Sleep apnea diagnosis $$
January 6, 2018 8:08 AM   Subscribe

Recently diagnosed with sleep apnea but need further testing - can't help but wonder if the hospital is being inefficient - requiring multiple visits - to save $$.

I recently underwent a sleep study and was told that I have mild sleep apnea. I found out a couple of days before the test what it would cost me out of pocket after insurance - a lot - but I decided it was worth it for my health, and paid. The technician told me that if I met a certain criteria during my monitored sleep (something to do with if and how often I stopped breathing and possibly other factors) he would wake me up during the night and put a CPAP on me to see if that helped. In the morning, he told me that I didn't meet the criteria but that I might have to come back. That was the first time I knew that I might need more than one very expensive study.

Now the hospital tells me that I have mild apnea and that I need a second study to see how I do with the CPAP. I've scheduled it but I'm also suspicious and anxious about the $$$ (they can't tell me yet how much the second study will cost me). I don't understand why I couldn't have tried the CPAP at my prior study. I really want to get this resolved but I also don't want to feel like I'm being taken for my (relatively meager) savings, or that I'm a pawn between the medical/insurance industries.

Can anyone help me understand why two sleep studies are necessary? I can pay it off over time but I'm also saving for a house and have some other big-ticket expenses coming up this year. If I understand that it's really necessary, then I can make peace with the $$$. I DO understand why it would be important to monitory my sleeping with a CPAP to be sure that it will help, but I don't understand why they have it set up so that it doesn't happen in the initial study if you have mild apnea.

I intend to call them again on Monday and also to call some other medical offices to comparison shop, though if they want to start over from the top it likely won't help me. Any suggestions on navigating this are welcome.
posted by bunderful to Health & Fitness (21 answers total) 6 users marked this as a favorite
 
Response by poster: The end of the first sentence should have read "to get more $$" and not "to save $$."
posted by bunderful at 8:09 AM on January 6, 2018


Do comparison shop. I went through this last year but I was able to take a home sleep study - really not that expensive - and from the results they could diagnose my CPAP need. I am boggled as to this notion of "putting a CPAP on to see if it helped." Of course it's going to help if you stop breathing at night.

You don't say what country you're in, but it sounds like whoever you're working with might be behind on the standard of care. Call your insurance company to ask if this meets protocols and what your options might be. Ask to speak to a patient advocate at the company if you aren't getting good answers.
posted by Miko at 8:17 AM on January 6, 2018


Also, it is worth it. It's important for your health and also a mood improver that makes solving other health problems much easier, too. But that's no reason to spend more than you really have to to solve the problem. Unfortunately this is an area in which sleep clinics and home device providers treat patients like a cash cow - so you have to watch every transaction.
posted by Miko at 8:20 AM on January 6, 2018


It might be a small price to pay if at the end of this you have better quality of life. My husband has sleep apnea but his was more severe and it was incredibly lifechanging to have a cpap.

Unfortunately the medical community at large never seems to think about how costs affect consumers but in your case it sounds like they thought about your first study and feel like you could be helped -but want to make sure cpap works for you. It is true some people cannot seem to tolerate it (but my husband never had any issues whatsoever fwiw)
posted by St. Alia of the Bunnies at 8:21 AM on January 6, 2018


Response by poster: You don't say what country you're in, but it sounds like whoever you're working with might be behind on the standard of care
U.S.

Ask to speak to a patient advocate at the company
This sounds promising. I assume you mean the insurance company?
posted by bunderful at 8:24 AM on January 6, 2018


Yes, the insurance company. There are also independent ones you can hire, but you can start with your company. You share with your company an incentive to keep billing costs down.
posted by Miko at 8:48 AM on January 6, 2018 [1 favorite]


When I was going through sleep studies, my insurance required a second one to see if I really needed a bipap machine or if a cpap would suffice to handle my apnea. I've been on a bipap now for over a year, and it's made an enormous difference.

I'm on Medicaid, so I didn't have to pay out of pocket. But if I did, I'd have moved heaven and earth to do so, because getting a good night's sleep helps with so many other health issues.

