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Post by craftedbys on Sept 4, 2019 19:50:18 GMT
For the entire Health insurance industry. My frustration level is at an 11 today.
So for years I have been told I snore (Who? Me?) and that I talk in my sleep.
It has gotten worse because I have gained weight to the point of I am not getting deep sleep and have even been waking myself up from snoring or gasping for air because I stopped breathing.
So I discussed it with my primary care provider and he said I needed to have a sleep study done, especially since issues there could be contributing to and/or complicate my high blood pressure and other health issues. So he wrote the order to have me evaluated for a sleep study.
I asked about doing an in home study, but he said the results are not as accurate as the ones done in a sleep center.
So over two weeks ago I had an appointment at the sleep center. I filled out the questionnaire as honestly and as best I could given the narrow choices of answers available. Lady spent about 10 minutes or less asking me a few questions and she looked in the back of my throat.
I was told they would submit it to insurance and if approved I would have to pay $155 as my percentage of the $775 test and they would be in touch to schedule the test.
Today I get the mail. In it were 2 pieces of mail. The first was from the sleep center. A bill for my portion of the $459 consult fee (of which the insurance only paid $124).
The second was a letter from my insurance provider saying that I was being denied an in center sleep study because I didn't "meet BOTH of the following criteria" and then listed 6 different criteria as bullet points.
The next paragraph said because I am fat and have these specific issues I would have been approved for an in home study if it had been requested.
The letter was signed by an ob/gyn.
What pisses me off is that this person wasn't the one who actually reviewed my file (I used to work for a TPA and know 90% of that stuff is done by an administrative person who just checks the boxes and has little to no medical training or background.) And even if the person did look at my file, how much does an ob/gyn know about sleep disorders?
So while I was at the doctor's office today for a bp check I asked about it, and no, they can't order an in home study I would have to go back to the sleep center and go through them.
Ugh. Called the sleep center. They said they just sent the request in for an in home study today and when they hear back THEN they will call me and set up a fime for it to be sent to me via UPS.
So now I have to wait another 2 weeks or more to get anywhere. I just feel like even though we are paying out the ass to even HAVE health insurance I am being jerked around and that my care is being dictated by someone far off paper pusher who doesn't know me or my health history and has the power to override what MY DOCTOR feels is medically necessary to diagnose and treat me.
Of course my doctor wants me to avoid things that might raise my blood pressure. SMH.
If you have made it through this long winded rant thank you for letting me blow off steam.
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Deleted
Posts: 0
May 11, 2024 8:06:01 GMT
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Post by Deleted on Sept 4, 2019 19:54:38 GMT
Oh I so validate you!
It took me 4 months to get my dd's IVIg settled. She meets all criteria. Insurance approved the med. Health group decided to play games and be dick heads.
I appealed and won after hours and hours on the phone and 4 months of proof.
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Deleted
Posts: 0
May 11, 2024 8:06:01 GMT
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Post by Deleted on Sept 4, 2019 20:05:20 GMT
I find it interesting how different insurance and medical groups approve and deny.
Ds was approved for his sleep study in 4 days after being submitted.
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Post by birukitty on Sept 4, 2019 20:10:26 GMT
It's so damn frustrating, isn't it? I agree with you-and I believe there is a hell and know that all of these CEO's who are racking in tons of profits while people like you and everyone else who struggle to pay their monthly health insurance coverage and deal with this kind of shit-those CEO's are headed straight for hell when their lives end. Whenever this crap pops up for me it makes me feel better envisioning them (and everyone else at the top level responsible for this) writhing in agony in the eternal flames. How they can sleep at night is beyond me.
If you don't mind me asking what type of health insurance do you have? DH is in IT, works as a systems analyst and through the years has worked as a contractor and as an employee. Because of this we've been with several different health insurance companies through the years. We've had Cigna, Aaetna, Blue Cross/Blue Shield and a couple others I can't remember. We just finished with Cigna and are now with Blue Choice-a type of Blue Cross/Blue Shield.
