Insurance Company Grievance - Advice please!

Just wondering if anyone else has come across this problem? So, I have been using an insulin pump and a CGM for the last several years. I just got new insurance through Anthem BCBS. I get my supplies through Edgepark. My warranty on my pump and CGM is now up and I am trying to get a new one. Insurance says to go through Edgepark for new pump and CGM. Edgepark says they aren't contracted to provide the pump and CGM. Called Anthem back and they keep giving me names and numbers for local Durable Medical equipment vendors. No local DME places do anything with pumps or CGMS! So frustrating. I just filed a grievance because I have spent hours upon hours trying to find someone in network. Anthem says my pump and cgm are covered 100 percent, but they can't/won't give me an in network provider!!!! Help please!!! I have submitted all my info to Dexcom too and they say they aren't in network either. There are only a handful of companies that do anything with Pumps and CGM's!!!

have you tried the pump companies them selves? that's what I did. gave my info to medtronic and they handled the insurance. you might want t give the company for the pump your interested in a call

I echo Jtausch's advice to go through the pump/cgm companies. That's what I had to do recently.

I share your frustration. The warranty on my dexcom transmittor recently expired and in the midst of trying to get a replacement through the supplier I've been using, Pumps It, my transmitter died. Pumps It was great about expediting, but my insurance company, BCBS of Louisiana, kept telling me that there was no pre-certification submitted for my cgm transmitter. The Pumps It rep contacted my case manager at BCBS and found out that BCBS thought I was requesting a pre-cert for a pump and they did not realize it was a cgm so they just weren't acting on it. Basically the Pumps It rep was able to straighten it out with my case manager from BCBS and get approval over the phone. It shipped the next day. So apparently the vendors can get to the right people at the insurance company, where the patient cannot.

Just an update to this post. First, I started with Dexcom. They told me that they couldn't verify my insurance coverage. I told them, no less than 8 times, that they needed to run my insurance through Anthem BCBS and under DME....NOT through my prescription coverage. Guess what? They ran it through my prescription coverage. Of course. Needless to say, I was beyond frustrated. They deal with insurance all the time. The Rep they hooked me up with was pretty much terrible. I filed a grievance with BCBS and had a phone call back within 24 hours, as well as a case worker that I was assigned to. The caseworker was clueless, but at least she tried to be helpful. I kept calling Anthem and finally got to a customer service rep who did what he said he was going to do. He researched it for me and found out that Liberty medical is in-network. Thankfully, I will only need to use liberty to get my Dexcom starter kit. After that, I'm going back to Edgepark to get supplies. Edgepark is pretty terrible, but Liberty is even worse. Hardly anyone at Liberty speaks English. They route you to a hundred different places before you can get to the right person. I'll be so glad when the maze of this insurance/Dexcom fiasco is over and that I won't have to go through it again for oh....well...another six months....when my Dexcom transmitter fails. Oh joy. Diabetes is such a common condition. You would think that these companies would have worked out a smooth system by now.

I have BS of California and they told me that they would cover the minimed 530g with enlite at 85%. After i get the pump in the mail I get a letter from BS saying that medtronic is out of network so they are only gonna pay about 15% so the part I have to pay jumped from $1150 to $6274. I called to ask what are your in network insulin pump providers then and surprise surprise they have 0 in network pump providers. So now I get to wait 30-45 days for them to review my grievance and hopefully add medtronic as an in network provider while my pump and cgm just sit in the box

Hey Simone, by law they have to provide someone in network for you. They can’t just say everyone is out of network. Edgepark and liberty are in network for me. I had to do a lot of research to even find that out. I think they try to keep it a secret so we will give up.

As of yesterday they had a total of 0 in network insulin pump providers. I searched their website, talked to two different people in the claims department and a supervisor and they all told me they have 0 in network at the moment. The supervisor said that since they had 0 in network there is a pretty good chance they will end up paying the 85% that they originally told me they would be paying

I have defended Liberty Medical for years as they have been excellent for me--until the past year. Now, I am going to send a note to my fed gov retirement group to argue against it for next year. I have been a customer for years and suddenly, in the past year, they can't keep track of my orders and I have to re-order. I used to get my pump supplies within 2 or 3 days. Now, I am on my last reservoir and I was supposed to call back today to get a UPS tracking order to get supplies over-nighted and guess what! No one is there! I called the main # plus the insulin pump number. So, I doubt I will get my supplies by tomorrow, or even Monday. (I ordered 1.5 weeks ago.)
I don't mean to redirect the thread but just to support that I hope you can use another mail order option if possible. Being with gov insurance, I am stuck with them until fed BCBS changes sources.

