Yeah try importing a CPAP from the states into Vietnam if you want a real adventure.<p>A $650 cpap machine costs well over $2K here. So I thought I'd import one. Apparently you need a prescription in the states? Ok, get a "prescription" from an online service that basically just asks you if you snore over a video call. Amazing.<p>Buy machine and have it sent to a freight forwarding service. They fuck up the paperwork.<p>It gets held in Vietnamese customs for almost 4 months. Go down to customs once a week to argue with the guy. One week you can't have it because it looks used. It doesn't look used.<p>Next week you can't have it because they think I'm importing to resell it. Yes it's a very hot market right now.<p>Repeat same processes with different people next successive weeks.<p>Finally someone says to bring prescription. But they don't write prescriptions for CPAPs here. A lot of hand waving when you tell them that. Go back to cardiologist who told me to get the CPAP and ask for a prescription. Oh no, he says, we don't write prescriptions for that. Can you write a letter saying that you don't write prescriptions and that I need the machine? Oh no, he says, I can't do that.<p>A couple of weeks later finally get someone at customs to agree that my sleep apnea test is proof enough. Bring the test in. Nobody looks at it. They still release the machine to me.<p>I would still take this random bureaucracy over American insurance any day of the week though.
Please folks remember that it isn't compulsory to use a companies byzantine process.<p>Instead, check your insurance policy wording that you are covered, spend the money on a new machine, send a single letter to the insurer asking to be reimbursed, and when they don't reimburse within 30 days file in small claims court.<p>They'll pay. They don't want to physically show up in court or have you send bailiffs to their HQ over $3000 that they probably owe you anyway.
"Compliance" is the other half of the US insurance nightmare with CPAP. Often insurers demand access to logs of the machine to verify you are actually using it before they will reimburse you. CPAP machines have an elaborate tamper-proof logging mechanism including a cellular modem for data uploads outside your control. Largely to enable surveillance by US insurance companies.<p>In addition to the surveillance being offensive and intrusive it also harms sleep apnea treatment. Some half of people who need a CPAP find they have a hard time learning to use it, difficulty sleeping with the mask on. It's mostly a psychological problem and one stressor for it is the fear that if they can't get it to work then they will be on the hook for $$$$. So they have a harder time sleeping and give up on the CPAP. It's hideous.<p>All that being said, CPAP can be life-changing if you have sleep apnea. If you suspect you have a problem breathing while you're asleep please talk to a doctor about it. CPAP works well for a lot of people but there are other treatment options too.
I've worked on the claims management process flow for payer like Anthem before. It's probably obvious, but this story hints at some serious deficiencies in the backend processes.<p>One way to look at it is that this Byzantine process helps Anthem by trapping valid claims in a black hole of bureaucracy. That way they don't need to pay, right?<p>It's not quite that simple. It's true that incentives are not usually aligned, but in reality the payment P&L impact is often far away from the claims processing administrative decisions. At many payers (like Anthem), the ultimate 'payer' for most of the cost may not actually be Anthem. They may be the third-party administrator charging back to an employer, or the Federal government. Even if it is Anthem, the owner of the cost center for this broken administrative process is almost certainly removed from whomever runs the actuarial accounting to decide what kinds of services to cover and how much to charge customers (except, as the author found, once they unite at the level of the CEO).<p>Ultimately for Anthem, this claim cost them a lot more to handle than if they had just paid out in the first place - even if they were the ultimate payer. Consider how much time the author spent on the phone with customer service representatives. Many of those were almost certainly contracted out and charged to Anthem by the minute. Then consider the claims processing backend, also likely contracted through third-party claims processing and management systems. It would have been simpler to manage the first one straight through.<p>Usually what it comes down to is that it is hard to estimate the ROI for investing in fixing a problem like this, because the benefits are spread out over many small cases. One way to prove it out is to highlight some of those small cases so that payers feel the pain and recognize the need for change. Thus, I am glad the author published this complete story.