What I've learned is that a lot of these requests to the insurance companies are almost always denied the first time. I would suggest calling your primary care doctor's office, letting them know it was denied and asking that they resubmit it with a letter from your doctor saying you must have this done at the sleep center. He's already told you he preferred you have it done this way. Doctors are used to this these days. That is if you want to continue to pursue (fight) this and have your sleep study done at the sleep center. Chances are it will be approved the second time.
I wish you the very best in health and that you get this approved in the manner you wish.
The health care system in the USA is unethical and deplorable. It makes me ashamed of this country.
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Post by heckofagal on Sept 4, 2019 20:12:42 GMT
I validate you and share in your pain! I’ve slept on the couch for quite a while as my DH snoring keeps me awake at night. He finally talked to his doctor about a sleep study and his primary doc referred him to a sleep lab. Insurance would only approve for at home sleep study so got the pre-approval for that and he got the equipment after several calls and much prodding. Report came back that he has sleep apnea and needs a CPAP. The company that was supposed to provide the equipment said that insurance was denying the approval. What? After pre-approval for the testing and a sleep specialist diagnosing sleep apnea? That was months ago. We are still battling.
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Post by lucyg on Sept 4, 2019 20:17:44 GMT
I validate your feelings.
This is part of the reason I appreciate so much having Kaiser. It isn’t perfect by any means, but if a doctor decides you need something, you get it. No going through those insurance roadblocks. And it never costs me more than $10-$15 for an appointment, service, treatment, or covered med. (I realize that is a function partially of my employee-sponsored coverage. Other people may have different coverage amounts.)
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breetheflea
Drama Llama
Posts: 5,903 
Location: PNW
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Post by breetheflea on Sept 4, 2019 20:20:03 GMT
DH has sleep apnea. He did the at home study. It concluded if he didn't get a CPAP he'd die (only slightly exaggerating he stops breathing 60-80 times an hour or something. I can't remember exactly but it's high.) Then there was a months long wait to actually get the machine. No hurry, or anything, it's not like he stops breathing while he sleeps. Oh wait...
Once we got the machine it has helped greatly. Getting it was the "fun" part. Hang in there!
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Post by cadoodlebug on Sept 4, 2019 20:25:53 GMT
I validate your feelings. This is part of the reason I appreciate so much having Kaiser. It isn’t perfect by any means, but if a doctor decides you need something, you get it. No going through those insurance roadblocks. And it never costs me more than $10-$15 for an appointment, service, treatment, or covered med. (I realize that is a function partially of my employee-sponsored coverage. Other people may have different coverage amounts.) This is so true. DH's dentist noticed a small white patch on the inside of his lip so DH called our Kaiser doctor and he scheduled an appointment with a dermatologist to do a biopsy within days. Turned out to be nothing but all it cost was $30. We are so glad we switched from Blue Cross to Kaiser years ago. OP, I hope you get results ~ keep fighting! |
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River
Pearl Clutcher
Posts: 3,510
Location: Alabama
Jun 26, 2014 15:26:04 GMT
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Post by River on Sept 4, 2019 20:43:06 GMT
I'm so so sorry. I know how frustrating it is dealing with insurance. I requested several times to my doctor only that I wanted the in home sleep study but he was insistent that it wasn't as good as the in hospital one and had me tour the room at the in hospital one, which was very nice and homey. After going through all that with my doctor, of course insurance denied it, they would only cover the in home test. After a ton of research and seeing the actual sleep doctor, I we decided to appeal. It got approved the 2nd time.
Why??? Just to try and save a few bucks!!! I'm glad I appealed and did the hospital one. I was able to only go through it once, after results of 3 hours they woke me and started a CPAP. We tried several types of mask and found exactly what I needed and could tolerate. I'm thankful results plus treatment was immediate. However, before I appealed I was told this could happen with in hospital test. Everything done in one night.
Good luck and I'm so sorry you have to deal with this.
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likescarrots
Pearl Clutcher
Posts: 2,879
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Post by likescarrots on Sept 4, 2019 21:00:23 GMT
I was also denied pre-approval for a sleep study by insurance and the hospital resent it. I don't know what they did to fix it but it came back approved within a day.
