Insurance Issues

Diabetes Technology Glucose Monitoring
1

So, I called Dexcom maybe two months ago and got my paperwork started. My doc totally supports getting it and I thought we were a go! I have Blue Choice of SC, a subsidiary of Blue Cross Blue Shield of SC. The first news was that Blue Choice would not work directly with Dexcom. Heather (super nice Dexcom lady) said that that was not so uncommon and that they would try going through a company that sells the Dexcom that Blue Choice may work with. So, Dexcom tried two or three of these other companies and STILL Blue Choice refused to work with them. Now Heather has started the process of directly contacting Blue Choice to see if they will do a one-time deal with them. But, if they do a one-time deal, what about the next person who wants one?! I am already planning to switch from Blue Choice to Blue Cross Blue Shield next year anyway, but Heather said that since that is the main company that she didn’t think it would matter.

So, I am wondering: 1. can I find out why they refuse to pay for the machine? and 2. How have others convinced their insurance co. that this is needed?

Thanks!

2

When I tried to get my Dexcom they called to tell me I’d be responsible for 20% of the cost. The reason I picked the health plan I did was because 100% of durable medical equipment was supposed to be covered and when I told Dex that they say that they weren’t a “preferred provider”. I had to push them to go through CCS Medical which is where all my Omnipod stuff comes from. I was lucky enough to know about CCS Medical because my pump company set me up with them. Once I told Dex that I wasn’t going to pay they said they’d give CCS Medical a call, a week later CCS called me to let me know it had been shipped and I owed nothing. I would suggest calling your insurance company and seeing if they have a list of preferred durable medical equipment providers. If this doesn’t work and it is a problem with it being the Dexcom itself you may be in for a long battle doing lots of research showing it’s effectiveness. Good luck

3

Every insurance company has its own criteria (although it is not always possible to get a copy of it from them). My insurer has started approving more and more of them. DexCom’s standard paperwork that was supplied to me by the DexCom rep, asks all of the right questions. They work together with your medical provider to present the best case for you as possible. Fill it out in a way that puts you in the “worst” light, within the range of honesty, and then hope for the best.

Good luck!

4

Gadzooks, Erika.

That’s my own insurance company (I’m in RNO). That “template” BCBS letter which I offered Jana (below), will make them cave in less than one hour. Do a “friend” request, we’ll trade email addresses privately and move forwards from there.

You do not need to have hospitalizations, or car crashes, or anything of the sort. You do need to have your treating MD agree that it’s medically necessary. (Your Endo did submit a PAR, right?) But after the denial arrives, you will need to send the appeal letter yourself. That’s because your Endo is an in-network MD, s/he can’t write a letter with the necessary anger and threats to another MD-- it simply isn’t done.

Do take note that even if your Endo did submit a PAR, s/he almost certainly didn’t initiate an appeal. BCBS is delighted to have you yack with their $8 per hour “customer service” reps all day, all night, for months and months, settling nothing. It takes an actual appeal, where another denial would actually risk the license of the MD who claims to be qualified and expert in this specialty, to get the correct result.

When it’s about that particular MD’s career, and not just about money, BCBS-NV (which is actually run out of Colorado) has never come up with the “wrong” answer yet. :wink:

5

Jana, YOU are the covered policy holder, but maybe your MD sent in the PAR (Prior Authorization Request) and and it was denied (as “not medically necessary”). If so, you need a copy of that denial letter from your MD. Your EOB (Explanation of Benefits) will not have enough detail to initiate your Appeal.

In nearly all States, all BCBS units are now “pushovers” for T1s getting CGMS coverage. The issue which you’re looking at now is whether or not it will be paid at in-network rates-- but if they’ve actually denied coverage, then you need to start by getting it covered. Which is easy-- I’ve got a form letter, which we can customize for your specific case and send as a request for Appeal, not a mere Prior Authorization. They’ll almost certainly cave immediately. (So far, customized variations of that same letter are six-and-oh for T1s against against BCBS units, and it’s won in multiple States.)

BUT, if they’re only playing with the money, and have already accepted responsibility for the coverage, then follow Rebecca’s steps to use one of their providers or demand that it be done through CCS if none of their providers will offer it.

6

Rick,
my insurance is BCBS Anthem in CA. Do you think your above advice might work with them? I’ve never understood the difference between BCBS Anthem vs just BCBS.

7

I’m in a similar position. I talked to Dexcom almost 3 months ago about getting a 7+. My insurance company told me they’d cover it and not to worry. But last week, they told me it was not medically necessary and I really didn’t need it. (Since I have many severe lows (like, seizure severe) a week, I really don’t know how my insurance can tell me it’s not medically necessary.)

But I got a letter from the insurance company telling me it’s not medically necessary. Dexcom has been really helpful about contacting my insurance company. I have 60 or so days to appeal the decision, and, since my insurance company has spent thousands of dollars for me to go to the ER for lows, I really feel like I have a good chance of getting an appeal in my favor. I think, for you, I’d try to get an official denial letter from your insurance company, and then I’d try an appeal. It’s working fairly well for me so far.