Maybe try talking to a nurse at your doctor's office to get the skinny on what's actually going on?
posted by The Almighty Mommy Goddess at 8:57 AM on January 6, 2018 [1 favorite]


I had the SAME experience, twice. I did a sleep study once and they did this to me and wanted me to come back. Cut to not doing it and then waiting a couple of years and moving to another state to try to get back on track with the follow up. I scheduled a new study and went to a new clinic. Told them about the history but they didn't pull the records or wake me up to put on the mask that night. They wanted me then to schedule a third study to wear the mask.

I raised a fit about being asked AGAIN to do a thing when it's obvious that i need the mask, otherwise I wouldn't be asking. For similar reasons to yours. The cost and the physical hassle of going down there again. They relented and just had the doctor prescribe me the machine.

The machine and equipment can be costly and there's a real racket going on with needing prescriptions for both of them. I just bought my most recent machine out of pocket for like 650, but usually insurance will pay the whole thing or most of it once every 5 years, which is probably why insurance is so concerned about getting the diagnosis right. My personal soap box on the prescriptions: It's physical equipment, not medication, what on earth is the reason that we'd need an Rx to buy a product? Like, if someone who doesn't need crutches but wants to own a pair, that's fine right? Who really cares if someone wants a machine that blows air into their face when they don't need it? Call some medical clinics and they'll refuse to sell this stuff unless a doctor has said it's okay. Legal liability I guess. Just be prepared for that. My current insurance doesn't really contribute enough to the bill on parts to make it worth the trouble of renewing my prescription. I usually just go to ebay now and buy the replacement parts on there. No one asks questions there and the parts are usually a lot less money there than a medical supply store (since their business model expects insurance reimbursements, I presume).

For background, I have snored pretty heavily since I was a teenager. In my twenties I developed really bad acid re-flux. I would wake up suddenly with agita in in my throat. It was so acidic that I'd start coughing and would do so until I threw up. This would happen like once every month or two. Doctors kept giving me more and more Ranitidine. After getting the machine, I found out for the first time that it was ALL related to apnea. The doctors had never suggested that both problems could be related. I've been using it for 7 years or so now and haven't had an episode since and dropped the re-flux meds other than I might use a TUMS like once a week or two if I happen to have spaghetti or pizza or something that day.

TL;DR

Just complain enough about your financial situation and they'll probably just give you the prescription.
posted by zero point zero at 9:00 AM on January 6, 2018 [1 favorite]


Husband says that likely means AHI (apnea-hypopnea-index) was not high enough. Husband suggests going on craigslist and buying a used ResMed Autoset and go on Amazon - you can't buy the full mask w/o a RX but you can buy all the components and put them together (husband notes, even if you bought the full mask with a RX, it still comes disassembled, so you'd be in the same boat).

If you don't feel like trying that, o to another sleep doctor, complain heavily about your financial situation, they'll write you a RX. We have been singularly unimpressed with many sleep doctors who appear to be merely CPAP salesmen and will write you a RX even if your sleep study shows zero apneas. So: do NOT buy a CPAP from them or their crappy sales reps.

Do you know anyone with a CPAP? When my husband was undergoing his sleep studies he borrowed a family member's CPAP and it was a life-changing experience. If you're paying out of pocket anyway, you may just want to cut out dealing with a sleep doctor on another sleep study and just check it out.

A few provisos. Mild apneas may mean you don't need a CPAP. And even if you do need a CPAP, compliance is tough. My husband is really compliant with his CPAP (e.g. puts and keeps it on no matter what) and even he has to switch around on masks occasionally and sometimes pulls his mask off in the middle of the night and sleeps like crap because he just can't deal with having the mask on for another second. Our family members with CPAPs are variously compliant - one wears it "when he feels like it" and the other tries to wear it, but sometimes takes it off. CPAPs take serious commitment.