This whole thread makes me extremely grateful my pump supplies come directly from Insulet and my CGM supplies come directly from Dexcom. All these "middle men" just drive up prices and complicate the whole process.

Hey Simone,

Sorry, I wanted to respond to you more earlier but was on my phone and it's hard to type there. Once you file a grievance, which it sounds like you did, they should assign you a BS Rep. If they haven't done that already, you may want to call and ask for one. After I filed my grievance, I was given a rep. She called Dexcom, even though they were out of network, and try to negotiate a price with them. Dexcom, of course, would not negotiate which is ridiculous. Anyway, I learned from someone else that if your insurance doesn't have anyone in net-work that they will often do what is called a "Gap Exclusion"...this means that they will use Medtronic (even though they are out of network) and allow you to use the provider as if they are in-network. I'm sorry for all that you are going through. Everytime I have to wait on the phone for 45 minutes with insurance, another 45 for Dexcom, and another 45 for Liberty I just get more and more angry at all the hoops we have to jump, fly, and dance over to get the things that we use on a daily basis to survive.


After my experiences with both Edgepark and Liberty, I would discourage anyone from using either of them if they can avoid it. Edgepark, on a regular basis, charges my insurance company for either too many supplies or for supplies I never got. I'm probably one of the few people who actually follow my claims and turn the mistakes into the insurance company. BCBS is losing millions from Edgepark if they are doing this to everyone! Liberty medical is a joke. You can't get a hold of anyone there. Ever. You will wait on the phone for 45 minutes to speak to someone who can't speak English or to leave a voicemail. I keep getting automated calls that there is something wrong with my order. They refused my dexcom paperwork because my doctor forgot to put my A1C on there. WHO CARES!!! Why do we have to keep "proving" we have diabetes to these people anyway?! Liberty messed up verifying my insurance 4 times. My doctor's office HATES them because they always have to send faxes to liberty no less than 5 times. There is no easy way to re-order. I so wish I could just get a year's worth of supplies and be done with it. I hate dealing with these people. For the first time in two months, I woke up this morning relaxed....knowing that now that my Dexcom fiasco is complete that I don't have to call insurance, Liberty, or Edgepark and be on the phone daily for hours.

Yes they sure do Clare! It's a huge mess!! I don't see how insurance companies think this is saving them money!!! Edgepark overcharged my insurance $2,000 just in the last month!!!!! That $2000.00 would have paid for my Dexcom system....directly from Dexcom itself!!!

Right. In my order 1.5 weeks ago I specified NO IV preps because I have an oversupply. Yesterday, they had the IV preps listed to deliver. They have a standard order and you have to really fight to get it tailored to your needs. They clearly "lost" my order and re-inserted their standard package. Though with Medicare (BC secondary), I don't get any extra syringes or infusion packs. I get individual packages thrown in the big box to make my set of 30 for 3 months. It is true, in my opinion, that medical supply companies are a main cause of health care costs, along with pharmacological companies. If those two orgs were under control, our costs would be more similar to European countries. Just ask someone who needs a $100 wheelchair, on Medicare, and they will tell you that Medicare "rents" it for a year of outrageous charges before you own it, at quadruple or more of the $100. Or any durable medical equipment! Sorry, that is my rant.

I know Nell! There definitely needs to be more regulation when it comes to these third party suppliers. I've had the same thing happen to me at Edgepark. They threw in all kinds of junk I didn't need, but boy they sure don't EVER throw in an extra sensor, infusion set, or reservoir. Boy buddy! Those things are like gold! My prescriptions are funded through our state Medicaid program. I get my alcohol wipes through that program. Well, I went to the pharmacy to fill the script. Denied. Why? They need a prior authorization. Denied. Why? It wasn't the brand they wanted. Denied again. Why? It was too many. I just went to urgent care because I have a terrible case of bronchitis. Went to pharmacy. They hand me a HUGE name brand bottle of $85.00 cough medicine with narcotics in it. No questions. No paperwork. What the heck?!!! Why was that so easy, yet something I use everyday of my life and that's really cheap is hard to get?!!! Makes no sense.