Sleep Disorders Center of Pulmonary Associates of Richmond
2354 Colony Crossing Place
Midlothian, Virginia 23112
Phone: (804) 639-9910
Sleep is not just "time out" from daily life. It is an active state required to renew our mental and physical health each day. It is estimated that more than 100 million Americans of all ages, however, regularly fail to get a good night’s sleep.
There are at least 84 disorders of sleeping and waking that can lead to a lowered quality of life and reduced personal health. These disorders can lead to problems falling asleep and staying asleep, difficulties staying awake or staying within a regular sleep/wake cycle, sleepwalking, bedwetting, nightmares, and other problems that interfere with sleep. Some sleep disorders can be life threatening. They also endanger public safety by contributing to traffic and industrial accidents.
To learn more about individual disorders check out our links to the below:
Restless Leg Syndrome / Periodic Limb Movement Disorder
Narcolepsy
Snoring & Sleep Apnea
Insomnia
More about Parsleep
Insurances Accepted
WHAT IS RESTLESS LEG SYNDROME ("RLS")?
WHAT IS PERIODIC LIMB MOVEMENT DISORDER?
HOW ARE "RLS" AND "PLMD" TREATED?
WHAT IS NARCOLEPSY?
WHAT ARE THE SYMPTOMS OF NARCOLEPSY?
WHAT CAUSES NARCOLEPSY?
HOW IS NARCOLEPSY TREATED?
WHAT IS SLEEP APNEA?
HOW COMMON IS SLEEP APNEA AND WHAT ARE THE RISK FACTORS?
WHAT ARE THE CONSEQUENCES OF UNTREATED OSA AND THE WARNING SIGNS?
WHAT TREATMENT ARE AVAILABLE FOR OSA ?
WHAT IS INSOMNIA?
WHAT ARE THE CAUSES OF INSOMNIA?
WHAT CONDITIONS LEAD TO CHRONIC INSOMNIA?
RISK FACTORS FOR INSOMNIA
WHAT ARE THE SYMPTOMS OF INSOMNIA?
DIAGNOSIS
TREATMENT
PREVENTION TIPS
NEW PATIENT VISITS
OVERNIGHT SLEEP STUDIES
DAYTIME SLEEP STUDIES
INSURACE ACCEPTED AT PARSLEEP
WHAT IS RESTLESS LEG SYNDROME ("RLS")?
This is a disorder that often appears in otherwise healthy people. Although it does affect the legs most often, it can also affect the arms. Symptoms often include an unpleasant "creepy, crawly" sensation that occurs in the legs when sitting or laying still, especially at bedtime. It is not the same sensation you feel when your legs have "fallen asleep" or have a cramp. The discomfort of RLS appears most often in the calves and can be temporarily relieved by stretching or moving the legs. Many people with these symptoms report they must actually get up and walk around at night to relieve them.
The constant need to stretch or move the legs can prevent a person with RLS from getting a good night’s sleep. Because of this, people with RLS are often very sleepy during the day. They can also have problems while sitting still in a car, an airplane, or any other place you might sit still for long periods of time.
HOW COMMON IS "RLS?" Five to 10 of every 100 people have experienced RLS at some time in their lives. While RLS is more common in older individuals, it can occur at any age and in both men and women. RLS has been known to come and go without any obvious cause, but can also sometimes be associated with pregnancy.
WHAT CAUSES "RLS?" RLS has been found to be hereditary in approximately 30% of all cases. The causes for the other 70% of RLS cases are not generally known, but there are several situations that seem to be able to produce symptoms of RLS. These include; poor blood circulation in the legs, iron deficiency anemia, nerve problems, kidney disorders, muscle disorders, alcoholism, and vitamin or mineral deficiencies. Other things that have been implicated in triggering RLS include; caffeine, smoking, fatigue, starting or stopping certain medications, and hot temperatures or extended time in cold temperatures.
WHAT IS PERIODIC LIMB MOVEMENT DISORDER?
Periodic Limb Movement Disorder (PLMD) is also known as nocturnal myoclonus. PLMD is another disorder that affects the limbs and prevents a person from sleeping well at night. While the movements experienced with RLS are voluntary and occur mostly while the person is awake, the movements of a patient with PLMD are involuntary and occur while they are asleep. Most people with PLMD are not aware of the movements but may be told by their bed partner that they kick or move excessively in their sleep. Most people with RLS will also have periodic limb movements, but patients with PLMD as their main complaint often do not have RLS.