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quiltedbrain
Full Member
Posts: 429
Jun 26, 2014 3:34:53 GMT
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Post by quiltedbrain on Sept 4, 2019 22:54:52 GMT
First of all, I'm sorry this is happening to you. I work for a provider, and I absolutely abhor health insurance companies.
I don't know if you feel up to the battle of an appeal, but you can request that they have someone with the correct speciality review the authorization request. My advice with health insurance companies is: Be nice, but be the squeaky wheel that gets the oil. Don't take no for an answer. I swear they give in sometimes just to get me off the phone with them.
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Post by deekaye on Sept 4, 2019 23:03:36 GMT
First of all, I'm sorry this is happening to you. I work for a provider, and I absolutely abhor health insurance companies. I don't know if you feel up to the battle of an appeal, but you can request that they have someone with the correct speciality review the authorization request. My advice with health insurance companies is: Be nice, but be the squeaky wheel that gets the oil. Don't take no for an answer. I swear they give in sometimes just to get me off the phone with them. I was just about to say the same thing. Don't sit back. Jump in and be your own advocate. It's a broken system but the insurance will eventually pay if you have the "right box checked" or "the right diagnostic code included". I work in a hospital and every day we play the insurance game. Patient denied? Resubmit with more documentation, different ICD-10 codes, etc. Good luck. |
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snyder
Pearl Clutcher
Posts: 3,948
Location: Colorado
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Post by snyder on Sept 4, 2019 23:13:53 GMT
I validate your feelings. This is part of the reason I appreciate so much having Kaiser. It isn’t perfect by any means, but if a doctor decides you need something, you get it. No going through those insurance roadblocks. And it never costs me more than $10-$15 for an appointment, service, treatment, or covered med. (I realize that is a function partially of my employee-sponsored coverage. Other people may have different coverage amounts.) Oh my! I was wishing I could turn 65 so I could get on Medicare and dump Kaiser. lol I'm fighting with them now. To me, they have the most naive service reps. They can NEVER answer a question on coverage and/or costs or even tell me who is in network. I have the choice of keeping them as my supplemental or Blue Cross when I do get Medicare and was going to dump them in a heart beat because of their lack of knowledgeable personnel. Those are the two that my retirement plan offers. Maybe I should look at it again. My mom has Blue Cross and Medicare and she has absolutely no problem what-so-ever.
OP, I feel for you. I pay out the rear for my health insurance and think I should receive a whole lot better service than I receive. I'm on my 3rd appeal of my hospital bill, which isn't so much an insurance issue, but they paid the bill and won't fight in the appeal with me. The hospital padded my bill big time. Added drugs and procedures I did not receive. Keep on appealing!
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Post by crimsoncat05 on Sept 4, 2019 23:19:42 GMT
why the heck didn't they tell you the cost of the consult, first of all?!? and I'm mad for you, too. They make us jump thru hoops, like someone said, only to save a few bucks. For their shareholders. And none of it has any bearing on actual health care for us, the members.
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Post by Lexica on Sept 5, 2019 2:05:38 GMT
I validate your feelings. This is part of the reason I appreciate so much having Kaiser. It isn’t perfect by any means, but if a doctor decides you need something, you get it. No going through those insurance roadblocks. And it never costs me more than $10-$15 for an appointment, service, treatment, or covered med. (I realize that is a function partially of my employee-sponsored coverage. Other people may have different coverage amounts.) I agree, I love Kaiser. I’m going to have to switch to the Oregon Kaiser and I’m hoping they are as good as the California one. OP, until you study approval comes in, I would strongly recommend that you sleep in an elevated position so you don’t die before they decide to approve you. (I swear that is what insurance providers hope for). Can you put a wedge of some type under your mattress to elevate yourself? Sleep apnea is deadly if not treated, no joke. |
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Post by lucyg on Sept 5, 2019 3:27:59 GMT
I validate your feelings. This is part of the reason I appreciate so much having Kaiser. It isn’t perfect by any means, but if a doctor decides you need something, you get it. No going through those insurance roadblocks. And it never costs me more than $10-$15 for an appointment, service, treatment, or covered med. (I realize that is a function partially of my employee-sponsored coverage. Other people may have different coverage amounts.) Oh my! I was wishing I could turn 65 so I could get on Medicare and dump Kaiser. lol I'm fighting with them now. To me, they have the most naive service reps. They can NEVER answer a question on coverage and/or costs or even tell me who is in network. I have the choice of keeping them as my supplemental or Blue Cross when I do get Medicare and was going to dump them in a heart beat because of their lack of knowledgeable personnel. Those are the two that my retirement plan offers. Maybe I should look at it again. My mom has Blue Cross and Medicare and she has absolutely no problem what-so-ever.
OP, I feel for you. I pay out the rear for my health insurance and think I should receive a whole lot better service than I receive. I'm on my 3rd appeal of my hospital bill, which isn't so much an insurance issue, but they paid the bill and won't fight in the appeal with me. The hospital padded my bill big time. Added drugs and procedures I did not receive. Keep on appealing!
I’m sorry you’re having trouble, but honestly I don’t really understand. I’ve had Kaiser for 40 years and I’ve never had to talk to a service rep about costs or coverage, or received a hospital bill of any kind. It’s all covered, other than small co-pays at the time of service. Is there really such a wide variation in Kaiser coverage plans?  So sorry. I don’t mean to sound dismissive. I guess I am on a large group plan and that keeps the prices lower. |
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snyder
Pearl Clutcher
Posts: 3,948
Location: Colorado
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Post by snyder on Sept 5, 2019 3:42:31 GMT
Oh my! I was wishing I could turn 65 so I could get on Medicare and dump Kaiser. lol I'm fighting with them now. To me, they have the most naive service reps. They can NEVER answer a question on coverage and/or costs or even tell me who is in network. I have the choice of keeping them as my supplemental or Blue Cross when I do get Medicare and was going to dump them in a heart beat because of their lack of knowledgeable personnel. Those are the two that my retirement plan offers. Maybe I should look at it again. My mom has Blue Cross and Medicare and she has absolutely no problem what-so-ever.
OP, I feel for you. I pay out the rear for my health insurance and think I should receive a whole lot better service than I receive. I'm on my 3rd appeal of my hospital bill, which isn't so much an insurance issue, but they paid the bill and won't fight in the appeal with me. The hospital padded my bill big time. Added drugs and procedures I did not receive. Keep on appealing!
I’m sorry you’re having trouble, but honestly I don’t really understand. I’ve had Kaiser for 40 years and I’ve never had to talk to a service rep about costs or coverage, or received a hospital bill of any kind. It’s all covered, other than small co-pays at the time of service. Is there really such a wide variation in Kaiser coverage plans? So sorry. I don’t mean to sound dismissive. I guess I am on a large group plan and that keeps the prices lower. My niece has Kaiser and hers is worst than mine, but she also pays less. I too am on a large plan as I retired with local government which is part of the state government plan; teachers, police, fire, etc. I really don't have to call for prices, but this one time, I wanted to know if it was worth my while to out and out purchase something myself (cheaper than my deductible) and I was receiving very conflicting information from both Kaiser and the vendor. I received a hospital bill because besides my deductible, one has an annual out of pocket amount and I needed to pay a portion of that. As I was glancing through the bill, I noticed several things on the bill that I did not receive, but Kaiser doesn't care, they paid it anyway. To me that is so very wrong. If they pad everyone's bill and the insurance companies don't care, no wonder our premiums are so high. |
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Post by lucyg on Sept 5, 2019 5:11:03 GMT
I’m sorry you’re having trouble, but honestly I don’t really understand. I’ve had Kaiser for 40 years and I’ve never had to talk to a service rep about costs or coverage, or received a hospital bill of any kind. It’s all covered, other than small co-pays at the time of service. Is there really such a wide variation in Kaiser coverage plans? So sorry. I don’t mean to sound dismissive. I guess I am on a large group plan and that keeps the prices lower. My niece has Kaiser and hers is worst than mine, but she also pays less. I too am on a large plan as I retired with local government which is part of the state government plan; teachers, police, fire, etc. I really don't have to call for prices, but this one time, I wanted to know if it was worth my while to out and out purchase something myself (cheaper than my deductible) and I was receiving very conflicting information from both Kaiser and the vendor. I received a hospital bill because besides my deductible, one has an annual out of pocket amount and I needed to pay a portion of that. As I was glancing through the bill, I noticed several things on the bill that I did not receive, but Kaiser doesn't care, they paid it anyway. To me that is so very wrong. If they pad everyone's bill