Page 3 of 5 FirstFirst 12345 LastLast
Results 21 to 30 of 48

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

  1. #21
    Quote Originally Posted by NW-Will View Post
    Are you using NM in Portland ?
    Salem

  2. #22
    Senior Member NW-Will's Avatar
    Join Date
    Apr 2008
    Location
    Vancouver WA USA - - Male T4 ASIA B incomplete
    Posts
    1,726
    Good to know and worth double checking I guess.
    Quote Originally Posted by August West View Post
    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).

  3. #23
    Quote Originally Posted by NW-Will View Post
    Every DME and PT I speak to act as though it's voodoo and there is some grand wizard somewhere making these decisions and no one is truly certain how it works.
    In my experience, this is 100% truth.

    Quote Originally Posted by funklab View Post
    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?
    That is an option, and, from what I know, you may have actually have a better shot at coverage than a DME would. You can find a "member claim form" on the BCBS website and send that to them. You'll need an itemized bill for the chair, and it helps to have a letter of medical necessity from your physician explaining why you need that specific chair and accessories.

  4. #24
    Quote Originally Posted by Matt Bellman View Post
    In my experience, this is 100% truth.



    That is an option, and, from what I know, you may have actually have a better shot at coverage than a DME would. You can find a "member claim form" on the BCBS website and send that to them. You'll need an itemized bill for the chair, and it helps to have a letter of medical necessity from your physician explaining why you need that specific chair and accessories.
    Man this really might be realistic. My PCP is a nice guy who will write whatever I tell him to and when Numotion got the chair approved and I realized they were out of network I called BCBS and made them give me all the approval codes for the different options on the chair, I think I’ve still got those somewhere.

    has anyone done this before?

    its a damn shame if I literally have to become my own DME to get a chair, but I will happily avoid giving those incompetent time wasters any of my or my insurance companies money.

  5. #25
    You definitely don't need to work with a DME supplier to get a chair, unless the chair manufacturer has some exclusive sales agreement with the DME supplier. They're supposed to make both the manufacturer's and the customer's lives easier by serving as a bridge that connects everyone, including the insurance providers. You could buy from an online retailer like SpinLife and then submit a claim for reimbursement to BCBS. Just make sure you have all the information for the claim in hand before​ you purchase the chair, just so you don't miss anything.

  6. #26
    Member
    Join Date
    Jan 2005
    Location
    San Francisco, CA, USA
    Posts
    41
    Funklab,

    I feel your pain. I am often caught in the Medicare as secondary world due to my wife's work insurance being primary. Every year about this time (because of deductibles) I usually see at least one mistake.

    I didn't see it mentioned, but recently I've seen DME providers substitute the TR with the Aero T + Justification for the "Titanium Upgrade" to get around the medicare rules that directly prohibit paying for a Titanium Chair.

    Clearly your in-network provider is motivated to get Medicare to pay for part of the chair. It's not clear to me why however. In my opinion, usually the reason is 1) They don't understand how the system works and it's easier to do what they know. (as suggested earlier) 2) They think they can get more money out of the system by billing medicare as well. (Sadly, this often works as I've seen on several occasions the medicare claims contractors assign a 20% copay without taking into account the primaries payment and the DME provider trying to pass the cost on.)

    I think some DME venders are scared of medicare as they may get flagged if they have an above average number of reimbursement requests for upgrades. Also, there are some weird rules about repairing a chair that medicare doesn't have documentation for which causes some headache. But I don't think either of those things should be relevant to you.

    Also, if my memory is correct, they can get in trouble if they don't submit a claim on your behalf... (but that has nothing to do with whether it gets denied.) They may not know how to (or have a computer system that doesn't know how) to submit a TR request properly... in which case, go back to option 1 above.

    Having said all that. The way it typically should work is as follows if you go in-network.

    1) Primary Insurance and the DME should have a contracted binding amount that the DME agrees to accept as payment in full for the equipment. If the primary agrees to it's medical necessity and coverage benefit under the plan, they will pay their portion. So, say 80% of $5000 ($4000) for example. (And the DME can't charge you more without breaking their contract with the primary).

