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insurance advice for denied CPAP claims
#1
I hope no one else has been through troubles with their insurance relating to OSA and CPAP, but if anyone has I am feeling your pain. Way back in June when I joined here I think I went on a rant about how it took me 6 months of fighting to get my titration study authorized. Well, now they're denying my reimbursement claim for the CPAP equipment and it's getting difficult to keep my cool. I'm honestly tired.

When I was purchasing my CPAP equipment, I had called my insurance and asked them if I could file a claim for equipment that I buy myself online. The service rep. thought it was odd, but I explained to her that I would be saving both of us money by doing so. I gave her a quote and she seemed shocked at the difference in price between what I could get an S9 AutoSet for vs. what insurance (and ultimately me through my high deductibles) would pay the DME for a generic CPAP device. Long story short she agreed and sent me an insurance claim form that I could fill out.

So I filled it out and sent it in. They sat on it for a couple weeks in "pending" state and I just noticed that it's been denied.

What am I doing wrong? Dont-know Would they have been more willing to pay the higher price? By not helping me to treat my OSA are they hoping that I develop more problems and become more expensive to insure (or even uninsurable)?

Appreciate any advice, or your own experiences. In the meantime it looks like I'll be playing phone tag again.
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#2
I had a similar experience, but mine involved Medicare and my insurance company in the mix. In the end, Medicare paid nothing for the S9 and the insurance company paid half. I was too tired to argue with Medicare to get them to pay their share of the machine and paid the other half myself. Six months later, Medicare denied my claim for a new CPAP mask, saying there was no evidence on file showing I had any CPAP equipment.
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#3
Get the name, direct phone number/extension and e-mail address of 1 rep and stick with that one if possible.

The big question: Why did they deny the claim?

They will have to answer that one; but, here are some possibilities:

1) Medical Necessity - Did you send/e-mail/fax them a copy of the Rx? They say they need a note from Doc. confirming medical necessity. My insurance accepted a copy of my Rx as long as it had "Dx Apnea" and "Rx CPAP" on it.

2) Codes - Man, these insurance companies are obsessed with these codes like they were TPS Reports or something. Make sure you have the right ones, in the right places - as well as the right code for the Dx of apnea and that it is in the right place.

3) Sometimes insurance companies deny claims whenever they find any little fault with the paperwork just because it often works. Believe it or not, a lot of people just give up and eat the cost. A couple calls and reminders that one of their reps agreed to pay the claim might convince them that you aren't just going to go away.

Whenever you talk to one of them, take down the name, direct number or extension (if they'll give it), date & time - make sure they know you are taking it down (i.e. "How do you spell that name?).

Cheer up!

Dealing with an insurance company isn't any harder than buying a used car from a televangelist named after a state.



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#4
I can get their name, but that's it. They do not give direct phone numbers or extensions, so every time I call the 800- number it's a lottery for which rep I'll get. When I ask for the rep that I spoke to last time, they are quick to point out that they can assist me and then put me on hold while they read the notes on my file (you know, the ones that say "run like hell").

I attached my prescription with the claim form which also has the diagnosis code on it. I also sent the invoice from the online supplier, and used the Tax ID that they supplied. Yep, I used the right codes. Actually, they were given to me by the CPAP supplier and I saw that my insurance company processed the codes and figured out what the disbursements would be. Here's the funny part... it looks like they might accept the mask, tube and humidifier, but not the main flow generator! That code got denied with reason "service not authorized." Oh-jeez

What in God's name would they have me do with a mask and humidifier without a flow generator?! Laugh-a-lot

Supposedly there is a nurse on staff there that looks at these and makes the decision about whether or not something is medically necessary...
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#5
Sorry your having such a problem as if having sleep apnea isn't enough. Is it possible they don't want to pay for the expensive S9?. I know you saved them more money than they would have paid but maybe they don't look at it that way. Maybe they wont pay for what they consider to be an over the top machine?
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#6
Hi Eddie, you might be right... maybe that's what crossed someone's mind, in which case I'm even more annoyed that they don't look at the data.

Insurance pays $x amount to a DME for any CPAP device that falls under a certain code, E0601 (and the S9 is one of those). They presumably don't care what machine it is since they pay a flat rate by code.

I'm going to call them again tomorrow to see what happened but I think I'm not going to go down the rabbit hole if they aren't being helpful. The main reason I'm doing this is just to fill out my deductible for the year, but it renews in December anyway. It wouldn't be a huge loss. At most I would get a few dollars back to put toward a mask. The thing that boils my blood is that it's been a struggle since day 1 to get anything done related to my diagnosis and treatment, and I have no confidence that they're going to hold up their end of the deal in the future.
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#7
Don't give up. Don't give the b------s the satisfaction. A normal person would thing they would be happy to have a patient taking responsibility for their own wellbeing ESPECIALLY when it's saving them MONEY.

I have an appointment with my DR on 9/10 to get my latest sleep study results from 8/9 (seems like foreaver). I will be fighting the battle for a new machine so I expect to be in the same boat as you are now.
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#8
(08-26-2013, 11:22 PM)Eddie702 Wrote: I have an appointment with my DR on 9/10 to get my latest sleep study results from 8/9 (seems like foreaver). I will be fighting the battle for a new machine so I expect to be in the same boat as you are now.

Good luck, I hope you get approved on the first try. I think most folks do, just something isn't lining up for me right now. If your policy makes it cheap enough for you to go through a local DME, that might be a good way to go as long as you get the machine that meets your needs and not what they want to give you. Let the DME handle the claims process.
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#9
I'm in Australia and went to make a claim (with BUPA) yesterday for a Resmed S9 Autoset I purchased from the USA. They denied the claim. The reason is that it was "purchased from overseas". I said but it was made here in Sydney, shipped to USA and I bought it from USA. Made no difference. $1100 with mask from USA, $2600 from local supplier.
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#10
(08-26-2013, 08:22 PM)Paptillian Wrote: Way back in June when I joined here I think I went on a rant about how it took me 6 months of fighting to get my titration study authorized. Well, now they're denying my reimbursement claim for the CPAP equipment and it's getting difficult to keep my cool.

Hi Paptillian,

There will be a formal, written appeal process. You may be able to get a customer service rep to help you by filling out the form while you are on the phone, but somehow a formal appeal needs to be written up and submitted within a certain amount of time (a month?) after the initial denial of the claim. In the US, there will be two levels of appeal. The first appeal will be internal to the insurance company; it will formally reconsider the claim. If the claim is again denied after the internal formal appeal, you can appeal again. The second formal appeal will involve both the insurance company and a State (government) review agency of some type. I've heard State review agencies sometimes have a bias toward siding with the patient, so it is certainly worth the extra effort to submit the second formal appeal.

So don't give up, and certainly don't just talk to them and have them write notations into your file. Get them to help you start the formal written appeal process.

Good luck and take care.

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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