Make sure you try all the different types of masks and attachment styles - and be open to switching out over time as you feel like your needs change. You can buy the replacement mask liners, hoses (buy the heated hose, it costs more but is very much worth it), etc. online. Buy them online, again do not screw with your sleep doctor's overpriced service. He is literally getting his boat payment paid based on your mask liners and CPAPs. If you find a machine you like, be aware that you can buy a used version on craigslist. Occasionally you can buy them on eBay (either coming from outside the US or before eBay pulls the listings down, eBay considers them illegal for sale to US customers but people sell them everywhere else around the world OTC).
posted by arnicae at 9:27 AM on January 6, 2018 [4 favorites]


Arnicae's husband here... North America is the only place in the world that CPAPs are Rx-only. Everywhere else, they're over the counter. Even if someone doesn't have sleep apnea, sleeping with a CPAP is not going to do any harm.

I'd recommend getting a previous generation Auto CPAP like the ResMed AutoSet S9 with H5i humidifier (be sure to fill it only with distilled water) on Craigslist. Craigslist doesn't care about rx. Depending on your luck, it will be between $300 and $700.

Masks are also Rx-only (also only in NA), but mask parts aren't. You can order mask parts on Amazon. The silly thing is, when you order a full Rx-only mask, it comes disassembled in parts in the bag. Again, ResMed is a good brand to start with. Full cost for a mask from parts off Amazon is around $150, +/- $75.

If you sleep with your mouth open (ask your SO) then get a full face mask. If not, get a nasal mask.

There's also a disposable floss air filter that goes inside all CPAPs to filter incoming air. They're about 50 cents a piece at Amazon or other online CPAP stores.

Finally, you'll need a tube connecting the mask to the machine. They're $20 for a regular one and $40 for a heated one, and don't require a prescription. If your bedroom is below 72 degrees at night, consider a heated tube. Not strictly necessary, but it can help.

Masks (at least the mask cushion) and hoses should be replaced every 3 months, filters every 1 or 2 months.

Compliance is the greatest challenge with CPAP therapy. It takes up to 9 months to fully acclimate to sleeping with it. Some people take to it right away overnight, but most don't. It took me a long time. Work on using it every night, at least for an hour to start with. Eventually, attaching the mask to my face triggered a Pavlovian sleepiness that mostly persists. Like Arnicae said, sometimes even I struggle with keeping it on at night, and I've been in CPAP therapy under a physician's care for four and a half years.

For a baseline, Medicare considers "compliance" as four hours a night, 70% of the nights per month. Basically 4 hours a night 21 nights a month.

Do this. If it works, it could be a major life change for the better; the advantages far outweigh the disadvantages. Even if it turns out that CPAP therapy is not for you, you can always flip the equipment on Craigslist, and you'll probably only be out $200-300 total for the experiment.
posted by arnicae at 9:51 AM on January 6, 2018 [4 favorites]


Response by poster: If you sleep with your mouth open (ask your SO)

This has been the fun part.

Doc: Has anyone told you that you snore?
Me: I live alone, and don't have a partner.
Doc: I see. Has anyone mentioned that you seem to stop breathing at night?
Me: I live alone, and don't have a partner.
Doc: I see. Has anyone told you ... etc etc.

Thanks for all the advice so far. It would be great to hear from anyone with a nitty-gritty understanding from the diagnosis end. I will also be making a lot of calls on Monday.
posted by bunderful at 10:15 AM on January 6, 2018


if you have an established primary care provider, they MAY be able to give you an RX or recommendation if they can review the sleep study results. Also, for mild disease, there are nasal and oral appliances that can help relieve symptoms even if there is not a ton of evidence that they affect the long term risks or disease progression. However these are relatively cheap and possibly better tolerated than the full enchilada CPAP, and many/most are over the counter.
posted by genmonster at 10:59 AM on January 6, 2018


i'm somewhere between you and zero point zero — i had massive snoring, reflux, my mother uses a CPAP, etc.

i did an at-home sleep study to confirm that i had moderate to severe apnea, which was much easier than going to a sleep center, and cheaper by far, and ended up with a dental appliance, instead of a machine, which I'm happy about. all of this was covered through my insurance. shop around. particularly because there are other options than CPAP for "mild" apnea.
posted by RJ Reynolds at 11:17 AM on January 6, 2018


