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Thread: Medicare as secondary.. still has to approve?

  1. #11
    At least there is a chance with Medicare Advantage. I agree there is no reason to have it unless the primary plan has large copays and/or out of pocket max exceeds the Medicare premium. In that case, it would make sense to have Medicare as a secondary.

  2. #12
    Quote Originally Posted by Oddity View Post
    Then your DME is wrong. You aren't limited by what Medicare will or won't cover if they aren't primary. By telling them to file Medicare first THEN BCBS you may have inadvertently given them the impression Medicare is primary. If they're insisting on filing Medicare first, then they definitely have this misconception. Get the documentation from CMS, Benefit Coordination Center, explaining Medicare pays second in your case, and stick it under their nose. They sound ignorant or willfully deceptive (as if the Aero T via Medicare has a better margin for them than the TR via BCBS).
    I don't think you're comprehending the retardedness of my DME, which is NSM, may their name ever be cursed...

    January or February 2017 they say that Medicare is secondary, BCBS approves all options on chair in something like 48 hours after the seating appointment. They get a denial from Medicare 3 months later. I'm like "wtf why are you charging medicare, they're not going to pay for anything, just run it through BCBS. Accept the denial and move forward." then they say "We will go to prison if we don't charge Medicare" I'm a pretty chill dude, like one of the most chill people you will ever meet, but I had to check myself when I responded to them saying they would "go to prison" if they accepted a medicare denial. So they go back and forth with medicare, takes 3 months for a response every time, they get a denial, they reappeal. Every... single... mother #$%ing time I say "please just accept the denial and charge BCBS" but they are hardcore going forward with the medicare joint. I'm getting busy at work so I give up and figure I'll just let them do their thing until they run out of steam (this is around the time my current cushion on my chair fails and Oddity literally saves my ass by shipping me a replacement roho insert) then I spent $400 out of pocket for a stimulite cushion because I figure Insurance aint gonna pay for a cushion and then a new chair a few months later... little do I know how long this is going to take.

    Finally, in early March 2018 (so like 13-14 months into this process for those of you who are counting) they say "congrats, Medicare finally agreed to pay". BCBS (who they know is primary) will pay 80% (my primary insurance is 80/20 copay) and then Medicare is going to pay like 80% or something of the rest, so I only have to pay $150... plus my $1500 deductible of course. I'm pleasantly surprised and like "lets do this".

    Then they send me the specs (and by "they send me the specs" I mean I sent them an email on a near daily basis and called the office more often than a stalker would starting a little before Christmas until they finally told me what they were ordering). They had "Aero T" on the order form. Now of course my hopes are dashed, it's taken me years (literally I first started this process in 2015, but was a few months shy of 5 years, didn't start with NSM... may their souls burn slowly... until early 2017) and now I seem to have gone nowhere.

    They tell me they had to change from TR to Aero T (without telling me ANYTHING) because Medicare wouldn't approve the TR.

    I tell them for the umpteenth time since I started telling them this MORE THAN A YEAR AGO, just let Medicare deny it. Literally if BCBS pays their 80% I will put the rest on my credit card, that day. It's not a big deal.

    When I tell them this they go silent and haven't responded to emails in more than two weeks (despite multiple multiple emails from me).

    So now I'm just asking them to tell me if they can get me a chair with a medicare denial, because if not I literally went through this entire process (only in less than 90 days) with one of their competitors who was ready to charge BCBS only and had everything approved lickety split (like I said it takes two days for BCBS to approve stuff). The other DME is out of network so I have to pay 40%, but had I known what a nightmare NSM... may their children have clubbed feet... is I would have paid the extra $1200 or whatever it cost and had my chair MORE THAN A YEAR earlier.

    Sorry for the rant... hopefully no one bothered to read all that...

    It's just that I expect at least an infinitesimal amount of competence on the part of a DME (foolish idea, I know). Like I'm literally telling them to stop trying to fox with Medicare, I will pay them instead, but they can't wrap their GED-earned-in-prison brains around the concept enough to get it done.

    I mean I really, really know they know BCBS is primary because they sent me a bill (for the Aero T) that had BCBS paying 80%. Literally all I want to do is have them bill for a TR and I will pay 20% and they will make a 45% profit off the whole deal and we will all go about our merry ways.

    Maybe I could buy the wheelchair in cash and then BCBS could directly reimburse me without going through a DME at all... is that a thing?