I use Kaiser Permanente as my health care provider. For those who aren't aware, it's one of the few "integrated care" providers in the U.S., meaning they act as both the health insurance and health care provider.<p>Now, Kaiser is FAR from perfect - they have their share of problems.<p>But....this sort of nightmare is not one of them. With Kaiser, doctors are free to prescribe whatever they think is medically necessary, and if they prescribe it, it's covered, guaranteed. There's no separate claims department.<p>Obviously there are some exceptions, like if it's an emergency and you need to get care outside of Kaiser and then submit a claim.<p>But, the vast majority of the time it just works.<p>Now, sometimes we aren't happy with what Kaiser offers. So then we go outside of Kaiser and pay out-of-pocket.<p>Our friends sometimes tell us we're crazy when we do that. We just spent $1200 out-of-pocket to see a specialist because Kaiser didn't want to refer us. What they don't realize, though, is that we saved $3000/year by choosing Kaiser over the next cheapest health insurance provider from our employer. So we're still coming out ahead.<p>And most importantly, we have the peace of mind knowing that any time we end up in a Kaiser hospital, we'll never once see a bill.<p>I think we really need more integrated systems like Kaiser. Imagine if there was actually competition in that space, where you could choose between competing hospital systems that came with complete integrated coverage, no middle man.
Reimbursement is the #1 barrier to bringing a novel therapy to market in the US for the company I'm working for. The technology is decades old and proven (the novel part is where it's being put in the body) - the clinical benefits are now proven.<p>But it's a battle to get US insurance to cover the therapy - we have about 3x more patients confirmed as clinically eligible than actually get the therapy. (That is to say, US insurance rejects ~75%+ of claims).<p>As a result, there is an entire segment of the org dedicated to reimbursement. We have a team of professional insurance-bullshit-waders - they call, they file claims, they follow up, and I hear them asking for Document Control Numbers and Call Reference Numbers.
There are 'Government Affairs' people who lobby with the VA and Medica{re, aid?}.<p>The payer barriers outside of US have been much lower. (But EU has it's own problems with medical device barriers... a rant for another day.)
Met someone coming from US to Australia to visit and was nicely surprised you can just go buy a CPAP, cheaply with no referral. Just like buying a dishwasher or something.<p>Makes me wonder if in the US a trip to mexico or canada or somewhere could make this easier.
I too had my bad interaction with my insurance company. Out of blue they start rejecting my doctor's prescription for a very common (and cheap) medication. It took me more than 1 month with my awesome primary care doctor's persistent to figure out that the 1000mg version of my medication is the reason it got rejected. My doctor has to prescribe the 500mg version and I simply take two pills.<p>But no communication from the insurance company told me that.
This was a nightmarish read. I'm glad he was eventually able to get the replacement paid for.<p>On top of your state's DOI, there are a few agencies that can (typically) be used to bring insurance and other companies more swiftly into compliance with the laws they're meant to proactively follow:<p>* Many state AGs are responsive to well-documented problems and will send a warning on official letterhead.<p>* This won't work for insurance, but the CFPB[1] has a relatively smooth complaint process for financial issues, and (anecdotally) generally produces a rapid outcome.<p>[1]: <a href="https://www.consumerfinance.gov/" rel="nofollow">https://www.consumerfinance.gov/</a>
From the article:
> Listen, gobsmacked, as they explain that they decided your claim was in fact an appeal, and transferred it immediately to the appeals department. The appeals department examined the appeal and looked for the claim it was appealing. Finding none, they decided the appeal was moot, and rejected it.<p>Tell me why this is not fraud. Tell me why insurance company employees are not facing prison time.
It’s surprising to me that not only in my home country is the process of having a CPAP machine covered by insurance a long and complicated one.<p>In my case, it took almost 12 months to receive my first CPAP machine, which then turned out to be refurbished. Initially, I had to visit a doctor, who had an available appointment in two months. He then referred me to a sleep laboratory (another two-month wait). After my sleep study, they sent me back to the doctor, who confirmed I had sleep apnea and said I needed to return to the sleep lab to test some settings—a further two months’ wait.<p>Then, after more than a month waiting for the next appointment, the doctor informed me that the settings they had tried were too low and wanted to send me back to the lab. I disagreed, but he gave me the prescription, and two months later, I received a CPAP machine with incorrect settings that didn’t help much.<p>Eventually, I purchased my own Philips Dreamstation Go because it automatically adjusts the pressure, and I’ve been sleeping well ever since.
