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

  1. #41
    Senior Member NW-Will's Avatar
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    Yeah I managed to get a titanium TR in 2012 on Medicare/medicaid, it was all surprisingly painless as compared to today.

    Quote Originally Posted by Oddity View Post
    A couple years ago CMS issued clarification on the use of HCPCS K0108 (the "unspecified wheelchair upgrade" code) for titanium frame upgrades. Since TiLite changed titanium to an "upgrade" option this code got used a lot, in conjunction with the ABN, to get titanium chairs. CMS, however, ruled this to be "un-bundling", which is against the rules (when you break a product or device down into its components, and bill separately for them, which gets the DME more $, when there is already a code that includes those components.) There is already a code that includes titanium, but it's not reimbursed via Medicare, so/but/however "un-bundling" titanium as an "upgrade" is fraud.

    Thats my understanding, anyway, and as it was explained to me by the billing folks at Woodrow Wilson Rehab Center.

    If anyone has gotten a titanium chair, through traditional Medicare, between late Dec 2016 and now, I'd love to see their EoB (otherwise I'm gonna call internet Bs ��). It definitely happened before that, occasionally.

  2. #42
    Senior Member Oddity's Avatar
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    Quote Originally Posted by NW-Will View Post
    Yeah I managed to get a titanium TR in 2012 on Medicare/medicaid, it was all surprisingly painless as compared to today.

    Interestingly, Medicaid has traditionally been the easier route to a titanium chair, since some state Medicaid departments never barred their codes from reimbursement. When I worked for a Medicaid contractor, years ago, covering ~15 states, most of them approved K0008 and K0009 chairs. It wasn't but so long ago that Medicare would too, with a bit of a fuss. Now they are K0005 only, in the "ultra-light" category.

  3. #43
    I thought about starting another thread, but maybe enough of you will read this post, so I'll try this first. I'll try to make the question as straight forward as possible so maybe someone might have an answer for me.

    Quick recap: I have BCBS thru work, it IS my primary insurance, no one in the below situation believes otherwise, including the DME. I have Medicare secondary because ??? I'm not sure I haven't had a medicare card in several years and I haven't paid a

    The DME jerked me around a while longer and then said that they couldn't move forward with ordering my chair for this reason:

    Medicare didn't approve the titanium chair (fine with me, this is my overall goal), but BCBC (my primary insurance) has approved the chair. I'm ready, able, willing, and chomping at the bit to pay whatever BCBS doesn't cover.

    The DME provider says they can charge BCBS, because BCBS is primary, but that they cannot then charge me for the titanium upgrade (and other things). My understanding is that BCBS has an "approved amount" that the DME has (this is apparently super duper secret and I'm not allowed to know it), so I'd have to (and desperately want to) pay everything above and beyond that amount. DME says charging me for this would in effect be like upgrading from aluminum to titanium chair and charging me the difference (something that I know is a no-no if you have Medicare).

    I say it's not the case, let Medicare deny the chair, then just run it through BCBS like any other "normal" claim... I fail to see why a Medicare denial would mean you WERE NOT ALLOWED to get the item. That's like saying if the titanium chair got denied by Medicare and I just went to Bike-on or sportaid and bought one with my credit card we would somehow be breaking the law. Or since Medicare doesn't cover toilet seats, if BCBS does cover the toilet seats the DME provider would be breaking the law by charing me any copays.

    Anyone done this before or know how I can prove this to the DME?

    Now I'm gonna get long and rambly because I have to vent. At first DME says BCBS won't give them a precert, so they won't know how much they will be paid and wont move forward for that reason.

    I call BCBS today and it goes like this:
    BCBS: "Hmmm is this a 'normal' wheelchair"
    Me: "Yep, it's a normal ultralight wheelchair"
    BCBS: "Is it over $500?"
    Me: "Ohhh yeah, waaay, waaaaay over"
    BCBS: "Hmm, it should be covered I think, let me check, can I put you on hold?"
    Me: On hold for 20 minutes.
    BCBS: "I spoke to 'her' and 'she' said it wasn't a normal wheelchair it was a titanium one, we don't cover things that are for convenience"
    Me: "It's an ultralight wheelchair, every paraplegic leaves the hospital with one, you definitely cover them."
    BCBS: with an attitude now, "I'm sorry sir, we just don't cover things for convenience"
    Me: "May I ask who the 'she' you were referring to a second ago is?"
    BCBS: "It's Evelyn (names have been changed to protect the incompetent)"
    Me: Stunned silence.
    Me: "You mean Evelyn the receptionist at the DME?"
    BCBS: "Uh, yes"
    Me: Stunned silence
    Me: "So the DME provider is telling you, my insurance company, what your policy covers?"
    BCBS: "Uh, she said they don't cover titanium chairs"
    Me: trying not to lose my shit because I've been shopping in Target while I'm on the phone, "Are you seriously telling me that the DME provider is telling you what your own policy covers"
    BCBS: "Well she said it wasn't covered."
    Me: "The DME provider said that"
    Awkward silence
    BCBS: "Well I guess I could look it up in your policy."
    Me: "... yeah, that would be great, thanks"
    Me checking out in Target in disbelief for another twenty minutes on hold
    BCBS: "Yeah, so we cover ultralight chairs and these codes (lists 9 different CPT codes) are covered"

