday and have a machine Thursday or Friday same week and be on the road to better health.

For those who got their machine via insurance how long did it take until you were satisfied with the equipment you eventually settled upon.

I guess I'm asking on average how long does it take to run the insurance gauntlet?

I am useless at this point.

Question #2

Have you successfully filed a claim for reimbursement for a PAP machine?

No doubt I could search here for the info but there is that ADD thing. Oh that thread is shiny which leads to the next shiny thread and before I know it the day is over and I have learned much and accomplished nothing concrete.

[DariaVader]

It took me a while to get the sleep doc visit scheduled... but once I had that the ball rolled well...

• Oct 6 - Consult with sleep doc
  
• Oct 13 - home sleep study
  
• Oct 18 - report on home sleep study
  
• Nov 8 - DME appt - walked away with S9 Autoset and a mask of my choice
  
• Dec 8 - changed mask to P10 which I am still using
  

My husband skipped past the consult and went straight to the home study... Waiting for his results

[Sleeprider]

I got mine in 2008, but the progression was January appointment to see doctor, raised issue of snoring and fatigue (my wife had started sleeping in another room), Referral to clinic sleep study which was completed in early April, referral to ENT to rule out physiologic issues also in April, Sleep apnea diagnostic and APAP prescription received in mid May, referral to Apria in May, started CPAP in early June.

It took 5-1/2-months and I did not have a titration study due to my intolerance of the sleep study. Back then, I paid $150 for Encoreviewer software and a card reader so I could do what you can do free with Sleepyhead today.

As an aside, I joined a forum and asked all the newby questions back in May, 2008, and the funny thing is, the same questions are asked all the time by new members today. It's a stressful and anxious time looking forward to starting therapy for a problem you KNOW you have and want to resolve, yet not knowing what machine you'll be granted, and all the uncertainty with insurance, DMEs and doctors that are out of your control. My first CPAP was fully covered by insurance and that's the route I went. I have since purchased everything out of of pocket because it's not worth it to me to "ask permission" to get what I need to feel better. The equipment delivery system today (and then) is a mess.

[Terry]

If I had to do it over, I'd do the home study and buy a machine for cash. It's easier, faster and not much more expensive. Maybe even less expensive.

As far as insurance goes, my insurance company won't pay a dime if I don't use one of their "approved" vendors.

[DariaVader]

I should add that for me, it is a no brainer, since Insurance covers 100% DME as long as it is in network. What is really frustrating though is *nowhere* do they have a guide on what they consider acceptable costs, procedures, or equipment! Irritating as H E double hockeysticks!

[worn_out_in_lebanon]

If I had to do it over, I'd do the home study and buy a machine for cash. It's easier, faster and not much more expensive. Maybe even less expensive.

This is exactly what I did.

Well I did a pre-test with a recording oximeter first, showed it to my doc, then got the home study.

Placed the order online for the apap, sent the rx as soon as I got it from the doc, and it shipped the same day.

The first appointment with the doc was Feb 23 and I had the apap in my hands Mar 16.

$250 for the sleep study.
$875 for the apap.
$149 for the ffm.
I have a $3k deductible, so insurance wasn't going to pay anything anyway.

One month on the apap now, and I'm at around 1.x AHI, vs. 39 untreated.

I have the machine I want and I got it relatively fast. After I realized what was happening to me, I was not willing to wait any longer than I had to.

[Mr. Van Winkle]

About 3 months of _ell waiting, every move I made I had to wait 3 weeks in between, but I went with the insurance route .... copays are bad enough if you know what I mean....
Good Luck

[OpalRose]

WAIT,WAIT,WAIT!
Between regular doctor, Pulmonologist, two sleep studies, waiting for tests to be read,
Waiting some more for Pulmonologist to write script.
Waiting some more for it to be sent to DME.
Waited for DME to call and make an appointment with them for mask fitting and machine.
About 5 months total!
But in the end, I went with my insurance coverage. I put up with all the waiting and anxiety because I have a low deductible.

[PaulaO2]

I have US Medicare. Took about 3 months I think. When I got the second one after 6 yrs, I think it took another two months or more.

It really depends on your deductible, if you have one. If you like your insurance and you feel you will get the right one, then use your insurance. If you have a high deductible (more than say $800), then pay out of pocket from Supplier #2.

[SaldusMiegas]

Here's my experience: 17 days with insurance

March 24 Family Doc suggested a sleep study
March 26 Appointment with Sleep Center Doctor
March 26 Sleep study part 1 in the lab
March 31 Sleep Study part 2 titration in the lab
April 2 Met with Sleep Center Doctor to review results
April 7 DME has the prescription and approval from insurance
April 10 Met the local in-network DME and purchased a machine

That was only 17 days from start to finish. May have helped that I was seeing the doc for months prior ruling out other things, so insurance probably had all the historical data they needed to make quick decisions. Also the docs were on the ball calling and coordinating insurance approvals.

Our insurance coverage is 80% of contracted rates for DME and supplies in-network, and 50% of reasonable and customary for out of network. Deductible (and out of pocket max) was already met so buying through the insurance was a no-brainer for us.

Also, felt fortunate that ins allowed us to pick out the machine we wanted and purchase it without a rent-for-compliance period.

I'm not sure about the question of how long until you settled on the equipment you were satisfied with.

- If you mean the machine .. In my case I'm sort of stuck with the machine I picked but I feel very good about what we bought (ResMed S10 Auto CPAP) based on what I learned here before ever meeting the DME. My prescription is fixed 10cm but I chose an auto machine based on advice I read here.

- If you mean the face mask.. the jury is still out. I opted for a F10 and after 4 nights I'm still trying to figure out how to adjust it properly and find a comfortable sleep position without massive air leaks.

First two nights I was uncomfortable from the air pressure but only had small leaks. I am getting accustomed to the air pressure but third night saw moderate leaks, and last night was off the charts. ResMed's eye in the sky is sending me emails an hour after I wake up each day with clever stuff like: Hey, bet you woke up with a dry mouth! Maybe you need to talk to someone about leaks.

Believe me I am not complaining... I don't feel wonderful yet but better is a good start and I get through the day without a nap.

saldus miegas