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Hello everyone,

I am sure everyone here has had insurance nightmares. I have a feeling that I am about to go down the nightmare road with mine....

Back in August when my primary doc referred me to the sleep doc, I found that Sleep Disorders are excluded on our insurance. I was able to get the Dr's to write a letter of Medical necessity for the sleep study. After one cancellation of the study I finally was able to get the first one done in September, with the authorization of the insurance. I knew that if I was diagnosed that I would need to get further letters of justification for treatment therapies. But hey I was just taking it one step at a time, and was happy to get the first study done. I was diagnosed the first week of September with Apnea, and had to schedule the second sleep study, which was scheduled then for this next monday.

I thought with the authorization that I recieved in August was for both sleep studies, then the next time I needed to have medical records and doc letters was after the second, with the tritaion levels and such. Also including the rental vs cost of the cpap.

Yesterday, I JUST GOT the letter of denial from the insurance for the first round of studies, and the doc consult. I was so upset. This was in the amount is about $2500 all together, that I thought would be covered at 80%. I was shocked, and called the insurance company yesterday, and the billing department at the sleep center. The sleep center said that sometimes after the insurance co authorizes, they will decline coverage. WHAT?! I was in a haze for the rest of the day. I called the insurance company, the rep said she would email the processor for further details.

After calming down last night, I started thinking I did not ask specific questions of the Insurance co. So first thing this morning, I called them again. I asked. Did you recieve the letter of medical necessity in August? They confirmed it was recieved. Then I asked, was the first consult, sleep study, and follow up appt authorized in augus?. The Rep was surprised when she found in the notes that they were to be authorized, and then all three were declined after the fact. She then emailed this info to the processor to take a look and reprocess. The rep was suppose to call me back today. I talked to her at 7AM... this morning. I called twice more today, and there was no word.

The last time I called I talked to a different rep. She looked at the notes, and started to say there was no word... Then her tone changed, and she "Strongly encourages me to call my rep early tmr morning." She even gave me her hours and extension #. I got the feeling she read something in the notes that she was not at liberty to tell me. So I am going to call the processor at 7am my time tmr morning to see what the heck is up.

I have no idea what to think. I am trying not to stress out about all of this. There is no way I can afford the first 3 apts, let alone go forward. I am so tired, that I feel like I am in a haze, then the more I think about all this, the more upset I get! I am afraid more so now that they might authorize me for the second round, and then deny it after the fact. Leaving me with $5000.00 worth of doctor bills... not included the cpap and accessories.

In the mean time I am talking to the sleep center. I have to cancel mondays sleep study, (well was suppose to cancel by today) to avoid a $300.00 cancellation fee. But they are letting me have until tomarrow to cancel.

Anyways, thank you for letting me vent. I am sure this will all pass. I am starting the think that the insurance is a legalized mafia organization... LOL just kidding... What are your thoughts on what I can do? I am trying to be diplomatic and kill them with kindness and trying to play their game... but that can only go so far... lol

Thank you,
Janey

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JANEY, MY WIFE & I STAND BY YOU 200% against the "Legalized Mafia" I don't have answers this minute, but want to pledge our support ...to get this covered on your insurance, and Sleep Apnea is a progressive deadly condition, I hope others here assist you also with the insurance logistics. Gordon(sleep apnea survivor ) & Linda( stage 2B breast cancer survivor)
My second thought is DOCUMENT EVERYTHING, if you can, save all phone messages, even get a new incoming tape. Ask for the name of whoever you talk to, write it down, time & date.
Thank you Gordan, Linda, and Cindy. I was not documenting at first, but as the day went on today I started! I have no idea why insurance companies are like this... It's not like the patients are under enough stress as it is. Let's just add to the stress by causing all of the confusion and grief. I guess I will know more when I call them first thing. If things don't go well with the insurance then I am also going to go in person tomarrow to talk to the billing department at the clinic. I hope that I might get some more help from the clinic, if I connect to them rather than be the desperate voice on the phone.
Yikes!!

Sorry to hear about all the trouble you are having!!

I know that our insurance excluded sleep studies and treatment for quite some time. I was talking to my primary care physician and she suggested I call my insurance and find out about the coverage and was delighted to find that their policy had changed to include sleep studies and treatment options. I did not experience the problems you have had with my insurance.

You shouldn't be penalized for this. In my view the insurance is in the wrong here. You got prior approval and did things "their" way. Now they should hold up to their end of the bargain!!! I agree, document and get who you talked to and when. Ask to speak to someone high up in the chain of command. Do you have copies of the approval letter? I would have copies in my hand when I talked to the reps. I know this is all a hassle, but keep pushing this issue.

I have been told that many, many times insurance companies will deny claims. This saves them money as many don't go through the appeal process and so then the insurance company does not have to pay the claim. Often you only have so many days to file an appeal. With the letter of approval you received, I think you should start the appeal process so that they don't stall you until it is too late to file an appeal.

Good luck and I hope things work out for you.
Insurance companies are evil.
Thank You everyone! I made my husband deal with the insurance this morning. They are "reprocessing" my claims... Apparently over the last 3 days and countless calls no one could tell me that their system will automatically decline out of plan claims. That each time I have sleep disorder claim I will need to wait for the denial letter, and call them to have them reprocess it. Any ways, I was worried that this would be this drawn out process with bad results...

All it took was online chat and the husband... who figures?

Take Care, and thank you for being there for me when I thought I was loosing it. =)

Janey
I really agree with you. It is astonishing to me. Isn't there a state insurance board that you can complain to?

Rock Hinkle said:
Insurance companies are evil.
if the insurance would just back off and let us do our jobs things would be so much easier. They spend more money on all of this BS redtape than they would if they just let things go. I say Phuck em. Excuse my french.
Janey, I'd encourage you to contact your state's Insurance Commissioner ASAP, before this goes any further. I know for a fact that insurance companies HATE having the State Commissioner get involved in hassling them. At least in Indiana, it's a surefire way for pressure to be brought to bear on them. State Insurance Commissioners are the watchdogs, and tend to get vigorous if people are being jerked around, particularly with a life-threatening illness.

Glad to hear you're documenting--that's critical to backing up what you report.

Hang in there. Jeez, this country is so far behind the 8-ball re: apnea--it's appalling.........

Stick with SG so you've got our support, which I guarantee you do, Janey.

Susan McCord
I live in Missouri and contacting the state insurance commissioner may or may not help. A few years ago I had major issues with our insurance carrier about some claims. At the time my husband was a Teamster. He was a trucker driver for a Mid-Mo asphalt company. The Teamster's insurance he had was union driven and administered by the union. Because "it was privately driven" the commissioner wouldn't touch it.
Well I guess there's one good thing about not having insurance! I don't have to deal with the insurance companies!
I don't recall learning that particular word in French class! Great word in ANY language.....

Rock Hinkle said:
if the insurance would just back off and let us do our jobs things would be so much easier. They spend more money on all of this BS redtape than they would if they just let things go. I say Phuck em. Excuse my french.

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