Insurance Issues

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Permalink Reply by Rebecca on October 17, 2009 at 8:09am

When I tried to get my Dexcom they called to tell me I'd be responsible for 20% of the cost. The reason I picked the health plan I did was because 100% of durable medical equipment was supposed to be covered and when I told Dex that they say that they weren't a "preferred provider". I had to push them to go through CCS Medical which is where all my Omnipod stuff comes from. I was lucky enough to know about CCS Medical because my pump company set me up with them. Once I told Dex that I wasn't going to pay they said they'd give CCS Medical a call, a week later CCS called me to let me know it had been shipped and I owed nothing. I would suggest calling your insurance company and seeing if they have a list of preferred durable medical equipment providers. If this doesn't work and it is a problem with it being the Dexcom itself you may be in for a long battle doing lots of research showing it's effectiveness. Good luck

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Permalink Reply by Erika Roe on October 17, 2009 at 11:41am

You can find out why they refused to pay for the system on your statement of benefits you get from your insurance company, usually it comes every time you get supplies, etc.
I've heard that BCBS is covering some on a case-by-case basis. Your sales rep can usually tell you about their expierence with the common insurance companies in the area and what the typical coverage might be for someone with your type of coverage. They told me you can get insurance coverage for the Dexcom system if you have documentation of having lots of lows and at least one hospitalization due to a low blood sugar and your doctor's support of this. I've had lows, but none of them have required treatment from someone else, and I've never been hospitalized due to diabetes. So, I have BCBS of NC and paid 100% of the costs out of pocket because I thought it would help me. They really should cover the CGM because it has been proven that continous use leads to lower a1c's and less health problems and more savings for them in the long term.

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Permalink Reply by etta v on October 18, 2009 at 10:15am

Every insurance company has its own criteria (although it is not always possible to get a copy of it from them). My insurer has started approving more and more of them. DexCom's standard paperwork that was supplied to me by the DexCom rep, asks all of the right questions. They work together with your medical provider to present the best case for you as possible. Fill it out in a way that puts you in the "worst" light, within the range of honesty, and then hope for the best.

Good luck!

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Permalink Reply by Rickst29 on October 18, 2009 at 3:41pm

Gadzooks, Erika.

That's my own insurance company (I'm in RNO). That "template" BCBS letter which I offered Jana (below), will make them cave in less than one hour. Do a "friend" request, we'll trade email addresses privately and move forwards from there.

You do not need to have hospitalizations, or car crashes, or anything of the sort. You do need to have your treating MD agree that it's medically necessary. (Your Endo did submit a PAR, right?) But after the denial arrives, you will need to send the appeal letter yourself. That's because your Endo is an in-network MD, s/he can't write a letter with the necessary anger and threats to another MD-- it simply isn't done.

Do take note that even if your Endo did submit a PAR, s/he almost certainly didn't initiate an appeal. BCBS is delighted to have you yack with their $8 per hour "customer service" reps all day, all night, for months and months, settling nothing. It takes an actual appeal, where another denial would actually risk the license of the MD who claims to be qualified and expert in this specialty, to get the correct result.

When it's about that particular MD's career, and not just about money, BCBS-NV (which is actually run out of Colorado) has never come up with the "wrong" answer yet. ;)

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Permalink Reply by Rickst29 on October 18, 2009 at 3:42pm

Jana, YOU are the covered policy holder, but maybe your MD sent in the PAR (Prior Authorization Request) and and it was denied (as "not medically necessary"). If so, you need a copy of that denial letter from your MD. Your EOB (Explanation of Benefits) will not have enough detail to initiate your Appeal.

In nearly all States, all BCBS units are now "pushovers" for T1s getting CGMS coverage. The issue which you're looking at now is whether or not it will be paid at in-network rates-- but if they've actually denied coverage, then you need to start by getting it covered. Which is easy-- I've got a form letter, which we can customize for your specific case and send as a request for Appeal, not a mere Prior Authorization. They'll almost certainly cave immediately. (So far, customized variations of that same letter are six-and-oh for T1s against against BCBS units, and it's won in multiple States.)

BUT, if they're only playing with the money, and have already accepted responsibility for the coverage, then follow Rebecca's steps to use one of their providers or demand that it be done through CCS if none of their providers will offer it.

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Permalink Reply by Don on October 18, 2009 at 4:29pm

Rick,
my insurance is BCBS Anthem in CA. Do you think your above advice might work with them? I've never understood the difference between BCBS Anthem vs just BCBS.