A typical periodic limb movement consists of movements similar to jerking or kicking. There is an extension of the big toe, together with an upward bending of the ankle, knee, or hip. They occur at periodic regular intervals, usually every 30 seconds and cluster in the first half of the night. PLMD can cause a complaint of difficulty falling asleep and remaining asleep, without the patient being aware they are arousing because of involuntary leg movements. It is also possible to not be aware of any nighttime disturbance, but feel excessively sleepy in the daytime due to brief unremembered arousals at night.
HOW COMMON IS "PLMD?" PLMD usually affects people over 30 years of age and becomes more common as we grow older. PLMD affects a small percentage of people age 30 — 50; one-third of people 50 — 65; and almost half of all people over the age of 65. Men and women are affected equally, and PLMD can be found in two out of every ten insomniacs.
WHAT CAUSES "PLMD?" The causes of PLMD and RLS are similar. See the section on causes of RLS for more information. Periodic limb movements are more common in those with kidney disease or a sleep disorder called narcolepsy. Antidepressant medications have also been implicated in increasing the severity of PLMs.
HOW ARE "RLS" AND "PLMD" TREATED?
RLS and PLMD can be treated by a variety of methods. Once diagnosed, it is important to determine if related conditions such as anemia, diabetes, arthritis, or antidepressant medications are contributing factors. Proper diagnosis and treatment of those disorders can often relieve the symptoms of PLMD and RLS.
If the disturbing movements continue, there home remedies for RLS. These include:
Hot baths, massage, applied heat, ice packs, regular exercise, and elimination of all caffeine. For those suffering from PLMD, following sleep hygiene rules can often help improve the soundness of their sleep. See our section on sleep hygiene for more tips to improve sleep.
When home remedies are not effective, both RLS and PLMD can be treated with prescription medications. Since one medication may work for one patient and not another, it sometimes takes a trial of several different medications over time to provide relief. Your family or primary physician should be notified of any changes in medication to avoid any unwanted interactions between medications you are taking.
For more information on Restless Leg Syndrome.
WHAT IS NARCOLEPSY?
Narcolepsy may best be described as a sleep disorder that causes excessive daytime sleepiness during the day with an irresistible tendency to fall asleep at inappropriate times. Narcolepsy is a fairly uncommon condition, but the impact it can have on a person’s life can be serious. A cure for Narcolepsy has not yet been found, but with recent advances in medicine, technology, and pharmacology most people with this disorder can lead nearly normal lives.
WHAT ARE THE SYMPTOMS OF NARCOLEPSY?
There are four common symptoms of narcolepsy. They are excessive daytime sleepiness, cataplexy, sleep paralysis, and hypnogogic hallucinations. In most cases, the first and most bothersome symptom to develop is excessive daytime sleepiness. The symptoms of narcolepsy can actually appear all at the same time or can develop gradually over time.
Excessive Daytime Sleepiness (EDS) is usually the first symptom a person with narcolepsy will notice. People with narcolepsy tend to not only fall asleep in situations many normal people do (after meals or during a dull class or lecture), but also when most normal people would be able to remain awake (while watching a movie, writing a letter, driving, or even talking to someone face to face).
Cataplexy is a brief, sudden loss of muscle control. This is usually a symptom that develops months or years after the onset of sleepiness. Cataplexy is usually triggered by strong emotion, such as laughter, joy or surprise and sometimes by anger. The muscle weakness can be mild — such as a brief feeling of weakness in the legs — or it may cause a complete muscle collapse and result in falling to the ground. A person having a cataplexy attack is fully awake and aware of what is happening around them. It is not the same as feeling lightheaded or shaking after a "close call". It is possible for a person to experience cataplexy without having narcolepsy. Many people before they are diagnosed with Narcolepsy try to cope with this symptom by avoiding situations that may cause them to experience strong emotion.
Sleep Paralysis is a loss of muscle control that occurs when a person is waking up, or just starting to fall asleep. This is often a frightening experience since the person may be aware of the surroundings, but is unable to move or to speak. Unlike cataplexy, sleep paralysis usually disappears when a person is touched.
