Announcement

Collapse
No announcement yet.

Getting Insurance to Actually Pay for Urologic Supplies

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

    Getting Insurance to Actually Pay for Urologic Supplies

    Not sure if this is the right forum, but it seemed to fit best here.

    Like most of us on this site I need X number of urologic supplies every month. It's been the same supplies for the past 8-9 years, no changes and no problems. I recently had to switch suppliers, and then my health insurance through work had some changes too.

    Now Care Centrix (as best I can tell they are some kind of subcontractor for my insurance company) is telling the supplier I can't have them, basically without giving a reason.

    I switched in October and got my supplies easy peasy no problem. But then they didn't come the next month, or the next. Finally I got another shipment in the beginning of January (apparently Care Centrix approved this one and the first one). So this time around I was expecting trouble and looking out for it, as soon as one month rolled around I called the supplier and they said Care Centrix had denied it.

    So I called Care Centrix. For the past two weeks they have been bouncing me from person to person (I think I have three "customer advocates" now, all of whom I call twice per day and leave messages that never get returned). They tell me my case has been "escalated" and tell me that they should be able to speak with someone from the department who denied the claim (I think it's technically under "clinical review"), but just put me on hold for 30-45 minutes and then say they were unable to reach them.

    I'm toying with the idea of just suing them in small claims court for the cost of supplies, more out of revenge than out of any hope of getting money (I'd probably lose as much money taking time off of work for that as I would get back a few hundred dollars for the supplies they're refusing to decide if I am qualified or not).

    Anybody got any advice on how to get them off of their asses?
    I really need my supplies and I'm clearly going to have to pay cash for them (at least for a few months backup) because this is turning into a pattern.



    It's super straight forward stuff I'm asking for, catheters, lube, leg bag, condom caths. I've been getting this stuff for almost a decade and every insurance company I've ever had covers it... because they're obviously medically necessary. They have an order from my doctor and for the past two weeks (I've talked to at least six different people from the company) no one has been able to give me any reason as to why they might have been denied except that "it's under further clinical review".

    #2
    Have you consulted the plan administrator at your company? If you work for a large company, there's a good chance that they are self-insured and the 'insurance company' is basically the administrator handling claims. Either way, your company should have a way to support your need to escalate the claim. Keep in mind that if your company is self-insured, going to court means that you are suing your own company. Hopefully that might provide motivation for your own company to do the right thing, but you want to avoid a situation where you lead with a legal threat b/c if your company senses a legal dispute they might channel the issue directly to their legal department and then the process will grind to a complete halt.

    Comment


      #3
      Denials have codes just like procedures and diagnoses. Your provider would know what denial code was returned on the initial claim, if the folks at the payer are too hard to deal with. I bet it was the 'insufficient information submitted to justify reimbursement' one, considering all parties (payer and provider) are apparently new to the equation. Referrals and scripts and par-provider status are probably involved somehow.
      "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

      Comment


        #4
        My best understanding (can't clarify until offices open back up on Monday, and even then probably won't get a straight answer) is that it hasn't technically been denied. It just hasn't been approved because it's under clinical review... which is effectively the same thing. Seems like clinical review took 2 months last time and 2 weeks thus far this time. No one can give me a straight answer as to why it would have been approved in October and again in January, but then put into some kind of limbo 1 month later.

        Comment


          #5
          Do you have a doctor script for them? I know I have to have one to even order them.
          Art

          Comment


            #6
            Originally posted by Art454 View Post
            Do you have a doctor script for them? I know I have to have one to even order them.
            yes

            Comment


              #7
              Mine won't cover mine . Calling them dme which is only covered every few years. I never fought it, don't have the time. I buy mine off eBay. I am able to just wild mine with a baby wipe and slide it back into the sleeve it came in and then re-use them. I wasn't going to pay a buck or more to just pee.