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Permalink Reply by Rickst29 on October 18, 2009 at 11:20pm

Yep, it will work. "Blue Cross/Blue Shield" is not an actual insurance company, it's an association. They share marketing materials, some back-office functions, and mostly agree to divide the country up so that each area is served by only one company (although, IIRC, there are several exceptions, including CA and ID, and others, where multiple companies compete with each other and BOTH are members of the association).

Anthem is a special case: "Anthem BCBS" units all used to be operating arms of another big company, but it was bought out/merged with WellPoint a few years ago. Anthem is now just another "doing business as" name of WellPoint corporation. Wellpoint is of the nation's largest, most obscenely profitable, and (IMO) most abusive for-profit health insurance companies. AFAIK, it owns and operates all of California's other "Blue Cross" businesses, too.

California persons under "Blue Shield" are not under Wellpoint. It's parent is a very old non-profit named "California Physicians Service". Being non-profit doesn't cure all ills (some people hate it), but there's at least a chance of the company not screwing all it's customers with every premium payment.

** off-topic screaming starts here** Wellpoint pretends that their profit margin is only about 3 percent. But with Wellpoint's income from premiums at 14.1 $Billion last quarter (the 10Q of 07/29/09), and payout of actual benefits at only 11.7 $billion, they're blowing obscene amounts of money on lobbying, bonuses, exorbitant salaries, jet aircraft for executives (they own 4), retained earnings, and etc. (etc. including the costs of growth via buying out all these companies which used to be their competitors. With their cash-equivalent war chest bulging at over $17 BILLION, they might start hunting again very soon.)

This is a payout "loss ratio" of only 83%. 20-30 years ago, Health Insurance companies typically had payout ratios in the mid-90s, but Wellpoint manages to gobble up almost 1/5 of their premiums with "expenses" and "profit", which return not a single dime to actually pay for health care. That's why "health care" costs so much in the USA-- a vast portion of that money is not! buying health care, it's being spent on obscene salaries, corporate jets, and other companies. And fraudulent stock options-- but I'll talk about UHC some other time.

BTW, a former Vice President of Wellpoint tells Max Baucus what to do about "reform", working for him as "Senior Counsel to the Chairman and Chief Health Counsel".

Here's a picture of a Dassault Falcon 2000 jet, just like Wellpoints': http://commons.wikimedia.org/wiki/File:Dassault.falcon.2000.vp-bdl.... Nice plane! Their 3 Hawker 800XP jets are slower and older, and less roomy. Wellpoint's CEO tried to hide their ownership of these jet by claiming that they only lease it from netjets, but that's a lie: Wellpoint is!!! a co-owner, just look at the FAA registry.

**off-topic screaming ends here**

Anyway, your Anthem Denial is easily overturned, with just one letter. Per above, it invokes the formal appeal process, and that puts an MD's license on the line, requiring a qualified response. (When you invoke the policy, it can no longer be answered by anyone in the "customer service" chain of command-- it has to be answered by a qualified MD.) She won't try to defend their stupid policy; she'll approve the coverage. The policy makes no sense, and she knows it.

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Permalink Reply by Don on October 19, 2009 at 11:10am

Tx very much Rick. Your info is encouraging. I do not have documented hypo-unawareness or history of hospitalizations so I've been holding off attempting to get coverage. I will expect and take in stride the initial denial and plan to invoke a formal appeal directly, not through my doctor, invoking my policy and out of customer service chain of command.

Very interesting to understand that the BCBS I have in CA may not be owned or have the same corporate chain as BCBS in other states. Another example of how health care service is not transparent and open to comparison. One person's experience of "BCBS" in another state may have no relationship at all with my experience of my BCBS in CA! Health care is complicated and the companies can easily bureaucratize and obfuscate and run us around endlessly because we don't understand how it works.

Beats me why the health care industry was ever granted exemption from anti-trust laws. Reverse the exemption and health care companies will be forced to serve us better as competitors enter the market. In theory, anyway.

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Permalink Reply by Kathleen Belisario on October 20, 2009 at 5:40pm

I've been paying out of pocket for my sensors since July 2009. It's a stretch for me since I'm retired. Medicare does not cover the Dexcom but I was thinking if I sent a letter (Request for Appeal) maybe I can slip under the system and try to get it covered. I've been a Type 1 for almost 50 years and it has been getting tougher and tougher to keep my levels even. The Dexcom is a tremendous help! Let me know about the form letter please.
Kathy

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Permalink Reply by Anna Martin on October 18, 2009 at 5:35pm

I'm in a similar position. I talked to Dexcom almost 3 months ago about getting a 7+. My insurance company told me they'd cover it and not to worry. But last week, they told me it was not medically necessary and I really didn't need it. (Since I have many severe lows (like, seizure severe) a week, I really don't know how my insurance can tell me it's not medically necessary.)