    SMH, what da fox, BCBS? How do you call some little incompetent ass DME to see what YOU cover on YOUR policy?!?!??!?!? That's like McDonalds calling the beef supplier to see if the store's policy is to give refunds to customers who got cold hamburgers...
    Also, by this point in the conversation I had made it clear that the DME is clearly the incompetent one in this trio of patient-insurance-DME, and they still called them. Breaks my mind.

    But when I got off the phone with BCBS I still had a little while before the DME closed and drove over there in person (Evelyn, the one who hasn't been able to figure this out in the past 15 months has ignored me every time I ask to speak to a manager). I get the manager (we'll call her Jane) and it goes a little something like this.

    Me: "Hey... [insert brief recap of the situation] so I have these CPT codes and BCBS says they're all covered at your approved rate, so we should be good to go, right?"
    Jane: "Uh, well... some of those codes don't have dollar amounts, the K0108 doesn't have a reimbursable amount it's just meant to cover miscellaneous upgrades and extras"
    Me: "But K0005 is an ultralight wheelchair, right?"
    Jane: Looking a bit confused, "Yeah I think."
    Me: "Cool, so just charge me the balance"
    Jane: "But we wouldn't get reimbursed"
    Me: "What do you mean? BCBS says it doesn't require precert, it's covered at the allowable amount. Just charge me the balance, I'll put it on a credit card right now."
    Jane: "Uh, but we can't do that because you have Medicare"
    Me: "So what, they denied it. Let them deny it."
    Jane: "But medicare won't allow titanium upgrades"
    Me: "Awesome, but that's irrelevant, this isn't an upgrade, Medicare denied the chair completely, so lets go forward with BCBS"
    Jane: "I can't do that, it's illegal"
    Me: "Nope, it's definitely not illegal. Who do I need to get on the phone with you to prove that it is not illegal?"
    Jane: flustered, "Uh, uh, it's policy" shrugs
    Me: "Well your policy is incorrect"
    Jane: "Well you'll have to take it up with corporate, I just follow the policy"
    Me: "Word. What's corporate's number?"
    Jane: Looking confused like I called her bluff.

    These incompetents don't know who they're foxing with. I work a lot, but I have monday afternoons off by 3:00 or so most Mondays for the next couple months, and Thursdays I can be there by 4:30 or so, I'm gonna pester them (in a polite, but annoyingly persistent manner) in person until they can't stand me any more and actually bother to do a little of the work. I mean that's all I want. If they would do a teeny, tiny bit of the work I'd be okay with it.

    Thus far I have personally done the following:
    1. Told them exactly what chair I wanted
    2. Told them exactly what measurements and options I wanted on the chair
    3. Told them who is primary and secondary on my insurance
    4. Told them again who is primary and secondary
    5. Waited for several months with me asking near daily for the exact measurements, then corrected them, because they were trying to order different parts and different measurements than I wanted.
    6. Told them it doesn't matter that Medicare denied
    7. Told them the EXACT codes that BCBS covers (they were apparently unable to get this information themselves)
    8. Told them that BCBS covers at an approved amount (suddenly they realize that this is indeed the case).

    I'm not sure that they've done anything at all for me besides waste 18 months of my life and few couple dozen hours of my time on the phone, emailing them and driving out there in person.

    Also, as I'm typing this I called Medicare and they say as long as they denied it, they don't care what DME charges BCBS or me. But they also say they will not put that in writing, the DME will have to call the Medicare Provider Line, and they can't give me that number.

    But obviously the DME isn't going to do that, besides, they don't really care as long as that is their policy. But I've got google, I can find a goddang Medicare Provider Line number.

