Twelve Phone Calls, Six Faxes and Three Hours for One CPAP Machine… Welcome to Primary Care

This is a rant about the hours and effort wasted to get ONE patient’s broken CPAP machine* replaced.

My patient had disruptive nighttime snoring, restless sleep, and daytime fatigue back in 2011, so we ordered a sleep study, which showed OSA (obstructive sleep apnea). She had been using her prescribed CPAP machine faithfully since then, until it broke. She called us and requested a new machine. Simple problem, right?

My nurse let me know. I opened the patient’s chart and found the original sleep study, wrote out the CPAP specifics (type of mask, humidified water, pressure range recommended) into a new prescription, printed it, and tossed it into the outbox to be faxed.

But it was rejected by her insurance. The original sleep study and a new prescription weren’t enough. They sent us a rejection notice with a phone number to call for more information. My nurse called, waited on hold, and then spoke with someone who explained that insurance required that the patient come in for a face-to-face appointment, and that I document why she needed the CPAP in my visit note.

We did that, which required calling the patient, scheduling a visit, and waiting for the visit. Of course when she came in, I touched base on her other medical issues as well, because to have to come in for this silly reason alone was… silly.

But we did what we were told, and then we printed out the note and the prescription, and again, faxed it all in.

It was all rejected again, with a rejection notice and a number to call for more information. My nurse called and waited on hold and then spoke with someone who explained that the visit note had to be written with specific language verifying that the patient not only had medically documented OSA and thus needed the CPAP, but was also using it as directed and benefiting from it.

So we did that. And it as rejected again, because the electronically signed copy of the prescription wasn’t good enough, it had to be printed and physically signed.

Twelve phone calls, six faxes and three hours is a conservative estimate of the time and energy wasted by me, my nurse, and the patient on this one small but very necessary medical issue, all because of ridiculous insurance rules and regulations.

You see, sleep studies and CPAP machines are expensive, and insurance doesn’t want to cover them anymore. So, they make it hard, and they hope that the patient and provider just give up. Untreated sleep apnea not only leads to fatigue, but is also a major contributing cause of high blood pressure, cognitive difficulties, depression, and even heart failure.

This is why I now refer every single patient of mine with suspected sleep apnea to a sleep neurologist. This sleep neurologist visited our office recently to give a talk on common sleep disorders, and she let us know that her staff was specially trained in handling the increasingly complex insurance rigamarole and that they were happy to see all of our patients who needed sleep studies. After all, she had pointed out, it’s a waste of our time to have to deal with all the paperwork insurance requires nowadays.

Damn straight, and welcome to my world.

*CPAP is Continuous Positive Airway pressure, a nighttime breathing machine for people with obstructive sleep apnea.