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+--- Thread: [CPAP] Insurance Question, potentially serious (/Thread-CPAP-Insurance-Question-potentially-serious)
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Insurance Question, potentially serious - SleepyTime1 - 05-10-2023
Hi - right to the point: My insurance is supposedly paying for my CPAP machine and I'm now changing the settings on my own as of yesterday. I know they are monitoring everything - I have a Resmed Airsense 11 with cellular connectivity and everything that happens is known to everyone including the vendor and I assume the insurance company.
Does ANYONE have any reliable information about whether the insurance company is going to deny coverage to me because I'm using the clinician menu and adjusting my own settings of pressure rather than taking weeks and sleep studies and waiting for appointments and for the vendor to actually push it through from their end? I can't continue with that anymore. It was doing so poorly that I stopped using the machine for months because it was physically impossible to manage with the pressure setting I was given. Now I'm making changes and within a day I've solved a problem that I've been struggling with for ten months mostly not able to use the machine.
I HAVE to continue this way. I'm not going back to letting all this be handled in ten-minute conversations with doctors who tell me CPAP won't work because it isn't controlling the events so I need surgery when in one day I've already gotten the numbers completely to within excellent ranges by making the adjustments based on my own experience. But I have a friend who is very insistent that I'm going to create a huge problem with the insurance company over this, even run into legal problems, which I can't believe, since the machine is letting me make these adjustments so easily.
I am thinking that the prescription to get the machine is based on the law but the need to be a dumb child and let them control every aspect of it is just their preference, probably good for most people, but not the way things were going for me. So even if I have to pay for this myself I'm not going to stop. Maybe if I find the best settings and I keep them there for a while I'll ask my doctor to make that a prescription, but for the moment, they had me out in the rain unable to use the machine so the insurance probably wouldn't have paid for it anyway.
So again, as they're monitoring me and noticing these changes on their reports, is this an issue with insurance or the law? Please, if someone actually knows the answer it would be better than people just guessing. Has anyone known of a person who lost their insurance coverage for the CPAP itself or even worse over changing their own settings? Does anyone have professional knowledge of this that is definitive? My insurance is Medicare and Aetna. I know the insurance companies monitor for compliance by hours, but do they care about my changing the settings? Do they look for reasons to not pay such as this? Could it not only impact the CPAP coverage but other aspects of my insurance? My friend, a reliable, generally wise and intelligent in his concerns, is quite insistent and alarmed about this. Thank you.
RE: Insurance Question, potentially serious - Crimson Nape - 05-10-2023
Welcome to the board!
Insurance companies only care about usage. They don't, and are unable to, see if the doctor has changed your settings.
- Red
RE: Insurance Question, potentially serious - Sleeprider - 05-10-2023
Apneaboard makes the clinical manuals available to members for exactly this reason. Read the preamble https://www.apneaboard.com/adjust-cpap-pressure/change-cpap-pressure-settings-adjusting-your-machine-with-a-clinician-setup-manual
RE: Insurance Question, potentially serious - SleepyTime1 - 05-10-2023
Thank you.
No disrespect, but I'm dealing with a very persistent person - is this something you know from experience, from what you've heard, from what you know from a professional involvement? I'm not saying that if it's none of those it isn't a valuable opinion, because that's the conclusion I've reached so far from what I've read, but I'm trying to go beyond that if possible.
Again, please don't be offended. I appreciate your answering.
If I explained the ten-month process I've gone through just to get to where I did yesterday when I found the clinician's manual and started making changes, it would make clear why I'm not going back. But I'm still being pushed to not do this and I'm trying to get a solid answer from somewhere I can pretty much count on.
Such simple things have made a huge difference. I got a mask I can sleep on my side with, just the fact that the mask has the gliding wires that allow the headgear some room to slide makes that possible, and on my side/front, the entire structure that was supposedly collapsing backwards into my throat is now collapsing forward, if anything. Consequently, instead of inexorably going up to 20 every time and blowing the mask off completely, it's going up much less. Ironically, I can handle up to 20 now the way I've got the mask and my position.
I'm just amazed at how little the doctors got involved and asked specific questions. I'm stumbling into this and just getting started. I'm still only getting around two hours at a time, but that's how my sleep has been for many years. Those two hours, though, are completely different and so is waking up, something that's quickly turning back into what it was many decades ago. I forgot what it's like to wake up out of sleep.
Anyway, again, thanks.