8

Yep, it will work. “Blue Cross/Blue Shield” is not an actual insurance company, it’s an association. They share marketing materials, some back-office functions, and mostly agree to divide the country up so that each area is served by only one company (although, IIRC, there are several exceptions, including CA and ID, and others, where multiple companies compete with each other and BOTH are members of the association).

Anthem is a special case: “Anthem BCBS” units all used to be operating arms of another big company, but it was bought out/merged with WellPoint a few years ago. Anthem is now just another “doing business as” name of WellPoint corporation. Wellpoint is of the nation’s largest, most obscenely profitable, and (IMO) most abusive for-profit health insurance companies. AFAIK, it owns and operates all of California’s other “Blue Cross” businesses, too.

California persons under “Blue Shield” are not under Wellpoint. It’s parent is a very old non-profit named “California Physicians Service”. Being non-profit doesn’t cure all ills (some people hate it), but there’s at least a chance of the company not screwing all it’s customers with every premium payment.

** off-topic screaming starts here** Wellpoint pretends that their profit margin is only about 3 percent. But with Wellpoint’s income from premiums at 14.1 $Billion last quarter (the 10Q of 07/29/09), and payout of actual benefits at only 11.7 $billion, they’re blowing obscene amounts of money on lobbying, bonuses, exorbitant salaries, jet aircraft for executives (they own 4), retained earnings, and etc. (etc. including the costs of growth via buying out all these companies which used to be their competitors. With their cash-equivalent war chest bulging at over $17 BILLION, they might start hunting again very soon.)

This is a payout “loss ratio” of only 83%. 20-30 years ago, Health Insurance companies typically had payout ratios in the mid-90s, but Wellpoint manages to gobble up almost 1/5 of their premiums with “expenses” and “profit”, which return not a single dime to actually pay for health care. That’s why “health care” costs so much in the USA-- a vast portion of that money is not! buying health care, it’s being spent on obscene salaries, corporate jets, and other companies. And fraudulent stock options-- but I’ll talk about UHC some other time.

BTW, a former Vice President of Wellpoint tells Max Baucus what to do about “reform”, working for him as “Senior Counsel to the Chairman and Chief Health Counsel”.

Here’s a picture of a Dassault Falcon 2000 jet, just like Wellpoints’: http://commons.wikimedia.org/wiki/File:Dassault.falcon.2000.vp-bdl.arp.jpg Nice plane! Their 3 Hawker 800XP jets are slower and older, and less roomy. Wellpoint’s CEO tried to hide their ownership of these jet by claiming that they only lease it from netjets, but that’s a lie: Wellpoint is!!! a co-owner, just look at the FAA registry.

off-topic screaming ends here

Anyway, your Anthem Denial is easily overturned, with just one letter. Per above, it invokes the formal appeal process, and that puts an MD’s license on the line, requiring a qualified response. (When you invoke the policy, it can no longer be answered by anyone in the “customer service” chain of command-- it has to be answered by a qualified MD.) She won’t try to defend their stupid policy; she’ll approve the coverage. The policy makes no sense, and she knows it.

9

Anna, you will not win your Appeal by claiming to know their finances better than they do. Even the discounted payments on your EOB’s don’t tell the whole story-- Hospitals often pay enormous kickbacks, under labels like “annual quality inspection/assessment charge”, for the privilege of being an in-network facility. The net costs to the insurance company, for transportation and ER treatment of all those lows, is probably a lot less you than you’re thinking. (DKA episodes cost a lot, but lows are cheap, cheap to treat.)

The beginning MUST invoke the formal appeal process, otherwise it goes “into your file”, where customer service can ignore it forever. The exact wording which they used in the denial is the key (even if it was very, very short). That’s what you need to refute. Keep repetition of information which they already have to a minimum-- stuff from your Endo and other treatment personel doesn’t need to be repeated again, it’s best brought up by reference (originating person date sent). You MUST demand that the response come to you, with a specific deadline of no more than 30 days ahead of the date sent.

You also don’t have to quote from the NEJM/JDRF study, or the FDA approval letters, or AACE guidelines, or anything like that: they’ve already seen it, a short reference and summary sentence is fine. With that background established, you state your case: Typically, for a denial that “benefits are not proven”, you would summarize than an MD who dares to deny this device as “medically necessary” for your treatment is claiming to be more expert than the FDA; and ignores the results of the JDRF-sponsored study in last October’s NEJM (the most respected of all American peer-reviewed journals); and feels free to ignore the findings and recommendation of your personal Endocrinologist.

Then comes your threat: “An MD who refutes all of these qualified experts and denies FDA-approved treatment, used exactly per FDA labeling, is very possibly practicing outside the scope of his/her medical competence. If the reviewing MD feels qualified to again determine that the device is “not medically necessary”, the letter which informs me of this decision will include the license number(s) and State(s) of license for that person, because I will possibly want to file a complaint with the Medical Licensing Board of that State to investigate that person’s behaviors and decisions. I recommend that you inform your decision maker of my intentions, in advance of the decision.”

