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Thread: DME refusing to accept BCBS negotiated rate, has anyone gone through this before?

  1. #1

    DME refusing to accept BCBS negotiated rate, has anyone gone through this before?

    Good morning,
    BCBS approved a custom wheelchair back for me, after demoing several, I decided on a custom Roho Agility back. My DME informed me they don't feel they're being reimbursed enough by BCBS and are refusing to place the order unless I sign a release, I know better than that. BCBS told me it's extremely unusual for a DME to refuse the work within their contract, unfortunately, this is the second time I've run into this. The different DME I ordered my chair from pulled the same thing, I paid up front so they'd place the order. BCBS tried to get my money back for me, the DME lost their BCBS accreditation, and I lost $3,000. We've been going back and forth for 4months. Has anyone had this happen to them and how did it work out? I know how lucky I am that the back was approved, and don't want to settle for my second, non custom choice, but I'm using a wrong size demo right now and at the end of the day the my CRPS is miserable. I've hit my out of pocket maximum but my year re-starts Apr. 1st.
    Thanks for the input!
    -Murphy

  2. #2

    Angry DME wants me to sign a ABN for pre-authorized service Anyone have this experience?

    I already posted about this,I reread it and realized it wasn't clear, sorry, trying again.
    I am going through an in-network DME. BCBS pre-authorized a wheelchair back for me. DME says BCBS's negotiated rate is 1/2 of the cost of chair back and is demanding I sign an ABN to pay for the other half. Is this allowed/legal? Other than not signing it, do I have a remedy? Everything I've read says ABN's are Medicaid and are used when an item is not covered by insurance. Mine is covered, DME isn't happy w/the amount it's covered for. I've been going in circles since November w/them. Has anyone had this experience? What did you do? How did it work out?
    Thank you!
    -Murphy

  3. #3
    Senior Member Oddity's Avatar
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    Really,only your insurance company can help you. The DME can bill you however their contract with BCBS, as an in-network provider, and your specific benefit plan, says they can. Since this is BCBS, and an ABN Form, it sounds like you're on a Medicare Part C "Advantage" plan. Are you? ABN process is original Medicare only. If you aren't on Medicare, then, (regardless really) you need to escalate this with your insurance company to find out exactly what you're allowed to be billed for.
    Last edited by Oddity; 03-28-2019 at 09:39 PM.
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  4. #4
    Thank you Oddity. I'm not on Medicare at all, strictly BCBS PPO. I'm pre-approved @100% of their contracted rate for the chair back. The problem is, DME isn't satisfied w/what BCBS is contracted to reimburse and wants me to pay the rest. *sigh* BCBS says they escalated it again today, I wonder how many times it can be escalated before it lands on someone's desk that can do something
    -Murphy

  5. #5
    "Sorry" but sounds like you are caught in passing the problem back and forth between the DME and insurance which is leaving you without your new chair back.
    I'd just ask for another DME/vendor in your insurance plan and give it a try with new DME.
    Otherwise the DME and insurance company will just keep going back/forth.
    I take it that you already spoke with a Manager or Supervisor at both the DME and your insurance company?
    "Good Luck!"

  6. #6
    Yup --they want you to pay what they want to get. That it violates their contract with BCBS is a mere nicety.

    I'd check your plan certificate and confirm with BCBS that they cannot balance bill you if in network, and that they are in fact in network -- sounds like you have but get a name and title and preferably email documentation for the next steps.

    Step 1 -- If this is a national DME, assuming you have exhausted options with everyone at the branch, I'd contact the regional director or manager. There will also be a national call center that takes complaints. Make sure both the call center and regional exec know you did both.

    Step 2 -- I'd send a copy of the plan certificate to the DME and, if applicable, its national HQ, in a registered letter along with the confirmation from the plan, and tell them you will be exercising your full legal rights if they do not supply the product accepting the BCBS reimbursement as legally required, under a contract in force. Copy BCBS, the wheelchair manufacturer, Permobil/Roho, your clinic, your legislators.

    Step 3 is a campaign on social media, your local TV station, the works.

    The reality is that BCBS doesn't have as much skin in the game as you. So while I would keep pushing them to rattle the DME's cage, if this has been going on since November, I would focus on the DME myself. It's your back.

    As for starting over with another DME, which will take time in itself, a DME who does this should be called out, not just for you but for everyone they have probably suckered/will keep cheating into payments they shouldn't have made.

  7. #7
    You need a legal advocate. Tell any and all local media, mention BCBS and the DME name.

  8. #8
    You say that the DME is offering you their services but they aren't doing it under the terms and conditions of their BCBS contract. When your DME tries to negotiate a different price than what is in their contract, they are essentially refusing service. In which case, BCBS should intervene and find a different DME. Remember that you have a contract with BCBS not the DME. The DME has a contract with BCBS. Hence, your recourse is through BCBS. More importantly, BCBS is obligated to provide a medically necessary service/product that is in your contract. In other words, make BCBS find another DME to provide the service at their cost not yours.

    I went through the same thing while getting a wheelchair. The first 2 DMEs weren't getting paid enough so they refused to provide service. One said so straight up while the other just played games and delayed. In hindsight, I appreciated the first DME being honest. Because they weren't wasting time. My medical group then told me, after 2 years, that they have a third DME that they can use but they don't like using them because they cost more (to them not me). Too bad. Ultimately, they approved the chair with this highest paid DME and I got my chair.

    I have a HMO not a PPO. Hence, my medical group was my point of contact. If you don't have a medical group, maybe you have a primary care doctor as your point of contact? If not, then you're stuck dealing directly with BCBS. Good luck.

    Slightly off-topic, I've been happier with an HMO than a PPO. They market a PPO by saying it offers more choice. Technically, that is true. But a more accurate representation is "PPOs are an option when a service provider who you must see isn't in-network. For this one benefit, you get less and pay more for everything else." But they would never say it that way. After all, an HMO is more cost effective for them so it's more cost effective for you.
    Last edited by August West; 05-05-2019 at 12:21 AM.

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