Recently, my supplier (Pumps It/Solara) arbitrarily delayed a shipment of transmitters, requiring me to use finger sticks for about a week until they arrived. When I inquired, they could not determine the reason for the delay. They mentioned that in addition to a prescription, they are required to have chart notes from my most recent endo visit and they have to be less than six months old. They claim this required by the insurance provider.
I’m curious if anyone else has run into this and if you understand this. Is this required by industry regulation, my policy or BCBS? Or is this a policy of the supplier?
I feel that notes of private meetings between me and my doctor are the most sensitive and privileged information in my medical records. How are they used in determining coverage for a claim? Why isn’t some other documentation sufficient, say a letter of medical necessity, sufficient for this purpose?
My insurer said the doctor should send them directly to the supplier. If they are required to determine coverage in certain curcumstances, why is the supplier privy to that information? Why doesn’t the insurer manage it?
If you are on Medicare, it is 180 days firm (not six months) if you are MDI and 90 days firm (Not 3 months) if you are on a pump in order to receive your supplies and medications. I was once within 6 months at day 182 and everything was delayed as it is all based on days, not months. That is when I got educated on their rules.
I’m not on Medicare (yet). And I get that insurance has an interest in medical necessity of any treatment they cover. But why is the supplier in that loop? Why should they have access to privileged information? Or is there something I’m missing?
I went through this recently for an order of pen needles. Like you I have private insurance, although it is Anthem Blue Cross. Under my insurance plan if I buy pen needles from an in network DME company I pay $0. When I had my endo send the prescription to the DME company it took two or three months for the first order to ship. One of the many reasons over those months I was given that my order hadn’t shipped was they were waiting on chart notes.
I nearly lost my mind when I heard that.
Now here is a good time to point out that @CJ114 is correct, medicare requires DME suppliers to keep documentation to support the medicare claim in case they get audited and this includes chart notes. Many insurance plans use medicare codes, requirements, etc. so they don’t have to reinvent the wheel. Except they do for some plans but there is no explaining crazy and US health insurance is c-r-a-z-y. This is why your insurance might classify a Dexcom as DME even though there is nothing durable about a disposable sensor. Medicare does it so the insurance plan does it too.
So when my sanity returned I decided to call my insurance company and make them deal with their evil DME company. I got a great agent on the phone, I over shared a bit, she said her mom was diabetic and chart notes for pen needles is crazy. We called the evil DME company and while waiting on hold the insurance rep is waiting for her computer to show her the actual requirements for a DME supplier to submit a claim for payment for pen needles. I’m filling out the HHS HIPAA reporting form. And the evil DME company rep gets on the phone and says we are waiting for chart notes and the insurance lady says I’m looking at our requirements and…
oh…
chart notes are required.
So yes, some insurance plans require the DME companies to keep a copy of chart notes for some DME items.
So my doctor has to send privileged information to what is basically a store so they can send it to the insurance company every time I place an order so they can determine if I am entitled to coverage.
Sure, just use a supplier that does not require doctor’s notes. They may require attestation and verification that you visited your endocrinologist within a certain period of time for CGM and pump supplies, but that is about it and that is determined by your insurance company, not the product(s) vendor(s).
I thought the chart notes were required by the insurance provider. That’s at the vendor’s discretion? What are you saying is determined by insurance?
Another better way: since it’s an insurance requirement, THEY should accept my doc’s attestation or chart notes and leave the vendor out of it all together. I don’t get why the vendor is involved at all. They have no need for access to that data.
The insurance company makes the rules. The insurance company determines what they require from the vendor to pay them. The vendor contacts the insurance company to determine what the patient must provide to get paid for the supplies and medications they deliver.
I am on Medicare and get supplies through CCSMed. It is a breeze and mostly an automated online ordering system. They ask how much of each item is needed and the date of last endo visit. A few days later my supplies arrive FedEx or UPS. They change carriers from time to time. They give you the option of getting your Dexcom supplies every 30 days or every 90 days.
I’m still on regular employer based insurance and I’m still 8 years away from Medicare. I don’t understand this need for chart notes. If I need cgm or insulin or whatever, today I will need it next quarter too. I’ll need it the next year and after that.
Are they suggesting that I will be cured or be able to ease off my type 1 diabetes, and some months hey, I don’t think I need to check my blood sugar.
Who is coming up with these rules, because it takes time and effort to fulfill the requests, when the data is useless past the first time. I mean yes I get there needs to be a doctor the first time showing the need, but after that it’s just annoying.
The insurance companies, including Medicare, say the reason is to prevent fraud. For example,
And what that $1.2 billion number doesn’t include is we are all paying more for insurance and supplies because the insurance companies are (sometimes) requiring the DME companies to keep extra records.
I think this will all soon become a moot point. Until recently, hospitals rabidly guarded their patient records, and it was difficult to coordinate patient records for patients being treated at different facilities using different portals to store their medical records. Over the past few years, hospitals found it much more profitable to share patient records, and it is now possible for many hospitals to see patient records across different portals. This is far more efficient and synchronized records lead to lower costs, fewer errors, and better knowledge of all medical treatments being received by a patient. It is only a matter of time before all suppliers of medical equipment and drugs share in the same portal.
Pharmacies in the US since a few years have access to all patient prescriptions regardless of which pharmacy they use. This is done to avoid a patient filling the same prescription at several pharmacies. The only exception is that this system is not yet in use across borders, so you could get a medication or equipment filled in the US, for example, and then get it filled in Canada or another country.
I think there is a balance. Accessibility to data can improve treatment and reduce errors. But it should be need-to-know and patients should have some measure of control.
I also think that with medical costs being what they are, fraud is a real issue. Settings side the very real and serious problems with the current model, ultimately, insurance is a business. If they fail, that will be bad for everyone. A good solution has proven to be elusive.
It may be that MC has to make choices about what and how much data it can mange and that the rest of the industry will follow suit. But cost should not be a factor in assessing need-to-know. Shifting that burden to the vendors is inheirently less secure.
CH114, 90 days is three months. Yes, it could be a day or two short of three complete months, but it is considered three months nonetheless.
Treatment notes show that you are still seeing your provider and in need of the Rx. We will need insulin today, tomorrow, and forever, but the Rx is only suitable for one year. The system is set up this way to help prevent fraud and corruption. While we patients may find this frustrating the doctor’s offices also find it frustrating. My previous endo in Colorado had two nurses on staff who only handled insurance PAs and these tasks.
It is only the same in your mind. The Medicare rules are firm and that is what counts, not an individual’s opinion. My supplies have been delayed in the past because my endo appointment was within the months established, however over the required number of days by 2 days. I learned this lesson the hard way and I am sure it will only seem a moot point to you until if and when this situation happens to you.
