In my last question I asked what to do about my insurance suddenly refusing to cover my pump 6 months after they approved it/I
began using it. They claimed that it was due to a rise in my A1c (they
are choosing to ignore that the rise was due to no longer having daily hypos),
showing the pump was not the best treatment, followed by claiming they never
approved it in the first place. I worked with Medtronic and my Dr. to put
together an appeal and have been waiting for word since then. (They told me
someone would get back to me in 30 days or more.) I didn't hear from
anyone. I filed the complaint on May 11th, it is now June 10th and today
Medtronic sent me a bill for the full cost of the pump, I called the rep that
was helping me and then my insurance.
The first time I called the insurance company today they claimed they never got the faxed
appeal but they sent out a request for more information to my doctor. I called
my doctor and confirmed that the fax was sent and documented as such.
Then I called the Insurance Company back and they said that they did in fact
get the appeal and the next day they sent out a request to my Doctor's Office
that I stop the pump and go back to shots for 72 hours while checking my sugar
every hour to see if it's really medically necessary.
So again my question is: Has anyone had this experience? This 72
hour thing sounds like a trap. Is that really going to show a clear picture of
my control? I could have 2 great days followed by 4 awful ones. I really don't
see how that proves anything, it feels like just another way for them to push
me around and deny me coverage now 9 months after approval.
Any information or tips you can give me is always greatly appreciated.
I love the pump, it's given me so much freedom and I'm able to live with much
less fear hypos. I can't imagine going back to shots and feeling like I'm
always playing catch up to all the variables.
I’ll probably get yelled at by someone for not supplying a constructive response, but it could still be somewhat useful.
Does your employer have a Benefits Administrator to whom you can direct some of these questions? My employer has one, and I’ve spoken with her on occasion but it’s sometimes difficult to keep up with the insurance-speak. (Which is to say, talking to one who knows insurance so well, they forget that you don’t – and you end up feeling shelled by the time the conversation is finished.)
I also believe that insurance carriers and those who work for them are bureaucracy personified. It would be impossible to ensure that 100,000+ employees all know the limits or inclusions of a given plan, much less have the same information at the same time for the same situation. The inevitable result is that it’s much easier and profitable to deny a claim and push the burden of proof back on the policyholder – after all, you have all the time the world, why are you bothering them?
Having said that, perhaps another letter to the insurance carrier is in order, worded in such a way that you’re asking them to explicitly state what they need from you to satisfy eligibility. Put it back on them, and if you’re lucky enough to get such a response, follow it implicitly. When they come back with a denial or hem & haw, you’ll have ammunition for an appeal addressed to the state Insurance Board.
Good luck.
-vicki
Vicki has a good idea in writing a letter to ask them to specify what they need - but don’t think anything you do is going to “put it back on them” because they won’t feel the pressure even when the ball is in their court. You’ve got to initiate the full court press, to carry the analogy further.
I find that the more you make a pest of yourself - even if the ball is in their court - the more likely you are to get the result you want. Send the letter then get all over them about a response. Send them data and information, then confirm that you sent it, then send it again.
If they want to be left alone, they’ll find a way to approve you. That’s my experience, anyway.
Good luck,
Terry
True enough, Terry, that pushback falls in the proverbial pipe dream category.
Still, I think I’d enjoy immensely making myself a complete and total pest rather than cave to the tenets of bureau-speak – which include blowing off the complainant until they become so utterly exasperated as to give up.
So, ish, adopt an Internal Revenue Service agent personae and hound those insurance people as if they owe you money to pay for the bank bailout or Gulf Oil spill. Be relentless and unforgiving until you receive the full complement of benefits you paid for!
-vicki
Do you have a copy of the initial documentation that insurance approved the pump? My insurance requires pre-auth and I have found keeping copies of all preauth’s to be helpful.
If you don’t have the initial approval medtronic probably has a copy. They generally won’t release anything unless they get it in writing so they probably have something.
And I agree with the others do everything they say.
The other possibility here when they’re talking about the checking hourly for 72 hours I wonder if they mean they want an 72 hour CGMS done rather than hourly fingersticks. That would make a lot more sense to me.
Diana
I say appeal appeal appeal! Go to the human resource department and talk with them. They may be able to help you. They would be able to tell you what is not covered and just go from there.
What … a … pain.
I highly suggest documenting dangerous hypos that you experience on injections.
I had to provide evidence that I still needed the pump and the doctor always said that the pump was mostly to prevent dangerous lows (I think that she emphasized this much more than lower A1c, but perhaps she mentioned that as well) .
This 72 hour logging shows that insurance companies done really get type 1 diabetes. You can’t get a real picture with three days, we all know that.
ALSO, my doctor told me to expect a higher A1c when I started on the pump UNTIL we got my rates tweaked. That is a good reason to explain it.
I did, I even printed up the graphs from sugar stats, highlighting all the lows and percentage of hypos before and the improved numbers after. It also showed that my A1c was going down and I was in range more than not on the pump and much less so on shots. I don’t understand how they possibly need more information than that!
It makes me crazy because I really had no part in the agreement between medtronic and my insurance, I mean after the paperwork it’s medtronic and the insurance company working out what exactly is and isn’t covered… I was told by both parties I was 100% covered and now I’m just getting the run around. I did everything by the book and now I’m getting bills I can’t handle.