I move around a lot and have run into all kinds of weirdness when it comes to CPAP stuff. Any time you establish a new doc, if your CPAP prescription is more than 1-2 years old you need to do another sleep study, so I think I've done 6 different sleep studies over the years.<p>The other thing to remember about CPAP is that it's not just the machine, you have to get replaceable supplies - masks, air tubes, etc every so often.<p>While not nearly as bad as linked blog entry, my worst situation was with Kaiser in the SF Bay Area. I had gotten a CPAP through them and then a few years later moved to a different part of the Bay. I set up a new doc also with Kaiser, but the records don't easily transfer and since it's a different Kaiser respiratory team, I had to (of course) do another sleep study AND go through a CPAP orientation on how to use a CPAP despite me already owning and using a CPAP and just needing a new mask, etc.
Are there any studies estimating the cost of this kafakasque nightmare? End of the day users pay for this via higher premiums. I am sure doctor's offices also face something similar.
This is too common. The author of the article asked for the wrong thing from the wrong people. He should have asked his sleep doctor (which he calls the sleep center) for a new CPAP. By asking for a repair from his insurance company, he caused himself lots of grief.<p>I doubt he has a list if his doctors that his insurance companies or doctors would agree with.
Congrats on triggering my chronic anxiety.<p>I dread the day I require anything complicated that requires medical/insurance bureocracy in this country. I've had already ungodly share of issues with Aetna because they capitalized my surname.
I have one rule when it comes to these things. Play dumb. Don't try to be smart. It's remarkable how the system detects people trying to be smart and considers it abuse and deals with it using high latency.<p>I found any number of people I worked with were much more productive (car repair, internet service, insurance) if I avoided any speculation about what the problem was, or what the solution could be. Like other folks in this thread, I identify as mildly autistic, and dealing with normies in the service industry took a lot of retraining my mental model of how things work.
Ha, I know Carelon! It's their pharmacy division for specialty (read: expensive) medication. Not a clue as to why they'd be involved in a CPAP claim, but this story does ring far too close to home.<p>I once spent months fighting United Healthcare to stop hounding me for a $2k bill that I categorically did not owe. Countless phone reps were unable to remove it from my account; I only solved the problem by making a big enough stink on Twitter for someone from corporate to get involved. Good times!
Insurance companies are just legal scams. They take your premiums then come up with whatever excuses possible to avoid or delay paying out on legitimate claims.
It is interesting to see how CPAP is used and covered by insurance in different countries. In my country, South Korea, CPAP is available for rent if you have certain medical conditions, and the rental price is fixed. I pay 15 USD (20K KRW), and the Korea NHS pays 60 USD (80K KRW) per month. I've been using Löwenstein's CPAP, and it works great without any problems.
I'm fortunate enough to afford to buy my machines out of pocket. Just trying to obtain a machine the insurance way was taking weeks (before covid even) and I got pissed off and figured out with my Perscription I could buy one on cpap.com with Amazon like service. However, obtaining the equipment was just the first hurdle for me. Thereafter, I approached finding the right settings as a search problem and eventually got some relief. Since I was not a severe case - at least by the "average of bad events" metric from the machine - I wasn't able to get much attention after trying several providers. I eventually bought a bipap machine after reading forums and hoping that more knobs to turn on the machine could yield better results. This helped a lot and again I'm lucky to be able to afford a new one without insurance. There's a lot of opportunity for improvement in this medical tech space.