My experience was that the second night wasn’t to see if a CPAP would help - of course it will! - but to find the type of mask that would work best and then find the correct CPAP settings to eliminate my apnea events. I can’t say that second bit was particularly necessary; if you get a CPAP model with data you can read yourself, you can screw around with the settings yourself at home over a few nights. It was good to be able to try out different masks, but depending on your insurance and cost tolerance, perhaps you would be just as happy buying a secondhand machine and a few different masks and again, trying them out at home. There are CPAP forums online that can walk you through all this.

But I imagine that if you DIY this your insurance might not pay for your ongoing supplies, whereas they would with a prescription, so that might be worth looking at. By saving money on the second appointment now, are you screwing yourself over long term? I’d run some numbers.
posted by Stacey at 4:46 PM on January 6, 2018


Since you live alone, set up a camera to film you sleeping to determine if your mouth is open or closed. If you decide to go the ‘cobble together a system’ route, film yourself again as you figure out what pressure settings will work best for you. My husband uses a CPAP and it has been life changing.

Keep in mind that you will likely have to try several different masks and troubleshoot a fair amount the first few months. The forums at CPAP.com are a treasure trove of information and will help you get sorted. If you’re having an issue, there is a solution. For example, my husband’s mask vibrates the tiniest little bit. He can’t feel it, but it’s juuust enough to cause some hyperpigmentation on his forehead and nose. He solves this by using a small strip of medical tape on his face every night. Point is, you’re going to have to treat this experience like it’s a puzzle to be solved.

Best of luck- good sleep is life changing!!!
posted by PorcineWithMe at 5:34 PM on January 6, 2018


you could consider just saying "yes" to the questions about snoring and sleeping with your mouth open.
posted by Miko at 6:15 PM on January 6, 2018


I am newly diagnosed (the past several months) with sleep apnea and just a tip, make sure your face mask fits you. I struggled for the past months with a full face mask (small size) that never fit me right. The people at the home healthcare office insisted it was the right size when I went in for my fitting. It turns out I needed a medium when it was time to get a new one. Be really insistent on trying everything. It's trial and error for sure. YOU GOT THIS!
posted by rabu at 7:41 PM on January 6, 2018


Response by poster: you could consider just saying "yes" to the questions about snoring and sleeping with your mouth open

Wow, that never occurred to me - to do that I would have to go in knowing the question would be asked and with a plan as to what to say. And I was only asked at the appointment with the specialist before the study. He just asked a lot of questions that could have been ruled out by the answers I had provided seconds ago. I don't expect it to come up again. It's just mildly annoying that the default assumption is that no one sleeps alone. Hah.
posted by bunderful at 8:10 PM on January 6, 2018 [1 favorite]


I think it's just that most people with sleep apnea have no idea they have it until someone who can see/hear them sleep lets them know of the problem. That's why it's a standard question.

For future reference, here are some of the typical questionnaire protocols.
posted by Miko at 8:21 PM on January 6, 2018 [1 favorite]


Traditionally the second night at the sleep center is the titration study where they figure out what pressure you need. A more modern practice (and what I did) is to use an auto CPAP (sometimes called an APAP) that dynamically adjusts the pressure based on what it thinks you need. You can get enough data off the machine to dial in an appropriate pressure setting.

So you don't need a second sleep study as long as you get the right machine.

Also, one of the best resources online for sleep apnea related topics is Apnea Board. You'll get a lot of help if you post your question there - they know a lot about sleep apnea.
posted by unix at 9:33 AM on January 7, 2018 [2 favorites]


Response by poster: For future readers - based on phone calls and internet searches, there are multiple types of studies. A split study involves first being observed while sleeping, then using a CPAP on the same night. Per multiple sources, this is only allowable (at least in the U.S.) when the patient meets certain criteria. Googling "types of sleep studies" and "split study" has been helpful.
posted by bunderful at 8:03 AM on January 20, 2018


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