​With this year’s changes in healthcare many people who think that what their physician has ordered or what they want should be paid for by their insurance.  They also may believe that since they pay for insurance there should be no cost for the study.  Both of these are not true. 
Who Truly Makes the Decisions
If you have insurance they will review any order and decide whether it is justified by doing a prior authorization.  At that time the authorization is done they can do several things,

  • Say yes you need this study and we will authorize it, however that does not guarantee payment
  • No we will not pay for the prescribed procedure but we will pay for a different procedure and they could require a different provider.
  • They could outright deny the procedure. 

If the study is denied the option for the ordering doctor to do a peer to peer review can change this decision.  A phone call by you most likely will not change this decision but they can give you an explanation of the denial.
Let’s Talk Money
Understanding the difference between premiums, copays and deductibles can be confusing; but each of these are different aspects of the insurance. 

  • Your premium is the amount you pay each month to the insurance company for your coverage.  If you fall 30days behind you start your grace period. This means that the insurance company will give you a chance to catch up on your premiums. 
  • A copayment or coinsurance is the percentage of the insurance company’s contracted fee for service you are required to pay.  Usually they are anywhere from 10% to 50%.
  • A deductible is the amount of money you must pay before your insurance company will pay for a service.  There may be services such as a doctor’s office visit or mammogram that do not apply toward your deductible. 

If you need to have a sleep study and you know you have a large deductible and you are only checking for sleep apnea you may benefit from having a home sleep test.  If you are looking at other disorders than a full night in lab sleep study is more beneficial. 
You doctor knows what is best for you but remember you get to have some input into your care.  

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