              Comment


                #8
                that's wrong I have noidea how except get the reason for denial then go from there but I would think that its literally a life threating situtation

                Comment


                  #9
                  I no I have had problems too. A lot of places don't like what medicare will pay so the delay you in hopes you try and find someone else. I have a case manger now so they find the people now.
                  Art

                  Comment


                    #10
                    Originally posted by Art454 View Post
                    I no I have had problems too. A lot of places don't like what medicare will pay so the delay you in hopes you try and find someone else. I have a case manger now so they find the people now.
                    I have private insurance thru my employer who (I assume) pays more than medicaid. The supplier is more than happy to get paid, this is all they do and how they make money, it’s just the middleman Care Centrix who is somehow between the insurance company and the DME that is holding things up.

                    got an email saying my supplies shipped from the supplier, but still no one has been able to tell me why they didn’t ship two weeks ago.

                    oh well, back to harassing them twice a day on Monday until someone can explain to me what has changed so that this won’t happen again.

                    Comment


                      #11
                      Oh private ins. is opening a can of worms....lol
                      Art

                      Comment


                        #12
                        In addition to the "prescription" and/or "doctor's order," you may need to have the doctor (or ghost write and have your doctor sign) write a letter of medical necessity, detailing when you were injured, your diagnosis (with the corresponding ICD-10 diagnosis codes), and line by line justification for each one of the supplies required and how often you need to refill the prescription for each supply.

                        You will probably have at least a couple to several ICD-10 codes. One describing you major injury or disease status, one for neurogenic bladder, possibly one for neurogenic bowel and any other conditions covered by the diagnosis codes that define your medical status completely. I think GJ had 6-8 ICD-10 medical diagnosis codes in his medical record with his physician. ICD means, International Classification of Diseases, and its codes hold critical information about epidemiology, managing health, and treating conditions.

                        Whether while on private insurance from his company or then on Medicare, he had his prescriptions for supplies refreshed by the doctor every six months. Private insurance was much more lenient with coverage of urological supplies than was Medicare (GJ did not use Medicaid). Private insurance covered catheters, lubricant & povidine wipes. or insertion kits for indwelling catheters (including prefiled syringes to inflate indwelling catheter balloons), leg bags and drainage tubing, up graded leg straps, securement devices, night drain bags/bottles, skin prep while using condom catheters, and cleansing wipes. Medicare only covered catheters (intermittent, indwelling, or condom sheath), leg bags and drainage tubing, and night drain bottles/bags.

                        GJ got his supplies from Edgepark. They were difficult always, but he learned to manage them, so he rarely came up short on supplies. Once, when he had a particularly hard time getting his supplies and got the "run around," he demanded to speak to the manager of the billing department. That contact proved to be the charm and was the best patient advocate he had at that supplier.

                        Just a recollection I thought to share. Hope you get some satisfaction soon.
                        NL
                        Last edited by gjnl; 18 Feb 2020, 11:46 AM.

                        Comment


                          #13
                          Originally posted by gjnl View Post
                          In addition to the "prescription" and/or "doctor's order," you may need to have the doctor (or ghost write and have your doctor sign) write a letter of medical necessity, detailing when you were injured, your diagnosis (with the corresponding ICD-10 diagnosis codes), and line by line justification for each one of the supplies required and how often you need to refill the prescription for each supply. ...
                          NL
                          gjnl-
                          You are such an amazing asset to the forum!

                          Comment


                            #14
                            My insurance has taken to refusing my usual order for 540 catheters/3 months. This is the third time they only approve 200, despite an active script on file from my Doctor. This is a pain and has delayed my order for 2 weeks. So far this morning I've made 4 phone calls to straighten it out. I use a probability model, meaning if the first phone rep does not help me i cll agin to seek a more cooperative phone rep. The last one seemed to know how to work the system, but I must wait and see, as her only option was to send an email to a different department. This is frustrating, and the only thing I can think to do next time is place my order earlier so it does not drag out so long. Apparently medicare's stock number to approve is 200. Then they send people jumping through hoops for the rest.

                            This sort of "harassment" only began this year.

                            Comment


                              #15
                              Why not simply order within the guideline of 200/1 month instead of going for an out of guidelines 90day setup (which is obviously being flagged now as being such. FYI, it has been for years. 200 monthly with a limit on over stock was put in place quite a while back. Their System doesn't seem setup to easily allow for more than 200 shipped any given month, even though its 90day order.)
                              "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

                              Comment

                              Working...
                              X