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Compliance too good? Insurance Company denial letter
#1
Compliance too good? Insurance Company denial letter
FYI: I found this on Reddit and hadn't heard this one before.


Compliance too good? Insurance Company letter


My insurance company sent me a letter saying that they had looked at my compliance data since I started using the machine in June 2018 and due to the fact that the average AHI of the entire time period is less than 0.8 after June 2021 they will no longer cover me for OSA which means I will no longer be able to get supplies.
There is a phone number my doctor can call to speak with the Medical Director.
Has anyone been penalized for their compliance being "too good"?

UPDATE: Sent my Doctor a message through the patient portal and he responded saying that he has received many of these letters since the first of the year from my insurance company. He said they are hoping people will not appeal and just go along with it. He said every single appeal he has filed has been approved the same day without any questions. He will file first thing Monday morning and expects the appeal to be granted before noon.
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#2
RE: Compliance too good? Insurance Company denial letter
What a terrible insurance company!  It makes me mad that they will no doubt manage to scare away enough people who really need pap therapy, especially older people, just in order to save themselves a lot of money.  I consider that abuse.
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#3
RE: Compliance too good? Insurance Company denial letter
(03-29-2021, 12:33 AM)Deborah K. Wrote: What a terrible insurance company!  It makes me mad that they will no doubt manage to scare away enough people who really need pap therapy, especially older people, just in order to save themselves a lot of money.  I consider that abuse.

Of course, it's perfectly legal. You and I may consider it abuse, but insurance companies are in business for profit, and patient benefit is important only if they can pay enough advertising to overcome patient discontent. There is an argument here in favor of a government national health plan, nut in my view such programs mostly just shift the villain from private insurance to the bureaucracy.
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#4
RE: Compliance too good? Insurance Company denial letter
Interesting. Coverage denial because CPAP does what it's supposed to do, treat Apnea. With that mentality, medications shouldn't be issued because they work. Speaking of medications, I think some wacko in that insurance company isn't taking theirs.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: Compliance too good? Insurance Company denial letter
Computer says "No"
Sleep-well
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#6
RE: Compliance too good? Insurance Company denial letter
(03-28-2021, 09:27 PM)Gideon Wrote: ...

My insurance company sent me a letter saying that they had looked at my compliance data since I started using the machine in June 2018 and due to the fact that the average AHI of the entire time period is less than 0.8 after June 2021 they will no longer cover me for OSA which means I will no longer be able to get supplies.
...

Car runs so well on gasoline that it must not be added to the tank any more.

Babies fed breast milk thrive, which means mothers shouldn't be doing that to their kids if they love them.

Patients whose heart function improves with a fitness regimen should stop purchasing running gear.  Oh, and stop running as well.
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#7
RE: Compliance too good? Insurance Company denial letter
I get better when I do that.
Insurance: then stop doing that.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#8
RE: Compliance too good? Insurance Company denial letter
Some insurance is a contract between you and the insurance company. You pay a premium for a certain level of coverage. Your contract should be clear, but always subject to some fine print terms and conditions.
Some insurance is provided through an employer sponsored plan, where the insurance company is just the administrator and gets reimbursed on a cost plus basis. If the employer is facing some financial difficulties for any reason, they may instruct the insurance company to try and reduce their (the employers) cost.

Physicians Can Do More
My initial diagnosis was based on 2 nights of level 1 polysomnography in a laboratory. Since then, every test has been using some form of external therapy. Why are of physicians not providing us with a sleep study that confirms our untreated condition to support equipment renewal? Why don't the insurers insist on getting an untreated and treated comparison report? To me this is reasonable, easy, and provides accountability to the whomever is paying the bill.  

Patients Can Do More
If you follow the manufacturer's guidelines, annual maintenance cost of your circuit is obscenely high. Especially when all you have to do is call your local provider, pick up the part, never pay a dime. Because it is medical equipment, the insurers go along with the manufacturers recommend maintenance schedule. I mean really - replace the silicone cushions every 3 months, then the entire mask every 6 months. Some might need this but many do not.
Fortunately my body chemistry is not that corrosive and I have relied on Dial antibacterial soap and a reasonably cleaning schedule, and a run to fail approach. I have never had an equipment failure. I was not as diligent with my first CPAP. I was using distilled water and while on a road trip noticed the passover humidifier had developed a "film" inside. I washed everything thoroughly with Dial, dumped the distilled water and used regular tap water ever since. These new mask assembly appear to made from lexan or similar. Other than the silicone seals, they can standup to a lot of wear. In my case the silicone seals have always lasted more than a year. 

Don
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#9
RE: Compliance too good? Insurance Company denial letter
(03-28-2021, 09:27 PM)Gideon Wrote: My insurance company sent me a letter saying that they had looked at my compliance data since I started using the machine in June 2018 and due to the fact that the average AHI of the entire time period is less than 0.8 after June 2021 they will no longer cover me for OSA which means I will no longer be able to get supplies.

Compliance has nothing to do with AHI. It seems some new-hire at the insurance company is confused.

Compliance is how much you use your machine. The typical minimum needed to satisfy compliance requirements is 4 hours a night for 22 out of every 30 days. Of course, using it more than that is even better. Personally, I use mine 30 out of every 30 days, for at least 8 hours each night.

AHI, on the other hand, is a measure of the severity of sleep apnea. Typically you need a AHI of at least 5 to get a machine through insurance. The machine is supposed to lower the severity of your sleep apnea, and in this case it's been lowered to 0.8. If you stop using the machine the AHI will go right back up to what it was before you started using the machine. It's a therapy, not a cure.
Sleepster

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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#10
RE: Compliance too good? Insurance Company denial letter
but... but... but...
It's innately obvious that if your AHI is 0.8 that your apnea is CURED. Therefore you have no further need for a CPAP machine. Thus we have no need nor reason to cover you for this malady.

but... but... but...
Sarcastic Mode off.
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