    2) Once your DME gets the EOB from your primary stating the amount of coverage, they submit that information to medicare, including the original binding price agreed upon by the primary insurance and any remaining amount due.

    a) if Medicare approves, they will determine a payment amount as if they were primary and initially based on their reimbursement schedule. So lets say they would pay $4500 for the same chair. They would determine their portion if they were primary as $3600 (80%). However, they will only pay up to the outstanding balance owed ($1000), which they should pay in full (and you would should owe any copay whatsoever.)

    b) if Medicare denies, then I think you have it correct. Your in network provider will determine the price and pay their share. You will be responsible for the rest, no more no less. Medicare can't influence that exchange.

    I don't know for sure but I'd be curious if there was an option with medicare that lets them pay what they would -as-if- you had bought an aluminum chair and also then recognize your chair in the system. I suspect that would be inviting a fair amount of more pain working with the DME provider so it may not be worth it.

    Also, be careful about buying in advance. If you pay cash DMEs will often charge you differently and depending on how you do it, they may not be bound by their contracted price with the primary insurer.

    My (not great) advice would be to see if you can get BCBS to confirm their contracted price and see if they can help advocate with the DME. If the DME is not living up to their in-network obligations, that could be an issue for them.

    M

    edit: Also... in case you feel like torturing yourself more... I often reference the Medicare Secondary Payers Manual and have relevant details ready to go whenever I talk to a provider that is trying to railroad me. It usually helps them switch gears from auto-pilot to actually figuring stuff out:

    https://www.cms.gov/Regulations-and-...CMS019017.html

  7. #27
    “Okay so I called BCBS and stayed on the phone with them for 58 minutes trying to get this taken care of. They told me there is no guarantee that they will cover the titanium until we submit a claim and at that time it would be too late. If they decide not to pay for it we won’t be able to bill Medicare or bill you and we won’t be able to return the chair back to the manufacture.”


    Above in quotes is what the DME sent me yesterday. Sounds like a load of horse shit to me (especially because I had an out of network provider show me a bill with them billing only BCBS and BCBS covering 60% of the chair). I basically replied asking them to clarify if they were unwilling to move forward with ordering a titanium chair. I’m gonna make them tell me they don’t want my business if that is the case.

    So my BCBS plan is 20/80 in network and 40/60 out of network. Any idea if BCBS would reimburse me 60 or 80 percent of their covered amount if I did it on my own? I mean if it’s just me and the insurance company, surely neither of us are out of network, right?

  8. #28
    Senior Member Oddity's Avatar
    Join Date
    Oct 2008
    Location
    Virginia Beach, VA
    Posts
    3,429
    Blog Entries
    1
    Quote Originally Posted by funklab View Post
    ?Okay so I called BCBS and stayed on the phone with them for 58 minutes trying to get this taken care of. They told me there is no guarantee that they will cover the titanium until we submit a claim and at that time it would be too late. If they decide not to pay for it we won?t be able to bill Medicare or bill you and we won?t be able to return the chair back to the manufacture.?


    Above in quotes is what the DME sent me yesterday. Sounds like a load of horse shit to me (especially because I had an out of network provider show me a bill with them billing only BCBS and BCBS covering 60% of the chair). I basically replied asking them to clarify if they were unwilling to move forward with ordering a titanium chair. I?m gonna make them tell me they don?t want my business if that is the case.

    So my BCBS plan is 20/80 in network and 40/60 out of network. Any idea if BCBS would reimburse me 60 or 80 percent of their covered amount if I did it on my own? I mean if it?s just me and the insurance company, surely neither of us are out of network, right?
    That's crazy. They can easily receive a "predetermination of coverage" before ordering the damn chair. BCBS has an entire department dedicated to doing this. Call them yourself. This DME isn't working for you IMO.
    "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

  9. #29
    Member
    Join Date
    Jan 2005
    Location
    San Francisco, CA, USA
    Posts
    41
    Totally agree with oddity. DME is trying to get rid of you now. Call BCBS and explain whats going on. Ask if they can walk you through the process. Heck, get both the DME an BCBS on the line (after you talk to them privately). I'd also ask if there is a process for leaving a complaint about a contracted vendor.

    They should have applied for a coverage determination with BCBS, which BCBS would likely have sent you a copy in the mail as well. This is done all the time to determine if a DME will get paid.