and the insurance companies don't care, no wonder our premiums are so high. oh, so it was a non-Kaiser hospital stay that Kaiser was reimbursing them for? That makes sense then. I am also on a city employee plan through CalPERS. The city treats the Kaiser rate as a baseline and pays that amount toward whatever insurance plan the employee or retiree chooses. So, if it’s Kaiser, it’s fully covered; for a higher-priced plan, the employee pays the difference. After next year, though, they will only continue to pay at 2020 rates, so our costs will start going up. I still think it’s great coverage and feel very fortunate to have it. And of course I agree it’s crazy to pay for services you never received. Our entire health care system is so nuts. |
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snyder
Pearl Clutcher
Posts: 3,948
Location: Colorado
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Post by snyder on Sept 5, 2019 21:45:29 GMT
My niece has Kaiser and hers is worst than mine, but she also pays less. I too am on a large plan as I retired with local government which is part of the state government plan; teachers, police, fire, etc. I really don't have to call for prices, but this one time, I wanted to know if it was worth my while to out and out purchase something myself (cheaper than my deductible) and I was receiving very conflicting information from both Kaiser and the vendor. I received a hospital bill because besides my deductible, one has an annual out of pocket amount and I needed to pay a portion of that. As I was glancing through the bill, I noticed several things on the bill that I did not receive, but Kaiser doesn't care, they paid it anyway. To me that is so very wrong. If they pad everyone's bill and the insurance companies don't care, no wonder our premiums are so high. oh, so it was a non-Kaiser hospital stay that Kaiser was reimbursing them for? That makes sense then. I am also on a city employee plan through CalPERS. The city treats the Kaiser rate as a baseline and pays that amount toward whatever insurance plan the employee or retiree chooses. So, if it’s Kaiser, it’s fully covered; for a higher-priced plan, the employee pays the difference. After next year, though, they will only continue to pay at 2020 rates, so our costs will start going up. I still think it’s great coverage and feel very fortunate to have it. And of course I agree it’s crazy to pay for services you never received. Our entire health care system is so nuts. My hospital stay was with an in network hospital. What I was attempting to explain was there were charges on my bill, such as duplicate anesthesiologist charges, 4 drugs I did not receive and an ultra sound that I did not have. I told Kaiser I did not receive those services and it was oh well. So they paid for stuff I did not receive and didn't care they were paying for something that they shouldn't have paid for. Another example of my aggravation with them was yesterday; since I was not getting my answers though phone calls, I messaged my question to them, explained I was given the name of 2 in network providers I could use for something I need, which, when I called them, was told they don't carry the product I need. I included in this message the name of these 2 providers and explained I still needed the name of a place I could obtain the product I needed as it is a covered expense. The return message listed the exact 2 providers I had told them didn't have what I needed. Ugh. Oh another one. I could list many. ha! I was 1 week post op and my doctor referred me to a specialized physical therapist. Couldn't get in to see them for 6 weeks, so I called Kaiser and explained the situation and wondered if they had another in network provider I could use. The reply was we don't have physical therapists in southern Colorado. What the heck. I called again, nothing. So again, I messaged the question to them. They came back with instructions on how to find providers on their website, which I had tried several times to do, but was not coming up with anything. Replied to that and told them I couldn't find anyone via the website. They told me there were 273 therapists listed and I could get on the phone and start calling each one to see if they provided the type of therapy I needed. Yeah right, what I wanted to do while recovering from major surgery. So ranted so much, but I truly understand the ops frustration and do know it is not just her that is suffering the raths of hell when dealing with them. |
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So sorry. I don’t mean to sound dismissive. I guess I am on a large group plan and that keeps the prices lower.