I'm hoping there are some insurance guru's on here that can help me with a question I have. So, about two months ago my Medtronic pump died and so I went through the hoops with my insurance company to find a new in-network provider so I could get an Animas pump. They sent me to Liberty Medical. I called Liberty and they got a certificate of medical necessity from my doctor and indicated that they also got prior authorization from my insurance company. They sent me the pump within a week and a half. My insurance pays 100% of Durable medical equipment.
Well, Liberty has submitted a claim to my insurance two times now. Both times my insurance wouldn't pay. When I called them today they said that they won't pay because Liberty didn't request prior authorization! It says on my explanation of benefits that I am responsible for $0.
So, what now? If Liberty did drop the ball and didn't get a PA does that they are going to try to bill me $6000 for a new pump?!!!
You need to ask your insurance company what your patient responsibility is. Have you received an Explanation of Benefits (the insurance statement you get when they pay something). You can see what your responsibility is. It may be that Liberty cannot charge you because they dropped the ball. I’d also let your doctor know what’s going on. Also, find out if Liberty has appealed the claim. Use those words. That’s what they need to do on their end. Crap like this gappens all the time. Sorry you have deal with the stress!!! Let me know what happens!
Hi Patti! Thank you so much!! It's so frustrating!!! :-( I don't know who to believe. Did Liberty drop the ball or is BCBS lying and saying they didn't get a PA so they don't have to pay?!!! Anyway, yes, I did receive an EOB. It says my responsibility is $0. Thank goodness for that! I never signed anything from liberty saying that I would pay them anything because everything I get through them is in-network and paid for 100%. They deal with insurance companies all the time. I just can't imagine why in the world they wouldn't have gotten a prior authorization for something that expensive!! That's crazy!!
I am so sorry for the issue. I know this is a long term headache.
Liberty will try, most likely, to bill you. However, do not pay. It is your responsibility but liberty shoudl never have sent it out without prior authorization. So here is what can happen Liberty can now seek preauthorization and as odd as this seems they can obtain preauthorization. Liberty can work this out so do not sweat it yet. Also remember you can send it back to Liberty, they will not want it.
Now the bigger concern are your supplies. You will over spend the cost of your pump in 6 months of supplies. SO it is in your best interest to get your pump authorized. I woudl call and involve Medtronic in this issue. They will not want to help but maybe you can get them involved.
Thanks Rick! That's a relief to hear that they can still try to get prior authorization!! Thankfully, I won't have an issue with my pump supplies. They are also covered 100% and I have been receiving them with no problem from Edgepark for several months. I just had to go through Liberty for the pump, which is good because they aren't the easiest to deal with!! I just don't understand why in the world they would have told me that my medical necessity paperwork and prior authorization went through! LOL...and yes I'm sure they definitely don't want a used pump!!! :-) I'm just flabbergasted that a company that sends out pumps on a daily basis would somehow overlook getting a prior authorization!! I worked for an audiologist and worked to get PA's for hearing aids all the time. We wouldn't even order the aids without a prior authorization and definitely would never despense them!!
Can I ask why it is that your pump supplies are through Edgepark and the pump through a different provider? I have coverage through Edgepark for all of my pump supplies but next month my endo will be ordering me the next pump upgrade on the minimed, which I thought would also go through Edgepark.
That's the best question ever and one I still have yet to answer!! I called Edgepark to get my new Animas pump and also to get the Dexcom system. They did all the insurance verifications and when they called me back they said that they could provide me with the supplies for the Dexcom and Animas pump, but they weren't an in-network provider for my pump and CGM. I was so confused. It doesn't make a bit of sense. So, after numerous calls to the insurance company and a grievance to them about not being able to find an in-network provider for my pump and CGM they directed me to Liberty Medical. Liberty was very quick about getting my Dexcom to me, as well as my insulin pump. However, I absolutely despise working with them. I tried at first, but it was awful. I would call to find out when my next order of supplies would ship and the customer service rep would transfer me to "James" (I changed his name for his privacy). Well, apparently "James" does everything at Liberty. He was always able to answer my questions and get things straightened out, but it would take him 1-2 weeks to get back with me!! (I'm not complaining about him...I"m sure he is overworked and underpaid). Anyway, another BIG issue I have with Liberty is they sent my supplies via regular mail which takes forever and then they require a signature for them!!! I'm not home during the day and they don't even give you any tracking info so you can at least make arrangements for the day the package is to arrive. One other huge problem with Liberty is that most of the customer service reps aren't English speaking and they know nothing about diabetes. It was beyond frustrating, so back to Edgepark I RAN! Edgepark has plenty of problems itself....like sending me wrong supplies and supplies I never ordered and then billing my insurance, but at least when I call Edgepark I get a human quickly. The people speak English. All my orders are at my house the next day AND I get tracking information via email.
I would also caution you. People lie. Making sure that you are using an in-network provider can be vital. Never trust a provider's claims that they are in-network and never ever trust a third party. Only the insurance company can be trusted and even then they still may make mistakes. Out of network providers may place you at very large risk from what is called "balance billing" where providers may be legally allowed to bill you outrageous amounts above and beyond what your insurance or medicare may consider allowable charges.
Same thing happened to me with my Dexcom. Dexcom told me they had pre-approval from IBX (Independence Blue Cross) and shipped me everything to get started. Turns out when the actual claim was processed, it was denied (same EoB, patient responsibility is $0).
Dexcom is in the process of appealing but until then, I'm not sure what to do about sensors. They aren't all that affordable without medical insurance.