    The letter will say something along the lines of "We've determined that a benefit exists..." and then a disclaimer that "this isn't a guarantee of payment" (which is their way of saying _if_ it turns out you have the right medical necessity than we cover it under our plan... but that's as much as we will say legally.

    Oh also, do you happen to know if your plan is a standard BCBS plan or a self insured plan just being managed by BCBS... If you're lucky enough for the latter, often you can go back to your HR and tell them whats going on. They usually have the power to get good people on the phone.

    Sorry, this gets my hackles up. You shouldn't have to pay out of network prices if you're health plan will cover you!

    M

    Edit: Oh yeah, and typically I kinda play dumb when people give me BS answers, and I just keep asking them to explain it... If they give me an answer that I know not to be true, I just ask a more detailed question. "So... walk me trough the normal process again... what forms did you have to submit to BCBS to confirm coverage? Oh... ok... so did you do that? What information did you put on that... do you have a copy so I see what BCBS thinks about it?.." etc... Usually if you don't get mad, but never stop asking questions, they eventually decide to work with you as its the only way out.

    Caveat: I've given up on two occasions with insurance issues. The first was over $5 that I had spend a good 40+ hours on. The second I found an alternative in network vendor and proceeded to tell everybody I knew how terrible the first vendor was. (Including plan administrators who had a sympathetic ear.) Both decisions increased the quality of my life.

  10. #30
    Quote Originally Posted by catalystpt View Post
    Edit: Oh yeah, and typically I kinda play dumb when people give me BS answers, and I just keep asking them to explain it... If they give me an answer that I know not to be true, I just ask a more detailed question. "So... walk me trough the normal process again... what forms did you have to submit to BCBS to confirm coverage? Oh... ok... so did you do that? What information did you put on that... do you have a copy so I see what BCBS thinks about it?.." etc... Usually if you don't get mad, but never stop asking questions, they eventually decide to work with you as its the only way out.

    Caveat: I've given up on two occasions with insurance issues. The first was over $5 that I had spend a good 40+ hours on. The second I found an alternative in network vendor and proceeded to tell everybody I knew how terrible the first vendor was. (Including plan administrators who had a sympathetic ear.) Both decisions increased the quality of my life.
    I have done similar things in the past when I had some time during the day. Unfortunately I am working a relatively "normal" schedule from 8 to 6ish every day so it's hard for me to find time spending hours and hours with the DME explaining in detail to them how they are supposed to do their job.

    Also when I did find some free time and call them the conversation would go something along these lines.

    Idiot - "Medicare denied the claim so we resubmitted it for the second time."

    Cripple - "Oh, okay. Is this the last time, can you explain to me why we can't just go ahead with BCBS only since they're primary?"

    Idiot - "Huh, what? We can't not bill Medicare."

    Cripple - "But you did bill Medicare, you just told me they denied the claim."

    Idiot - "Yeah, but we resubmitted it. We won't hear anything for at least 30 days."

    Cripple - "In the mean time can we just move forward with BCBS?"

    Idiot - "No we can't do that. I would go to prison!"

    Cripple - stunned silence

    Cripple - "Why would you go to prison?"

    Idiot - Exasperated sigh as if the cripple is the stupidest person in the world "It's illegal for us to not bill Medicare! I already told you that. I would be arrested and go to jail. I don't know what you want me to say."

    Cripple - "I'm just a little confused what would prevent you from billing my primary insurance just because my secondary insurance denied the claim. Like I've been saying for the past year I never expected Medicare to cover anything."

    Idiot - "Look that's just all I can tell you. We'll let you know if they approve it in 30 to 90 days."


    What really burns my ass is that if I do their job for them they will actually make a little money off of the whole transaction. I'd happily pay the extra $1000 today to get the last 15 months of my life back, but since that's not a thing I'm at least gonna waste a healthy amount of their time with emails and texts.

Similar Threads

  1. Replies: 3
    Last Post: 05-21-2014, 06:06 PM
  2. Have medicare and I need a secondary
    By terry_s1968 in forum Work, School, & Money
    Replies: 4
    Last Post: 03-04-2012, 10:57 PM
  3. Replies: 4
    Last Post: 01-27-2009, 12:46 PM
  4. Replies: 0
    Last Post: 11-21-2002, 08:49 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •