Insurance questions

Hello everyone! I am so glad I "stumbled" on this site. I have read some of the discussions and have been quite impressed!

I currently pump using an Animas pump, however, I've had numerous issues with it and have decided, with my doctor's help, to switch to the minimed pump. My insurance has approved it, they got the claim and paid a portion of if. My explanation of benefits shows that they paid just shy of $3000 on the $6500 bill. I don't owe anything. My insurance is Anthem Blue Cross/Blue Shield question is, does this sound correct? Will minimed just eat the rest of the cost because they are a contracted provider? I don't want to switch pumps and then get hit with a $3000 bill.

Anyone else go through a similar situation?



Hi Melcordell,

There should be a billed amount /allowed amount/ and a contractual adjustment amount. If the billed amount minus the contractual adjustment amount is the amount that bcbs paid I would think you would be ok. Although with PPO insurance, deductibles and copays may also need to be concidered.

Hope this helps

-Tony/ mysugartv

No, they will not eat the cost. MOST Anthem plans have a DME cap of $3000 annually. Here’s what you need to find out. You need to find out if you have a cap on your durable medical equipment. To do this you have to call Anthem. Most likely you will have around a $3000 cap per year. This is not the same for all medial plans so this is why you have to call Anthem. So what will happen is Anthem will pay $3000, then you will have to pay the remainder to MM. MM will let you bill it out, but…

Did Anthem receive a bill for $6500? according to your EOB? If it did, and they only paid $3000 or a little less, the rest of that cost will be transferred to you.

The EOB (explanation of benefits) tells you what your insurance covered. You won’t owe anything on that,because Anthem is not billing you the pump. You will get something from MM. Insurances are sneaky. Usually what happens is the insurance pays a part and you either pay the remainder or if you have a deductible you pay that. It’s kinda tricky and each plan regardless of what state you are in is different. Sometimes, if you have a deductible, your insurance pays whatever it will, and you pay the deductible and that’s that. Other times, even with a deductible, you may end up paying the entire balance. For me. I have a $700 deductible but I would still have to pay the remainder of the balance to get my pump.

Also- are you trading in your Animas Pump- because you may get a credit for that. If you are, that will take some off your total, but if you aren’t you will still have the WHOLE thing to take care of.

Really the only way to know is to call your insurance company. Their number should be on the back of your insurance card. If you tell me your state, I might be able to give you more info on your plan. If you do call your insurance company, make sure you don’t get off the phone until you understand what they are telling you. I work with medical insurances for a living and when I called for info on MY plan, I got flustered. So keep asking until you are confident you understand!!! Good luck!

I know that I have a 10000/year cap, when I call anthem they say that it is covered 100% up to 10,000. The EOB is showing that they charged 6500 but that anthem only paid about 3000. My animas is still under warrenty but they are allowing me to get a new one because of the many problems I have had. Minimed recommended not opening it until they receive payment.

Hi. I have BCBS of CA and on my EOB it will also say coinsurance/copayment amount which is what I will be billed. Hope this helps and good luck!

Hmmm… I’m scratching my head on that one. If you have your EOB, Minimed most likely has their payment so I would double check with them. Normally they don’t send things out until they know for sure they are getting payment so you might be all set. I’ll ask my girls and see if they have any input. I’ll let you know if I find anything out. It sounds like your plan has you covered. At this point I think Minimed is holding the ball. If they say you are paid in full, open the box!!!

Generally in the case of something like a pump, the insurance plan will have ‘negotiated’ a rate that is usually much cheaper than the going rate. That’s right, if you walk up off the street to buy your own pump you probably have to pay more than the insurance company negotiated (or allowed/agreed) rate. That is true of most medical equipment and drugs. I consider it a total scam.

For the most part, as Devon notes, you will get an EOB. It will show you what the company Animas billed, the negotiated rate, what the insurance company pays and what you owe. In most circumstances, you are “NOT” responsible for any difference between the negotiated rate and the full rate on the pump. You only have to pay the difference between the negotiated rate and what you insurance paid. If the negotiated rate is $6500 and the insurance only covered $3000, then you will owe $3500. If the insurance company billed $6500, but the negotiated rate is $3000 and the insurance paid $3000, then you don’t owe a penny.

The most egregious recent example of this cr*p I was a walk up charge of $232 for a vit D test and a negotiated rate of $17.

I found out from Anthem that they paid the contracted amount due to Medtronic. Anthem said I will owe nothing, that medtronic would take care of the amount that was not paid.