RE: Insurance Question, potentially serious - Sleeprider - 05-11-2023
"Compliance" is a defined term. Most insurance and Medicare define compliance the the use of the device must meet or exceed 4-hours per day for 70% of the days in a 30 day period. Basically this boils down to at least 4 hours on 21 of 30 days. I am not aware of any case where compliance includes conditions pertaining to settings. Your insurance should probably have a fact-sheet available that describes the requirements to qualify for insurance reimbursement of CPAP DME.
For treatment beyond the first three months, most insurance requires:
Continued coverage documented between 31st and 91st day after initiation of therapy
1. Face-to-face clinical re-evaluation by treating physician and documentation of improved symptoms of OSA; and
2. Physician review of objective evidence of adherence (defined as use of PAP ≥4 hours per night on 70% of nights during a consecutive 30-day period) via direct download or visual inspection of usage data.
There is no requirement that the therapy be actually performed only at the prescribed settings, however you are relying on the physician to assess that your therapy is effective and resulted in improved symptoms, and that you met the compliance criteria. If your doctor is a real butt-head he could deny this finding. My bottom-line recommendation is not to use that physician. Transfer your care to a doctor , preferably non-specialist, that is there to help treat you, rather than stroking his own ego and power-trip.
RE: Insurance Question, potentially serious - Synestheat - 05-11-2023
Resolute answers of legality and potential ramifications thereof should be solicited from an attorney well-versed in the subject matter. The first piece of advice said attorney would likely proffer is to NOT post any such admission(s) to any potential violation(s) you may have ALREADY committed in a publicly-viewable forum / format. We do NOT provide medical or legal advice.
The best we can offer is our own anecdotal experience, be it personal and / or professional, reference material, and how it helped us; apparently, you place a high level of value on your friend's seemingly anecdotal, well-emoted opinion. Whether or not you try the advice proffered and whether or not it works for you is entirely within your purview.
The angst of managing the relationship with one's doctor in the field of sleep therapy is oft discussed herein. That information, and all of the other information, has been priceless to me. It enabled me to educate myself, dedicate a sufficient amount of time documenting results via OSCAR, and then walking into the doctor's office with a 2 1/2" thick binder of well-annotated sleep reports and other pertinent information that no one wanted me to even open. They simply said that I obviously did my homework, knew far more about the details than they did, and wrote the prescription for a new xPAP exactly the way I wanted it written, down to the machine that would be prescribed. I also pointed out that in the sleep study, the pressure for which they wrote the original prescription, resulted in me achieving zero Stage N3 Sleep, which is important. When I see the doctor now, they ask if I've needed to make any further adjustments and how things are going; they only ask for compliance data. With the immense help of this forum, my sleep therapy is no longer the first and foremost thing on my mind. In the past, I hoped for an anomalous good night of sleep and now I go to bed at night with surety that I shall; a bad night of sleep is rare, but I usually know exactly why it occurred. Not having to worry about the doctor's office or the insurance company anymore is certainly a major contributing factor to good sleep.
After having my new xPAP machine for a period of about 90 days, I received a call from the Durable Medical Equipment (DME) provider and they left a message that they wanted to get the data to see how well the treatment was working for me. I knew full well that they only wanted compliance data, but I took some reports as well as the data card. Kindly and firmly, when I spoke to the person at the DME, I told them I didn't appreciate them leaving me a disingenuous voice mail when they only wanted compliance data for insurance reasons. I showed them the reports for several nights of sleep and the compliance data for various lengths of time even going back years, explained what the reports meant in detail, and everyone's eyes got really big. With amazement, they responded that I knew far more about this than any of them did and they only needed compliance data showing that I actually use the new device. They've never contacted me again about getting my data.
Since it's the quality of your sleep and life that hangs in the balance, take control of it and put yourself in the best position you can to cull a beneficial relationship with your doctor or fire your current doctor and find a new one that is more amenable to helping you achieve success.
RE: Insurance Question, potentially serious - SleepyTime1 - 05-11-2023
thank you very much. And I'm going to make an adjustment. I appreciate all the detail even if I don't refer to all of it in this thank you. I'm going to read that and try to be more like you.
Again, thank you.
RE: Insurance Question, potentially serious - Gideon - 05-11-2023
The first two paragraphs raised my hackles as well. Seemed to be too legal for here.
Me, I don't know where I get some of the things I post, maybe I'm an AI
RE: Insurance Question, potentially serious - Crimson Nape - 05-11-2023
Synestheat - I'm curious, what AI site did you use to generate the base text?
- Red
RE: Insurance Question, potentially serious - Synestheat - 05-11-2023
Crimson Nape, that's funny! I got it from myownwetware.bod and I'll take that compliment any day! Thank you!