Note the run-on. That’s intentional :wink: A sentence about your anger is also needed, to emphasize the threat: Every lawyer whom I’ve ever heard or read, when talking about medical lawsuits and “defensive practice” techniques, emphasizes that you need to take extra-special care of the angry pts. and relatives. Your letter needs to show you as one of those extra-angry policy holders, one who might go to great trouble to ruin a career if someone at InsCo dares to confirm the denial again.

When it’s a career, and not just money, you win. No one whom I have worked with has EVER had to follow through on such a threat.

I hope that this has been firm without being nasty to you (that’s how I intended it, just “firm”). For everyone, I hope that this longer display of appeal letter format and contents shows why your MD or nurse absolutely can’t send it. (Heck, even when an MD learns that a colleague is practicing under the influence of drugs or alcohol, it will hardly ever be brought before the Board by that physician. It’s usually handled with a personal phone call, that “… you need to stop seeing patients immediately, then retire or get treatment, or I WILL probably have to inform the board of your problem.” Direct threats of to file a complaint with the medical licensing authority, as in this letter, come only from patients and lawyers.

But only the lawyer-coached patients use the correct terminology. That’s what makes your “coached by Rick” letter utterly terrifying. (I’m not a medical professional of ANY kind, but I have listened to several relevant presentations at conferences with my DW-- an MD in a totally unrelated specialty. I know the words, especially for the case of the Nevada Board of Medical Examiners.) Please don’t make a mistake by sending an improperly prepared, un-reviewed letter. It takes many, many hour to undo the damage caused by a bad appeal letter-- a bad letter often doesn’t work, and after it fails, they’ll pick at EVERYTHING you provided in order to use it all against you at the next level.

Above all, watch your dates-- do NOT let an appeal deadline pass without taking action!

10

Tx very much Rick. Your info is encouraging. I do not have documented hypo-unawareness or history of hospitalizations so I’ve been holding off attempting to get coverage. I will expect and take in stride the initial denial and plan to invoke a formal appeal directly, not through my doctor, invoking my policy and out of customer service chain of command.

Very interesting to understand that the BCBS I have in CA may not be owned or have the same corporate chain as BCBS in other states. Another example of how health care service is not transparent and open to comparison. One person’s experience of “BCBS” in another state may have no relationship at all with my experience of my BCBS in CA! Health care is complicated and the companies can easily bureaucratize and obfuscate and run us around endlessly because we don’t understand how it works.

Beats me why the health care industry was ever granted exemption from anti-trust laws. Reverse the exemption and health care companies will be forced to serve us better as competitors enter the market. In theory, anyway.

11

Jana, did you ever follow up and win this? I’ve not received a PM with your email address or a phone number. It’s almost certainly winnable.

The FIRST which you need to do is check your dates with your MD’s office-- in many contracts, you MUST submit a request for review or appeal within just sixty days after the initial PAR was denied. If you let that time period expire then your right to appeal is absolutely, totally, DEAD. The date which matters is the date on which they received the PAR denial.

BCBS of SC is a privately held company, it’s not merely another DBA name of WellPoint. With WellPoint, people hardly ever even need my help anymore-- I’ve forced them to cover so many times that they’ll often accept responsibility without even a single denial. When they do deny, their MD in charge of CGMS has seen variations of my “form letter” so many times that she immediately recognizes “…this person is working with Rick; cover it, we won’t win.” I fought with them just a few times, and now everyone else wins too.

But let me get back to your BCBS/SC. Of course the greedy, privately held company won’t VOLUNTEER to work with anybody to provide costly, use-once DME equipment on an ongoing basis. At least once, they need to be forced to do it. So I’d love to work with you and establish the benefit at BCBS/SC.

The second thing to do is get a copies of the letter which they sent in reply to your MD’s PMA, and a copy of the Prior Authorization Request (PAR) which your MD submitted to them. These are both in your medical record-- the originals stays in the office, but you can ask them to make copies for you. (Get the DATE on the denial letter before you let them mail these things, because mailing will lose another 3 days which you might be able to spare anymore.)

The denial is probably only one sentence long. But if they said “not medically necessary”, that’s WAY different from saying “I’s experimental/investigative technology and/or not medically necessary”.Most of the time, they’ll say both-- throw as much mud as they can, and hope that some of it sticks to the wall. But legal battles are battles of words, and it’s bad for your side to waste lots of words on something irrelevant to the reason(s) which they actually claimed.

Then PM me with both items: the exact wording they used, and the date they sent the denial. Or a phone number, and/or an email addr at which confidential things maybe received from me in reply. I’ve described, in other post to this Thread, why Heather and your MD cannot play hard-ball with your insurance company. You must do it yourself.

12

Blue Choice is a subsidiary of BCBS. They didn’t deny the coverage they just don’t deal with Dexcom or any of the other companies that Dexcom deals with. They do deal with the Medtronic and said that I could get that, but I don’t want that one. So, I am changing to BCBS of SC in January and I will just wait and get the Dexcom then. I have checked and they work with Dexcom.

Thanks for all of the info!!
j.

13

sounds good!