Hypnogogic Hallucinations are vivid dreamlike experiences that occur when a person is drowsy, either just falling asleep or starting to wake up. These hallucinations may involve disturbing images or sounds and can be upsetting if they are mistaken for the hallucinations or delusions of mental illness. Many people report thinking someone or something is inside their room or outside their window. These hallucinations can be even more frightening because the person is only partly awake and thus cannot control the events.
Additional symptoms of narcolepsy include automatic behaviors (tasks done routinely without remembering or being aware of them), and difficulty remaining asleep at night even though able to fall asleep quickly initially. People with narcolepsy also sometimes report double vision, inability to concentrate, and memory loss.
WHAT CAUSES NARCOLEPSY?
The exact cause of narcolepsy is unknown currently, but it appears to be a disorder of the part of the central nervous system that controls sleep and wakefulness. In normal dreaming, people experience loss of muscle tone similar to that of cataplexy and sleep paralysis. In those with narcolepsy the lack of muscle tone and dreamlike experiences occur at inappropriate times. Narcolepsy sometimes runs in families, but there are many people who have no family members with the disorder. There is research that points toward certain genes combined with other factors in a person’s life, as the cause for narcolepsy.
HOW IS NARCOLEPSY TREATED?
To diagnose narcolepsy a person must first undergo an all night sleep study and an MSLT. See our section on "What to Expect" for a description of these tests. Once diagnosed, the patient and sleep specialist should work together on a plan of treatment. Narcolepsy cannot yet be cured, but the symptoms can often be controlled with medications, behavioral treatment, and management of the environment. Many people with narcolepsy find it very helpful to join a local or national support group. They may also bring family members to their follow up visits so they can gain knowledge of the disorder and be supportive of attempts to find a treatment that works.
WHAT IS SLEEP APNEA?
Snoring is a condition that affects 10% to 30% of adults. For an estimated 5 out of 100 people, extremely loud snoring every night is the first sign of a potentially life-threatening disorder called obstructive sleep apnea syndrome, or OSA.
When we sleep, it is normal for the muscles that stiffen and open our airway to relax somewhat. This causes a narrowing of the throat that does not affect most people. In those with OSA, however, the throat narrows so much that it becomes very difficult to breathe. The brain senses that breathing is labored and the person wakes up briefly just enough to stiffen the muscles in the airway and take a few normal breaths.
The person usually will not remember this awakening, and falls back asleep only to be aroused again when the airway closes. This cycle repeats itself throughout the night, sometimes several hundred times, leaving the sleep fragmented and the person with OSA exhausted when they rise in the morning. A complete closing of the airway is called an apnea, and a partial closing is called a hypopnea. Both types of event can lead to the same disruption of sleep and cause excessive sleepiness.
HOW COMMON IS SLEEP APNEA AND WHAT ARE THE RISK FACTORS?
Sleep apnea is more common in men than in women, by a factor of about 2:1. Being overweight, having a smaller-than-normal jaw, large tongue, enlarged tonsils, or excess tissue in the airway can be factors. Drinking alcohol, taking sleeping pills, tranquilizers and other sedating medications can also reduce muscle tone and can make your airway much more likely to collapse. Hypothyroidism has also been implicated in contributing to increased sleep apnea and excessive sleepiness.
WHAT ARE THE CONSEQUENCES OF UNTREATED OSA AND THE WARNING SIGNS?
The most common complaint of those suffering from OSA is excessive daytime sleepiness. For some people, the sleepiness may be so severe that they are unable to remain awake even in dangerous situations. They may fall asleep while driving or operating machinery and thus cause injury to themselves or others.
Other consequences of untreated OSA are hypertension, increased risk of myocardial infarction and stroke, symptoms of depression, menstrual irregularities in women, and frequent nighttime urination. Sleep apnea is also known to worsen the heart failure cycle. There may be a loss of interest in sex, and men may complain about impotence. Adults with OSA may have trouble concentrating, and can become forgetful, irritable, and anxious. Most complain of morning headaches. Family members may notice snoring so loud it is described as being "like a jack hammer", cycling with silences and then gasping or snorting noises.
WHAT TREATMENTS ARE AVAILABLE FOR OSA?
There are general measures and specific treatments for OSA that may be of benefit to you.
GENERAL MEASURES:
Normalizing weight — a weight loss of even 20 lbs. in a person who is 40 lbs. overweight may be enough to improve breathing during sleep.