But I got a letter from the insurance company telling me it's not medically necessary. Dexcom has been really helpful about contacting my insurance company. I have 60 or so days to appeal the decision, and, since my insurance company has spent thousands of dollars for me to go to the ER for lows, I really feel like I have a good chance of getting an appeal in my favor. I think, for you, I'd try to get an official denial letter from your insurance company, and then I'd try an appeal. It's working fairly well for me so far.

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Permalink Reply by Rickst29 on October 19, 2009 at 1:33am

Anna, you will not win your Appeal by claiming to know their finances better than they do. Even the discounted payments on your EOB's don't tell the whole story-- Hospitals often pay enormous kickbacks, under labels like "annual quality inspection/assessment charge", for the privilege of being an in-network facility. The net costs to the insurance company, for transportation and ER treatment of all those lows, is probably a lot less you than you're thinking. (DKA episodes cost a lot, but lows are cheap, cheap to treat.)

The beginning MUST invoke the formal appeal process, otherwise it goes "into your file", where customer service can ignore it forever. The exact wording which they used in the denial is the key (even if it was very, very short). That's what you need to refute. Keep repetition of information which they already have to a minimum-- stuff from your Endo and other treatment personel doesn't need to be repeated again, it's best brought up by reference (originating person date sent). You MUST demand that the response come to you, with a specific deadline of no more than 30 days ahead of the date sent.

You also don't have to quote from the NEJM/JDRF study, or the FDA approval letters, or AACE guidelines, or anything like that: they've already seen it, a short reference and summary sentence is fine. With that background established, you state your case: Typically, for a denial that "benefits are not proven", you would summarize than an MD who dares to deny this device as "medically necessary" for your treatment is claiming to be more expert than the FDA; and ignores the results of the JDRF-sponsored study in last October's NEJM (the most respected of all American peer-reviewed journals); and feels free to ignore the findings and recommendation of your personal Endocrinologist.

Then comes your threat: "An MD who refutes all of these qualified experts and denies FDA-approved treatment, used exactly per FDA labeling, is very possibly practicing outside the scope of his/her medical competence. If the reviewing MD feels qualified to again determine that the device is "not medically necessary", the letter which informs me of this decision will include the license number(s) and State(s) of license for that person, because I will possibly want to file a complaint with the Medical Licensing Board of that State to investigate that person's behaviors and decisions. I recommend that you inform your decision maker of my intentions, in advance of the decision."

Note the run-on. That's intentional ;) A sentence about your anger is also needed, to emphasize the threat: Every lawyer whom I've ever heard or read, when talking about medical lawsuits and "defensive practice" techniques, emphasizes that you need to take extra-special care of the angry pts. and relatives. Your letter needs to show you as one of those extra-angry policy holders, one who might go to great trouble to ruin a career if someone at InsCo dares to confirm the denial again.

When it's a career, and not just money, you win. No one whom I have worked with has EVER had to follow through on such a threat.
- - - - -

I hope that this has been firm without being nasty to you (that's how I intended it, just "firm"). For everyone, I hope that this longer display of appeal letter format and contents shows why your MD or nurse absolutely can't send it. (Heck, even when an MD learns that a colleague is practicing under the influence of drugs or alcohol, it will hardly ever be brought before the Board by that physician. It's usually handled with a personal phone call, that "... you need to stop seeing patients immediately, then retire or get treatment, or I *WILL* probably have to inform the board of your problem." Direct threats of to file a complaint with the medical licensing authority, as in this letter, come only from patients and lawyers.

But only the lawyer-coached patients use the correct terminology. That's what makes your "coached by Rick" letter utterly terrifying. (I'm not a medical professional of ANY kind, but I have listened to several relevant presentations at conferences with my DW-- an MD in a totally unrelated specialty. I know the words, especially for the case of the Nevada Board of Medical Examiners.) Please don't make a mistake by sending an improperly prepared, un-reviewed letter. It takes many, many hour to undo the damage caused by a bad appeal letter-- a bad letter often doesn't work, and after it fails, they'll pick at EVERYTHING you provided in order to use it all against you at the next level.

Above all, watch your dates-- do NOT let an appeal deadline pass without taking action!

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Permalink Reply by Kathleen Belisario on October 21, 2009 at 5:45pm

Tell you the truth, my endo was not very encouraging about me getting a dexcom. I had to really insist that I needed one. When I went back after getting it I think I made an impression on how much it was helping me.
Anyway, I do have severe lows, and living alone they can be very scary. I have never been to the ER for a low and I hope this doesn't work against me. I am going to try to put a letter together with your notes and see how It goes.
Wish me luck as I wander thru the Medicare maze!!
Kathy

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