  3. #13
    Senior Member Oddity's Avatar
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    Wow. I'd say "unbelievable", but who are we kidding?! Not looking forward to my first foray into getting a chair using Medicare. I use an SCI rehab facility for seating, I can only hope they have a handle on the process. Jesus. What a shite show.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  4. #14
    I have medicare and BC/BS Advantage, And I got a TR two years ago or maybe three without a problem. And I have NM for a dme. And it’s the second time I received a TiLite titanium. I think it’s probably not your insurance but the particular agent at your dme just not wanting to do the work.

  5. #15
    Senior Member NW-Will's Avatar
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    Are you using NM in Portland ?
    Quote Originally Posted by spinner View Post
    I have medicare and BC/BS Advantage, And I got a TR two years ago or maybe three without a problem. And I have NM for a dme. And it’s the second time I received a TiLite titanium. I think it’s probably not your insurance but the particular agent at your dme just not wanting to do the work.

  6. #16
    Senior Member NW-Will's Avatar
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    This Medicare Advantage you speak of.... what are the disadvantages of this? Why would someone on Medicare not move to Medicare Advantage ?

  7. #17
    Quote Originally Posted by spinner View Post
    I have medicare and BC/BS Advantage, And I got a TR two years ago or maybe three without a problem. And I have NM for a dme. And it’s the second time I received a TiLite titanium. I think it’s probably not your insurance but the particular agent at your dme just not wanting to do the work.
    Imo your implication that the agent is lazy is probably a nice way of putting it. But I mean who is overseeing these people? I assume they're gonna make a couple grand off of selling me an overpriced chair and accessories. They have to communicate with me all the time, I'm sure I've wasted several hundred hours of their office staff's time. Is no one overseeing them to say "hey why hasn't this guy got his chair yet, it's been a year and a half?"... I guess not. They probably make much more money throwing geriatric patients with broken hips into ill fitting transport chairs because they just order whatever they're told to.

    I left out of my above story, but I was working with Numotion or whoever they were bought out by prior to finding out that they were out of network. Inside of 3 months they had everything ready to go and sent me a bill, billing BCBS only, no muss, no fuss, but they were out of network so I would have had a 40% copay.

  8. #18
    Quote Originally Posted by NW-Will View Post
    This Medicare Advantage you speak of.... what are the disadvantages of this? Why would someone on Medicare not move to Medicare Advantage ?
    1. It's a network. You can't chose any service provider. You have to select a service provider that is in the network. Just chose a network that your doctors belong to. Problem is all your doctors may not be in the same network. I had to give up one of my doctors for this reason. But I was pleasantly surprised that the new doctor was excellent.
    2. It's managed care, which means that you may have to fight for some services. That may be a big problem for some types of insurance. But Medicare Advantage has to follow Original Medicare guidelines so it's not an issue. Hasn't been a problem for me. In fact, I appreciate how Medicare Advantage contacts are local and know your doctors vs some stranger on a 1-800 line with Original Medicare.
    3. Doctors get less autonomy with Medicare Advantage. This may be a disadvantage for the doctor but it may be an advantage for the patient. Not all doctors are competent and ethical. How would you know until it's too late?
    4. Medicare Advantage plans vary in terms of cost and benefits. Your location may not offer a good plan.

  9. #19
    Senior Member NW-Will's Avatar
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    thank you for the insight.

    If I choose to go on medicare advantage, and find it is worse, can I switch back to my regular medicare that I am on now ?

    Quote Originally Posted by August West View Post
    1. It's a network. You can't chose any service provider. You have to select a service provider that is in the network. Just chose a network that your doctors belong to. Problem is all your doctors may not be in the same network. I had to give up one of my doctors for this reason. But I was pleasantly surprised that the new doctor was excellent.
    2. It's managed care, which means that you may have to fight for some services. That may be a big problem for some types of insurance. But Medicare Advantage has to follow Original Medicare guidelines so it's not an issue. Hasn't been a problem for me. In fact, I appreciate how Medicare Advantage contacts are local and know your doctors vs some stranger on a 1-800 line with Original Medicare.
    3. Doctors get less autonomy with Medicare Advantage. This may be a disadvantage for the doctor but it may be an advantage for the patient. Not all doctors are competent and ethical. How would you know until it's too late?
    4. Medicare Advantage plans vary in terms of cost and benefits. Your location may not offer a good plan.

  10. #20
    My understanding is that if don't like Medicare Advantage, you can switch back to Original Medicare anytime. But if you don't like Original Medicare, you can switch to Medicare Advantage only during open enrollment period (end of year).

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