Avoid alcohol within four hours of bedtime. The depressant effect of alcohol can trigger apnea in a person who would otherwise only snore.
Avoid sleeping pills and sedative hypnotics. These can have a negative effect on your breathing when asleep. Seek a healthcare professional’s advice if you are thinking about discontinuing any medication.
Try sleeping on your side. Some people only suffer from OSA when they are lying on their backs. A tennis ball in a sock pinned to the back of your pajamas, or pillows piled up behind you can be enough to keep some people from rolling onto their backs during sleep.
SPECIFIC TREATMENTS:
Continuous Positive Airway Pressure (CPAP, pronounced see-pap):
With CPAP a small light mask is worn over the nose during sleep. Air pressure is delivered through the mask into the nasal passages and throat. This gentle pressure keeps the throat from collapsing. CPAP is the most effective therapy currently available for OSA. The most common side effects are nasal congestion, dryness of the mouth, air leaks from the mask causing drying of the eyes, and skin irritation from the mask and headgear.
Other treatments include oral appliances and surgery: Severe OSA usually does not respond fully to appliances and surgery. Success rates vary and patients may still end up needing CPAP after their surgery is complete.
WHAT IS INSOMNIA?
Insomnia refers to inadequate or poor-quality sleep. Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more.
WHAT ARE THE CAUSES OF INSOMNIA?
There are many causes of insomnia. Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:
• A life crisis or stress
• Environmental noise
• Extreme temperatures
• Change in the surrounding environment
• Sleep/wake schedule problems such as those due to jet lag
• Side effects of medicine:
• Nonprescription: diet aids, decongestants, cold and cough remedies
• Prescription: steroids, theophylline, phenytoin, levodopa
CHRONIC INSOMNIA OFTEN RESULTS FROM THE FOLLOWING CONDITIONS:
• Depression
• Mania
• Anxiety
• Arthritis
• Kidney disease
• Fibromyalgia
• Liver failure
• Heart disease
• Asthma
• Sleep apnea
• Narcolepsy
• Restless legs syndrome
• Parkinson's disease
• Alzheimer's disease
• Hyperthyroidism
• Gastroesophageal reflux disease (GERD) or ulcer
Chronic insomnia may also be due to behavioral factors, including:
• Misuse of caffeine, alcohol, or other substances
• Disrupted sleep/wake cycles from shift work or other nighttime activities
• Chronic stress
In addition, the following behaviors have been shown to perpetuate insomnia in some people:
• Expecting to have difficulty sleeping and worrying about it
• Smoking cigarettes before bedtime
• Excessive napping in the afternoon or evening
RISK FACTORS FOR INSOMNIA
A risk factor is something that increases your chance of getting a disease or condition.
• Age: 50 or older
• Sex: Female (especially during and after menopause)
• Stress
• A history of mental disorders such as anxiety and depression
• Chronic pain
• Alcohol, drugs, or certain medicines
• Shift work
• Obesity
• Use of multiple medications
SYMPTOMS OF INSOMNIA
Symptoms include:
• Difficulty falling asleep
• Waking up frequently during the night with difficulty returning to sleep
• Waking up too early
• Feeling un-refreshed after sleep
DIAGNOSIS
The doctor will ask about your symptoms and medical history, and perform a physical exam. You will also be asked about your job, eating habits, schedules, and travel patterns.
TREATMENT
Treat Underlying Medical Conditions
A number of physical and mental disorders can disrupt sleep. Diagnosis and treatment of underlying illness may help alleviate insomnia.
Identify and Modify Behaviors that Worsen Insomnia
Reduce or avoid caffeine, alcohol, and drug use. Go to bed and wake up at the same time each day. If you must take naps, keep them short. Do not smoke close to bedtime.
Sleeping Pills
Sleeping pills are available by prescription or over-the-counter. Some doctors advise against the long-term use of sleeping pills for treating chronic insomnia because they may cause dependence.
Herbal Therapies and Supplements
Some people use the herb valerian to reduce insomnia. Others take supplements of melatonin. In the United States, herbal products and dietary supplements do not undergo the same testing as drugs. Their long-term impact, side effects, and possible interactions with other drugs or medical conditions are often unknown.
Relaxation Therapy
Techniques such as deep breathing, thought stopping, and progressive relaxation may reduce or eliminate anxiety and body tension. This stops the mind from "racing" and allows the muscles to relax so that restful sleep can occur.
Sleep Restriction
A sleep restriction program at first allows only a few hours of sleep during the night. Gradually the time is increased until a more normal night's sleep is achieved.
Reconditioning
Reconditioning helps people to associate the bed and bedtime with sleep. This means not using the bed for activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy.
PREVENTION TIPS
To reduce your chance of having insomnia:
• Minimize intake of caffeinated food and drinks (coffee, tea, chocolate, cola drinks) after lunch.
• Avoid eating too fast, too much, or too close to bedtime.
• Avoid drinking fluids before bedtime.
• Don't smoke.
• Exercise regularly, but not within less than three hours of bedtime.
• Use the bedroom only for sleep and sex.
• Schedule relaxing bedtime routines. Listen to quiet music or soak in warm water.
• Make sure that the bedroom is not too cold or too hot.
• Use a humidifier or dehumidifier as needed.
• Get more sunlight or ultraviolet light during the day.
• Use shades, lined drapes, or wear an eye mask to reduce sleep disruption.
• Use earplugs or listen to relaxing music or white noise. This helps reduce the disturbing effects of noise.
• Make sure your mattress is supportive and the bedding is comfortable.
• Avoid "clock watching" after going to bed.
• Keep bedtimes and wake-times consistent throughout the week.
• If you cannot avoid naps, keep them short.
NEW PATIENT OFFICE VISITS:
When you schedule your first office visit, we will mail a packet of information to you along with an appointment letter stating the date and time and some general insurance instructions. Office visits are always during the daytime, and usually take about one hour if you complete all of the information we send out before you come in. You can also bring in any recent medical exam results, blood work, or office notes from your referring doctor to help us gain a better understanding of the sleep disorder you may have, and what type of sleep testing you need.
You may also download our sleep history questionnaire and a sleep diary with instructions from our website to bring in with you if you wish. After your office visit, we will schedule you for the sleep study(s) you need. See our insurance information in the section on appointments if you have insurance questions, or call your customer service # on your member card.
OVERNIGHT SLEEP STUDIES:
ARRIVAL and DEPARTURE: The Sleep Disorders Center of Pulmonary Associates performs overnight sleep studies in the Colony Crossing location on Sunday through Friday nights. Since we are an outpatient clinic and are not associated with a hospital, there are several special considerations when making an appointment for a sleep study.
We are not open 24 hours a day. The night technicians are on duty here from 7:30 PM to 7:00 AM, so please do not arrive before your scheduled appointment time. There are several places within a few miles of the Center to eat, and since we have no cafeteria or vending machines you should eat dinner prior to coming in for your study. We usually ask that you arrive between 8:30 and 9:30 PM to be checked in and assigned a bedroom.
We often have patients on a waiting list for sleep study appointments so we ask that you notify us by calling (804) 639-9910 if you will be here later than your scheduled time so your room does not go to someone on the waiting list. We also ask that anyone relying on someone else for transportation arrange for their ride to be here by 7:30 AM to pick them up the morning after the study.
ACCOMODATIONS: Each bedroom is private, has a television, bathroom with shower, and an individual thermostat so you can control the room temperature. There is a large recliner in each room that is often used by a spouse or caregiver for sleeping in during studies. If the patient is unable to care for their own needs during the night, we ask that a caregiver remain for the duration of the sleep study since there are no nurses or doctors at the center at night.
WHAT TO BRING: Please bring any medications you are on with you, and take them on your regular schedule unless you were told previously by the sleep specialist that you should discontinue any of them. As always, if in doubt please call our office to discuss your medications.
You need to bring pajamas (preferably two-piece) since we do not allow sleeping in the nude. You should bring any personal hygiene items you will need such as:
- shaving items,
- shampoo,
- toothbrush and toothpaste,
- combs, etc.
We also only carry small "hotel size" towels so you may want to bring your own.
Many of our patients find it enhances their sleep to bring their own pillow to use along with ours.
You can bring snacks and drinks with you if they are caffeine and alcohol free, and bring a book or something else to occupy you since you will not be going to bed immediately.
We ask that you not drink any caffeine after 4 P.M. on the day of the study as this can affect your sleep architecture.
WHAT WE DO:
After you arrive at the center on the night of your sleep study, you will be checked into a bedroom and asked to change into your pajamas. Make sure you notify us of any braids, weaves, or hairpieces before your test.
We generally advise patients to shampoo and dry their hair before coming in, and not to apply hairspray. This ensures the sensors adhere to the scalp properly.
The technicians will be placing small dime-sized sensors on you to record your sleep, heart rate, and muscle tension. You also will have two elastic bands placed on your abdomen and chest to monitor respiratory movement, a sensor on your finger to monitor oxygen saturation, and a small sensor placed under your nose to monitor airflow. Even with the sensors on, most patients find that they have no problem getting to sleep. You can still walk around with the sensors on, and once your "hookup" is complete, you can go back to your room to relax for awhile before bed.
Bedtime is generally around 10:00 or 11:00 PM. Once the study starts, you are monitored from the control room by the technicians. They are there all night so if you need to get up to go to the restroom or if you need anything else you can just call out and they can hear you over the intercom in your room. If you have to get up in the morning at a specific time, please let the technicians know when you arrive at the center.
DAYTIME SLEEP STUDIES (MSLT or Multiple Sleep Latency Test)
MULTIPLE SLEEP LATENCY TEST (MSLT): A Multiple Sleep Latency Test is required to diagnose certain sleep disorders. Most patients do not need an MSLT. These tests are done during the daytime, and are only done after you have had an all-night study. The MSLT consists of four or five short naps throughout the day at two-hour intervals. The naps are usually anywhere from 20 minutes to half an hour long, and then you must stay awake until the next nap.
Certain medications that might not disturb a nighttime study can interfere with an MSLT’s results. Please be sure that you discuss all of your medications and any other supplements you may be taking when you come in for your office visit. Please call us at (804) 639-9910 if you are unsure about instructions you were given for the MSLT or for discontinuing medications.
HOW TO PREPARE FOR A MSLT:
An MSLT requires a full day to complete. Make sure you bring something for breakfast and lunch since we have no vending machines. We have a microwave and refrigerator you can use. Please do not bring any drinks with caffeine in them. Make sure you bring projects with you to keep you occupied during the time you are awake. You can bring in short videos to watch, or books you wish to read.
Make sure you come in with comfortable daytime clothing to wear for the MSLT, as we would like you to remain active between naps. You can ask a friend or family member to visit you throughout the day also. The test is usually finished by 5 or 5:30 PM, but some patients are through by 3:30 PM. We can let you know by 3:30 PM if you need to stay any longer, once we have reviewed the first four naps.
FOLLOW-UP VISITS
If you had a test that included CPAP or BiPAP therapy, your sleep specialist will usually review the study in the morning with you before you leave. You will have a chance to ask questions before you meet with a Home Healthcare therapist for setup of your equipment.
If your test did not include CPAP or BiPAP, you will receive a call from our office to let you know what your next treatment step will be after the sleep specialist has had a chance to formulate a plan.
THE SLEEP CENTER CONTROL ROOM:
All recording and monitoring equipment is enclosed in a large, well-lighted control room that is separate from the testing bedrooms. The equipment includes state-of-the-art sleep recording systems that save all patient data digitally for faster analysis and diagnosis. Our well-trained and professional technicians monitor the sleep studies from our control room.
THE BEDBROOMS:
Each of our four patient rooms is furnished like a "real" bedroom, with soft lighting, wood floors, and decorative touches that create a relaxed and comfortable environment.
Each room also contains an oversized reclining chair. Some patients elect to sleep in this chair, while others offer it to a spouse or other family member whose presence provides them peace of mind during their stay.
To further add to the comfort of our patients, the Sleep Disorders Center of Pulmonary Associates is 100% smoke-free and handicap accessible.
Participating:
Anthem (with the exception of Healthkeepers Plus which is the Medicaid product)
Medicare (to include RailRoad and Black Lung)***We do not have any formal contract with any of the Medicare Advantage Plans however we will accept the Medicare allowance on those patients. If they come in the office they are required to pay their co-payment amount.
Southern Health
Carenet
Aetna
Cigna
Medicaid of Virginia (we are non-par with some of the Medicaid HMO's)
Non-Participating:
Tricare
PHCS or One Health Plan
Mamsi
Alliance
MDIPA
Mailhandlers
United Healthcare
Virginia Premier
CCN
First Health
Multi-Plan or CVHN