(07-15-2012, 04:30 PM)Winkler3 Wrote: Hi Everyone,
I have recently been diagnosed with OSA.
After 2 weeks of waiting for the authorization, I just got a letter from my insurance co.
They are denying authorization for the auto pap that my sleep Dr. prescribed (I talked him into it).
The letter stated that I have to fail on a regular CPAP machine before they will authorize an auto pap.
This seems funny, because they pay by the code and both the CPAP and APAP use the same code.
Has anyone else ran into this?
Any advise would be appreciated.
I certainly do not know this for a fact, but my bet is that your DME Provider is the one that talked the insurance company out of providing you with the APAP.
When I got my 2nd machine almost 9 years ago, I was replacing it because my 1st machine was broken (but fixable) & I had it for 5 years (almost to the day).
Since I was replacing my machine anyway & I did NOT like my DME Provider, I decided to try to deal with another provider.
I had already talked to my insurance company & they had agreed that although my 1st machine could be fixed, it was already 5 years only & it could die at any point. So spending money for repairs on a 5 year old machine just did not make sense (both to me & to my insurance company).
About a day later, the DME Provider called me & said that my insurance had refused to get me a new machine & that I would have to have the old one repaired. The DME provider had convinced a 2nd person at my insurance company of that.
So, I called my insurance company, talked to yet a 3rd person who aggreed with the 1st person & said she would contact the DME Provider & that I could in fact get a new machine.
Another day goes by & I get another call from my DME Provider.
She had convinced a 4th person at my insurance company not to give me a new machine.
So, I went back to my previous DME Provider & got my new machine the very next day.
You know - A bad DME Provider can look a lot better when compared to a really bad one.
About a week later, the owner of that 2nd DME Provider called me to ask why I had decided not to deal with them.
I told him the entire story.
He said he would check it out & call me back.
He did call me back & said that ex-employee was just plain wrong.
He offered me a hefty discount on a new machine.
He understood the ramifications of not satisfying an insured in a self-insured plan of over 10,000 people in a city of only 300,000.
But unfortunately I already had a new machine & certainly was not going to start that process all over again.
The owner of the 2nd DME Provider was lucky because I had not even bothered reporting that problem either to the insurance company or the insurance committee of the self-insured plan.
Although it is a self-insured plan, it is administered by Blue Cross / Blue Shield & BC/BS does provide catastrophic coverage over $ ??
Moral of this story is:
Even if your DME Provider says they have your best interest in mind in everything they do - Trust, but verify !