Insurance Question

I got an explanation of benefits today from my insurance company, which happens to be Colorado Kaiser. There was a charge of $7495.00 from Tandem for my insulin pump purchased on 8/18/18. They just billed Kaiser on 4/12/19. Kaiser paid $0 and said I owe $0. I called Kaiser to have this explained and they basically said Tandem did not bill them in an agreed upon time window so the bill is basically void and Tandem has to write it off as a loss. WHAT??? Can anyone explain this to me?

I paid $895 to Tandem the day I ordered the pump (that was pre-approved by Kaiser). It included the pump and one month of supplies.

Thanks for any input.

Sounds like this has nothing to do with you. You don’t handle billing disputes between the insurers and device manufactures. I would write that down in a very short letter and send a copy to each of their billing offices. (Thats above and beyond the call of duty, as far as I’m concerned, but might serve as some protection if they persist…which they will). Tell them that it is LISA’s policy that she bears no responsibility in resolving financial disputes between their 2 companies. Also write that if they do not respond, in writing within 2 weeks, you consider the matter resolved.

@Lisa_Craig, @mohe0001 is right. This is an insurance game, just like denial of DME benefits. By denying the claim, Kaiser can effectively force Tandem to lower the acquired pump price and get better terms (eg. 30/60/90). You paid your share, now the kids have to fight it out in the sandbox for the sippy cup. Just stand back and watch. In the next 90 days all will be resolved. Enjoy your new pump!! :grinning:

Plus the price is excessively high. That appears to be some sort of list price which it is not expected that anybody is paying.

And even if part of that price included one month of supplies, how much could the supplies cost? $150~200?

Tandem generally receives about $4000 to their bottom line per pump sold (via insurance direct or via distributor any method). Cash price for an X2 from Tandem should be right about $5000. (USA pricing. International different pricing.)

There is no possibility that Kaiser is paying Tandem $7495 for an X2 pump.

In any event - none of that should be relevant here. This is not your problem.

In my experience, providers generally have 1 year to complete billing to the insurance company. I have had a few times where the provider failed to bill the insurance company in a timely fashion (ie - over 1 year). The insurance company informed us that the contract between the insurance company and the provider accounts for this possibility and the provider is contractually prohibited from billing us for the services rendered or equipment provided due to this situation.

Which I believe is the same thing that Kaiser told you? Tandem failed to live up to the terms of the contract between Kaiser and Tandem. This is on Tandem. Very bad business practice for any company. Hopefully this is an isolated incident and they (Tandem) corrects whatever business problem they have.

Bottom line this is not your problem.

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I feel good that I will not have to pay more. I paid my part…but maybe I shouldn’t have…upfront.

I am guessing Kaiser was expecting to pay $4000 since my 20% co-pay (which I had to pay upfront) was $800.

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