  4. #44
    Senior Member Oddity's Avatar
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    Wow. TiLite TR chairs are coded K0005, right?! You should be totally good to go. Stick to it opihi. You've sunk so much time into this BS already, I'd love to see you get what you want. And I'd love to see this DME find a bag of flaming shit on their door step the morning after you get your chair.

    Here's a crazy thought: If Medicare hasn't sent you a card in a couple years, and you're not on SSDI any longer (where they deducted your premiums), are you even sure you're currently enrolled?!? Are you sending them the premiums every month? Your eligibility span might be over if you haven't been sending them monthly premiums. I'd call CMS and verify. It would be awesome to be able to tell DumbassME you don't have Medicare anymore, wouldn't it?
    "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

  5. #45
    Now I've figured canceling medicare all together will probably be the ticket (I don't really need it anyway and since disability ran out and Medicaid hasn't covered me for the last 18 months, I expect they're going to ask me for a monthly premium at some point. Not sure where those bills have been going or who (if anyone) has been paying.

    Called Medicare. Apparently you can't cancel Medicare through Medicare (had to wait 20 minutes before I got someone to tell me that, of course), all you have to do is mail a form to social security, sounds easy, but unfortunately the only way to get this form is by calling Social Security and requesting it...after ten minutes battling through endless inane chatter about exactly what law this disclosure covers and asking me repeatedly if I want more information, not understanding either me when I say no, scream no or just curse like a sailor at the stupid automated machine I finally made it to the queue... expected hold time... 55 minutes...

    I swear if I thought it was humanly possible I'd make it my life's goal to fix Medicare's broken ass system just a little bit. I'll have the credentials to do it, but alas I'm pretty sure I lack the administrative, bureaucratic bullshittery necessary to succeed in a job where you're main purpose is to create the largest amount of red tape and paperwork humanly possible and use said red tape as an excuse to avoid actually doing any work.

  6. #46
    Lol, I was already typing that out before I even saw your reply, oddity. We really are on the same wavelength sometimes.

    I am still definitely on Medicare, cuz I spoke to coordination of benefits today and they said Medicare was secondary.

    I wouldn't be surprised if I get a bill for 18 months worth of premiums (like I said medicaid was covering it at some point, but they dropped me a month or two after I started working, almost two years ago now). I just did the math and it could be $2000... that would really suck if I gotta pay them 2 grand and all Medicare did for me during that time was complicate my insurance to the point that the pea-brained DME couldn't figure it out.

  7. #47
    Senior Member Oddity's Avatar
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    Hah! That's funny.

    One potential benefit to sticking with both insurers is the waiting period between going back on SSDI and re-enrolling in Medicare, which the first time you go on SSDI is ~24 months. If you will ever go back on SSDI it might be worth it to keep Medicare to avoid the 2 years of expensive COBRA. I don't even know if ObamalamalakumCare will allow you to enroll if you're on the SSDI/Medicare waiting period. I'd seriously recommend looking into this before making the decision to drop Medicare.
    "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

  8. #48
    My understanding was that for some period of time (I want to say 5 years, but it's probably some odd number of months like 107 knowing the SS administration) you could just reenroll pretty quick like. Maybe I'm wrong though.

    But in this brave new world instead of Cobra you could just go Obamacare until Medicare kicked in, couldn't you? I ran the numbers on a silver plan a couple years ago and it was like $15,000 a year total out of pocket including premiums, deductible and max out of pocket copays, which isn't great, but it isn't terrible. Hell it's better than Medicare if you got a bunch of outpatient bills to pay at 20%. Either way I plan to work for at least the next 5 years before I would even think about getting back on Medicare, so I'm not gonna pay $8000 in premiums for that gamble. Even if the rules say I have to go the Cobra route now, there's no telling what will change in the next five years. Hell, worse case scenario I'll just mail order a bride from Thailand and make her get a job with benefits, then have her add me to her insurance before I quit so I can wait out the medicare waiting period in style.

    After an hour and fifteen minutes on hold SSA agreed to mail me the form to cancel medicare, and also informed me that this month is the first month that medicaid is not paying my premium, they asked me if this was why I was calling. I told them nah, I hadn't seen anything from medicaid or medicare in over a year. Pretty dope timing, if these bozos at NSM weren't bumbling idiots I might have noticed for years until medicare somehow found my new address and sent me a massive bill. I thought medicaid wrote me off well more than a year ago. But looks like I'll only be on the hook for one month of Part B premiums.

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