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Advise please - navigating US health system for a sleep study
#1
I am asking for advise on behalf of my young Australian son who has recently started working in California on a long-term visa, and who needs a sleep study for likely familial OSA (he'd be 3rd generation).

To us the US health system is a complete mystery. He has high-deductable employer sponsored health cover (which doesn't appear to cover sleep studies anyway) and pays into a health savings account.

What is the best way for him to proceed, given he is likely to have to pay all costs out of pocket? I am advising him to get an in-hospital study, rather than a home study, but cost might dictate that one way or another. From an Aussie perspective, since a simple visit to a US doc amazingly costs over USD130, I imagine this could easily run into many thousands of dollars? The saving grace I guess it that then the CPAP gear itself (if he needs it) will be a lot cheaper than in Aus.
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#2
getting a home study is much more economical, and then he can pick up a machine anywhere, once he's got a rx, though used ones are FAR cheaper, and then he can take advantage of the knowledge here to maximize the effectiveness of his treatment.
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#3
Just because he has high deductible insurance doesn't mean the insurance company does not have a contracted rate for a service.
So, he may choose to contact his insurance to see what they pay; and if approval is needed.

It may work that the provider gets paid nothing by insurance; but has to abide by a lower reimbursement schedule worked out by a contract with the insurer.
(And, that amount counts toward annual deductible.)
Then, the provider is paid out of the HSA.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
G'day Carbon. You know it might actually be cheaper for him to come back to Oz for the test, (depending on circumstances). My sleep test in a hospital facility cost nothing at all out of pocket - between Medicare and Medibank Private the entire cost was covered. I assume he still has Medicare coverage - is he eligible to use your family private cover? If so, it's worth checking out. (And he gets a trip home).
DeepBreathing
Apnea Board Moderator
www.ApneaBoard.com


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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
He needs to have the sleep study pre-appoved (pre-authorized). That will both ensure it is paid for by the insurance and will let him determine what his part of the cost will be. Sadly our healthcare system is mostly broken compared with the rest of the world. Things you take for granted will not necessarily be covered. He needs to ask every single step of the way "what is my cost" and NEVER take, "we don't know" as an answer. Having anything done without a written statement of his cost is basically signing a blank check for them to charge him anything they want, and legally he will be responsible for paying the bills, when they start showing up a couple months later.

Question everything, trust no-one.
I am not a Medical professional and I don't play one on the internet.
Started CPAP Therapy April 5, 2016
I'd Rather Be Sleeping
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#6
(05-21-2016, 07:58 PM)justMongo Wrote: Just because he has high deductible insurance doesn't mean the insurance company does not have a contracted rate for a service.
So, he may choose to contact his insurance to see what they pay; and if approval is needed.


On most insurance plans, the insurance company's contracted rate only applies if he goes to an in-network provider. He will have to pay the full cost if he goes to an out-of-network provider. Each insurance company's in-network providers are different, and it can even vary by each health insurance policy.
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#7
So this was my path:
1. had my regular doctor refer me for a sleep study (required for insurance)
2. the sleep study in the lab run by the sleep doctor was billed to insurance at $3,800
3. had to meet with the sleep doctor before and after the test

The good news is that even a dentist can write a script for a machine and he could just buy one from most of the supplier on the supplier list at the top of the page and post the data here to find out the results and what to set the machine for if he needs it.

My out of pocket was already fulfilled from other things so all this cost me nothing. If I had to pay out of pocket and knowing what I know now, I would have just seen my dentist.
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#8
I concur with Deepbreathing. When he comes back for a visit, get a bulk billed sleep study done with someone like SNORE Australia. With the current exchange rate this might financially be the best way to go.
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#9
If he is young and has a high deductible plan, it is best if he calls around and asks for a 'cash rate'. Most sleep labs will be happy to do a full night split sleep study for ~$700 in SF Bay Area.

If he has plain vanilla OSA then a home sleep study may be better. That should be ~$150.
Started APAP 4-20, Closed range to 7.5-14, then straight 8.0 w/ Aflex 3
RDI always below 1. But sleep much much better at straight pressure.
Started on F10, Tried Quattro Air successfully. Finally settled on P10.
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#10
I'm reading all these replies and wondering if Carbon is feeling as confused as I am. Smile

Seriously, though, "confused" is pretty much the typical state of mind when using the US health care system, and what Frank said about asking the cost of every single service is excellent advice.

If you really think he needs to have an official sleep study, Carbon, then I'd agree with the person who suggested calling around and asking for a cash price.

He can check with his insurance provider to be sure, but my experience with health insurance has been that the contracted insurance rate doesn't apply to anything until after you've met the deductible.

If he does decide to do a formal sleep study, be sure to find out how many doctor's visits will be required along with it (I'd think one before and one after the study) and if those will be discounted as well. If they aren't, an initial visit to a specialist is often $250-$350, and the follow-up to get the results of the study is also a longer (more expensive) visit than typical doctor's visits.

Going the sleep study route will give him access to a sleep doctor which can be helpful. (I had two sleep studies and they were billed at around $1,000 each, which was actually much cheaper than I would have expected.)

The least expensive and simplest route would be to get a primary care doctor or dentist to write a prescription and just buy an APAP and mask online and do his own titration. That will leave him without access to a sleep specialist, though, and he also won't have a respiratory therapist at a DME to help him with mask fitting.

Oh - I have seen on some of the online suppliers' pages that they sell home sleep studies that a doctor (or facsimile) will review and then write a prescription for the machine.

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