Problem: A patient was diagnosed with sleep apnea 5 years ago and has been treated with CPAP since. At his office visit this year he complains of poor sleep and a return of symptoms of OSA. He has gained 60 pounds and has other lung problems as well.
His doctor orders a new sleep study since it's been 5 years. Said sleep study is promptly denied by the strategically aimed, absolute and total no-care comprehensive major government services coverage plan he has. Default request of HST denied promptly as well.
It seems that all approvals for this scenario hinge on the download data over the last 5 years. No problem, it's a reasonable request. Patient can't locate the smart card, thinks it was lost a while back during home renovations, but, that he has not been using it for a while since "it got mold in it ." Ok, let's check with the DME, who is unable to provide documentation, and says that's most likely because patient did not keep their follow up appointments.
This is a nightmare. You have a patient who legitimately needs something but can't prove they were ever compliant, an equipment provider who can offer no evidence either way and a hardline payor who absolutely will not approve any testing without the requested information.
There are missing links here all along the way and it's very difficult for the person stuck in the middle who is trying to obtain what is now needed for the patient. Did ultimate responsibility lie with the patient? Were the rules this strict 5 years ago? Did the DME do all they should to follow up? And should it even matter? If you consider just the new symptoms only wouldn't he qualify for at the least an HST?
Where do you think the ultimate responsibility lies?