CPAP = Continuous Positive Airway Pressure ventillation - a mask, a hose and a flow generator. Treatment for obstructive sleep apnea.<p><a href="https://en.m.wikipedia.org/wiki/Continuous_positive_airway_pressure" rel="nofollow">https://en.m.wikipedia.org/wiki/Continuous_positive_airway_p...</a>
Another avenue of escalation is also via your state congressional rep / federal congressional rep. Their offices should always have a constituent services function whose very purpose is to help their constituents navigate these bureaucratic mazes.<p>(Disclaimer: I’ve never had to exercise this personally.)
Why dont you just ask someone coming from India to get you one ? They are available over the counter in India and there are a lot of Indian people hopping on a flight to the US all the time. I am sure there is someone in your office you can request, or someone in your locality.
The longer I've had a CPAP the more I've thought they should be more over the counter because literally any problem is unresolvable without it taking too long. Though this case is extra insane.
For those who are looking for a cpap now in the US (maybe for other countries - haven’t tried) - <a href="https://cpapx.com/collections/resmed/products/airsense-10-autoset-auto-cpap-with-humidair-heated-humidifier-card-2-cloud-version" rel="nofollow">https://cpapx.com/collections/resmed/products/airsense-10-au...</a><p>You can order one for 450 before taxes there.<p>You will have to email your prescription though before they process the order.<p>Ordering a backup one (or more) is very useful to leave in your travel suitcase etc
God, reading this is awful. I have a CPAP and I would not be willing to go one night without it. I'd buy the parts/machine out of pocket and make insurance pay for it later. The impact on my health and quality of life is way too high.<p>But I'm privileged to be able to do that. I can shell out $1,000 for a medical device in an emergency, and my doctors are local and return my calls. Not everyone is so lucky.
I had a similar story once on an medical insurance coverage situation, which only resolved itself when I dug up the contact information of an employee at the insurance company from Google/LinkedIn and directly contacted the person.<p>Going through the official "process" was just handing me from one department to another until it went back to the original department, and the cycle started again.
Might have been useful to establish a paper trail instead of calling them.
Have a look at the great article by patio11 for ideas how to establish one:
<a href="https://www.kalzumeus.com/2017/09/09/identity-theft-credit-reports/" rel="nofollow">https://www.kalzumeus.com/2017/09/09/identity-theft-credit-r...</a>
Have had similar experiences with UHC for some very expensive injectables. Fortunately, my doc’s back office handled the appeals process to get it approved. Keep in mind I am paying a higher premium for a PPO plan vs an HMO plan offered by employer.<p>Doc’s back office submitted 3-4 “appeals” to get it covered. Each review was reviewed by UHC personnel. Probably someone like this guy [1]<p>I fucking hate private insurance. It’s a useless middleman that is driving the costs of healthcare up. We can have the most advanced healthcare available but it’s largely inaccessible because of health insurance industry. They will make it as difficult as possible so you either give up or end up paying out of pocket.<p>[1] <a href="https://m.youtube.com/shorts/YF6MDTvZlNA" rel="nofollow">https://m.youtube.com/shorts/YF6MDTvZlNA</a>
I ended up just buying a CPAP. Ultimately, its not easy to sleep with one. I use a MAD now and my experience has been substantially better in terms of persistence in using it and less snoring. However, it has caused my teeth to move which is a tradeoff I can deal with.
Health care needs an enema.<p>I think one thing I would have done different when i switched primary I would have gotten a new Rx.<p>Not sure how much trouble that would have saved in the end but that is just what I tend to do.
Having one's tonsils and adenoids removed and getting palette-hardening RF treatment seems like it would be a lot easier and more permanent than this rigamarole. Worked for me, and I suspect it would for a lot of other folks too.
Medical, and especially medical related insurance stuff, is one of the few things that drives me up a wall enough to add to my 'burn this chickenshit outfit down' list.<p>This is a great example of why.
Reading this depressed me: I imagined the title being “How to get your GMail/XBox/PlayStation account back in only 666 days.”<p>I worry that, some day, tech companies will be under a regulating agency like insurance is today. If that happens, we’ll probably deserve it.
Alternatively, try a low histamine diet. Many people who have been told they need surgery to correct "deviated septum" or need cpap have found their problems go away.<p>Edit: to downvoters - why the closed mind?