Announcement

Collapse
No announcement yet.

Medicare as secondary.. still has to approve?

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • Medicare as secondary.. still has to approve?

    Getting a new wheelchair (possibly hopefully) so I figured this was the best forum for it. Maybe some of you know if I?m off base here.

    Basically i have private insurance as primary through my job, BCBS. I also still have Medicare cuz I just came off of SSDI a few months ago. But for sure that means BCBS is primary and Medicare is secondary.

    My intellectually disadvantaged DME tried to switch my TR to an Aero T (without telling me) because they said Medicare would deny the titanium frame. I said that?s fine, let them deny the hair and move forward with BCBS. Now they?re saying they can?t do this because they will go to prison if they don?t charge Medicare and therefore if Medicare doesn?t approve the TR they won?t order it.

    what the hell?

    that can?t be right, right? I mean I get my meds without ever billing Medicare, is my pharmacy gonna to to jail for that?

    surely they are just full of it and don?t know what they?re doing, Right?

    i was working with another company and they had the order ready to go charging just BCBS in 3 months. Then I found out they were out of network. I?ve been working with the incompetence of NSM for 15 months and now they?re trying to tell me I can?t have a titanium chair.

    Its super frustrating to me because if I have to go back to the first company I?ve waisted a year and a half for no reason and I also have to pay an extra 20% copay which is gonna be another $1000 out of pocket or so.

  • #2
    You're in what's called a "coordination of benefits" scenario. The rules are varied. Start here to educate yourself a bit. Medicare might still be primary, but you'll have to research via CMS a bit for authentic/knowledgeable advice.

    https://www.medicare.gov/supplement-...#collapse-2437
    "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

    Comment


    • #3
      Medicare is definitely secondary, I work for a big huge corporation and I am no longer getting disability. Even my current DME says they’re secondary.

      Comment


      • #4
        Ti lite lists the TR vs Aero T frame weight difference as 9 vs 14 pounds. My shoulders are already giving me hell, I don’t need to lug any extra weight in and out if the car six times a day.

        Comment


        • #5
          I feel your pain.

          I really wish there was a definitive place to go to find info about how this works. 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.

          It seems like it's in everyone's interests but ours to keep this process and rules as obfuscated as possible to keep us in the dark. (similar to how real estate agents like to think of themselves!) And like real estate, we do this so infrequently, you don't do it enough to know the intricacies of the rules, my favorite quote is, "Oh it's all changed from the last time you got a chair!"

          Where are DME's going for information that they use for these arbitrary decisions? I say arbitrary as it seem different DME's and PT's have different interpretations. Find the right combination and you have GOLD!

          Comment


          • #6
            In my last DME battle, I called Medicare and badgered people up the food chain until someone agreed to write me a “benefits clarification letter” which I then took to the DME provider and suddenly they shut up and did work. Best wishes.

            Comment


            • #7
              My understanding is that Original Medicare disallows titanium upgrades but Medicare Advantage may approve it. I don't understand why. But I am being told it has something to do with fraud control.

              Comment


              • #8
                Originally posted by funklab View Post
                Medicare is definitely secondary, I work for a big huge corporation and I am no longer getting disability. Even my current DME says they?re secondary.
                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 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

                Comment


                • #9
                  In that case, the primary may pass along the 20% copay to Original Medicare who may deny it completely leaving the entire 20% copay to the member. Medicare Advantage shouldn't do that.

                  Comment


                  • #10
                    He doesn't have Medicare Advantage. That's basically an HMO contracted to coordinate benefits for a Medicare enrollee, using the HMO's benefit package (as long as it meets minimum requirements). Whether, or not, an Advantage plan will reimburse for a titanium chair is entirely up to them, and different plan to plan.

                    His primary BCBS plan probably doesn't have the same 80/20 co-pay. It's just a traditional large group plan via his employer.

                    There really is no reason to continue to carry (and pay for) Medicare coverage, as secondary, other than to maintain continuing coverage, and avoid the 2 year wait in the future if he wants to go back on SSDI and Medicare only 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

                    Comment


                    • #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.

                      Comment


                      • #12
                        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?

                        Comment


                        • #13
                          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

                          Comment


                          • #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.

                            Comment


                            • #15
                              Are you using NM in Portland ?
                              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.

                              Comment

                              Working...
                              X