My doctor thinks it’s madness and absolutely pro-pump and I’ve definitely been won over.So I guess I just have to keep jumping through hoops.
The insurance company doesn’t care about the sane argument. My doctor has explained to them, I’ve tried to explain. At the end of the day they say “whether or not it was due to hypos, your A1c was better on shots” there’s no logic going on, just b.s.
How did you provide evidence that you needed the pump? I have no idea where to start now.
I’ll try that, the problem is that the insurance says they never agreed to cover it in the first place. But I was told by both the insurance and medtronic that it was fully covered and then it was sent to me. I’d been using it for 6 months before the insurance company decided it suddenly wasn’t allowed.
It seems that no matter how many times my Dr. tells them otherwise they claim it’s not and never was medically necessary.
It’s so frustrating.
No because they didn’t send it to me, medtronic has the email from the insurance company giving the confirmation/approval code. But my insurance company says they didn’t send it and if they did, it’s not valid. (how is this possible?) Medtronic tells me they have the paperwork but they can’t do anything with it. Whatever mistake was made on either side, it seems I’m the one of the hook.
I asked them if that’s what they meant and they said that wanted me to test with my meter.
I really am at a loss here.
Thank you for the advice. I plan on nagging them non-stop at least press them for correct information, because each time I call it’s a new excuse or flat out lie.
Thank again, I need it!
A link to a site dealing with insurance issues including some information you might want to consider during your appeals process: http://www.advocacyforpatients.org/how_appeals.php
My insurance is through my Father’s work so I really don’t know what my options are in this case.
Thank you for your input, I’m going to try writing them and being a pain in the side until I get a straight answer.
Thank you, I appreciate your help!
Sounds like you have taken all the right steps. I got my insurance company saying that the pump was not medically necessary about 1 year after I started on it. I contacted my doctor and she contacted the insurance company telling them that the pump was what prevented me from having dangerous nighttime lows. That was all it took.
I think that they did a quick calculation that the pump is cheaper for them than one ER visit due to nighttime lows. I don’t get why your insurance company thinks differently.
It’s SO frustrating that insurance companies, rather than our own doctors, try to decide what is medically necessary. Ugh.
The exact same thing is happening to me. I’m at the point of giving up. I have emails/letters from my insurance and Medtronic, saying it is covered with quotes and so many agents names and the whole shananagans, but for some silly reason, the insurance is able to twist things to their likings. I’m bitter. I’ve had way too many apologies from my insurance company and from Medtronic (who really dropped the ball on this).
Truly I should not blame anyone else, but I was spoiled in the past with Animas. They always took care of things for me and I never had to do anything with my insurance. Anyhoo, bottom line, after months of appealing and calling Medtronic and my insruance, I’m now at a lost of what to do next.
I know what you are going through. Sad. I hope the end result is in your favour.
If you have documentation that the insurance co. authorized the pump, and they are now making you pay for it, I say get the state insurance board involved, the better business bureau, the state attorney general, the local press, anyone that will put pressure on the the insurance company to give you some solid answers. If you have documentation (which it sounds like, medtronic at least as an e-mail from the insurance co), than maybe you just need some pressure from an advocate in some kind of official agency to get either the insurance co. or medtronic to foot the bill. It’s time to stop getting the run-around, and start getting some solid answers. If that takes threatening from some agencies like the state insurance board, then go for it!
I am so sorry this is happening to you as well. I hope that despite the setbacks you will soon have some luck with this.
How does it happen that both sides say the other is in the wrong and yet we’re on the hook for the damage? It really doesn’t make sense to me. I don’t know how else I could have protected myself, I took every precaution. I asked over and over if at any point I was told that I was only partially covered or not covered if I could stop the process or decided against it. I was told I could. Medtronic called me while I was on vacation and told me that I was approved, when I asked them what was going to be covered and they said 100% pump and supplies. I even had them double check. A week later I had my pump. After I did my part and filled out the paperwork, Medtronic did the rest and like you now I’m stuck. Medtronic was great with me until recently when it was found that the insurance wants more info, the guy who had been working with me suddenly decided I shouldn’t talk to him anymore, I needed to go through billing now.(Funny since there’s where I started before he came in to help me. Billing told me I could maybe send the pump back but they’d expect me to pay for all supplies used during the last 9 months.) He assured me months ago he wouldn’t stop until the appeal was successful and that in no way would I be expected to to pay. I don’t know what changed.
it’s all b.s.
My doctor faxed them a brilliant letter explaining why it was medically necessary and showing the stats. I really don’t get why that’s not enough.
Before the pump I was testing low 11% of the time. probably more but those are just the ones recorded by my meter. (the lowest recorded was 48, but I had lows worse than that where my siblings had to give me juice/tabs and by the time I tested it was higher.)
After the pump (just in first 3 months of starting it I tested low (meaning under 75) only 5% of the time. And my in range sugar was up by 4%. I really don’t see what problem is here.
thank you for your input, I always appreciate it.
Thank you for your comment, all very good advice. Today, I’ve spoke to everyone I can and I’m glad to know that worse comes to worse I can contact people in higher places and perhaps they can help me.
I don’t know of any advocates or an official agency that helps with this sort of thing but my Dr. and I are looking into it. What’s happening to me and others is not right and I certainly intend to fight.