Medicare & cgm medical supply online

Diabetes Technology Glucose Monitoring
1

As a fed retiree, I have used online cgm supplies since 2011 (pump since 2000).
Recently was switched from failed Liberty Medical to Edgepark. Edgepark and Apria have both told me that Medicare no longer will do denial letters so my supplementary insurance can pay for my cgm supplies. I have federal BC and they are willing and have been paying all along. These companies will not submit a bill directly to BC either.

Has anyone else run into this yet? Federal BCBS has only Edgepark, Apria, and Walgreens (which does not do cgm) on their list of suppliers.

Medicare told me, just now, that I can pay for the supplies, submit a bill to Medicare and then submit their letter to BC. Medicare also said they do not accept billing for a denial letter any more. Great!

I can find nothing about this on tudiabetes or another couple of forums i have checked.
I canā€™t, I hope, be the first person to run into this issue. If anyone here has, have you found a workaround other than the long process of paying and waiting for understaffed Medicare to respond? I can see it taking 6 months to go through this process every 90 days.

Thanks.

2

I do not have an answer, but with Medicare now approving Dexcom in some instances it may be necessary to use the Medicare benefit to get to the secondary benefit? Just a thought.

3

Thanks Rphil,
Sorry, I omitted critical info. I am using the Medtronic Enlite. If it were the Dex G5 I would not have this problem!

And the point is that Medicare does not allow companies to submit bills to get a denial any more. So the only path to secondary is for the individual to pay out of pocket and apply to Medicare yourself to get a ā€˜statementā€™ that is not a denial but can be used to send to your secondary.

This is convoluted and may be difficult for those not affected to get the craziness here.

4

Bluebird:

While I may not have all of the answers for you, this is what I have done and am doing:

First, I am a retiree, have Medicare as my primary coverage,Ca BCBS as my secondary, and, until recently got my CGM supplies from Liberty Medical.

Second, while you may not be in this boat ā€¦ I had been a Dexcom G4 CGM user for the past 2 years. I meet all of the requirements for the therapeutic (rather than adjunctive) Dexcom G5 that is now being covered by Medicare. To the best of my knowledge, Dexcom is the only CGM that has yet been designated a therapeutic CGM and, as a result, is now Medicare-eligible. I have to assume that the other CGM manufacturers are working overtime on getting their units similarly approved at therapeutic CGM devices. Note: I believe, however, it is true that some people that currently use CGM may NOT necessarily qualify as being eligible for Medicare coverage of their CGM.

However, prior to all of this, I was also finding it difficult to find a CGM supplier that would go through the process of getting a Medicare denial and was also an ā€œin networkā€ provider as far as Ca BCBS was concerned. At that time, however, although it took me a couple of phone calls, I found that Ca BCBS was quite helpful in finding a supplier that was capable of both getting a Medicare denial and of qualifying as an in-network provider. Ultimately, Ca BCBS found Liberty Medical for me ā€¦of course, that was a year ago and no longer relevant. However, at that time, Byram Healthcare was in the process of getting approved to distribute CGM supplies both in terms of getting Medicare refusals and then qualifying as a Ca BCBS provider.

While I realze that Ca BCBS is not the same as Fed BCBS, I would first suggest that you contact Fed BCBS. I found my BCBS to be quite helpful in tracking down a legitimate CGM supplier. They were sympathetic to my reasoning: CGM is a covered benefit under my Ca BCBS plan ā€¦ but I canā€™t find an in-network provider that can also get a Medicare denial. When BCBS calls a supplier, they seem to get further than those of us who are merely customers. If your BCBS covers CGM but you canā€™t find an in-network provider, then I would ask them to help you find a suitable supplier ā€¦

Best of luck ā€¦ all of this insurance stuff takes a lot of time and effort. That said, I consider myself to have had supplemental coverage that DOES cover CGM ā€¦ and now to be eligible for primary coverage under Medicare.

John

5

John, thanks for another attempt to help. The fact is, I have talked to fed BCBS three times. As noted in my post, there are only two medical suppliers on their approved list. BC wants to help but they are at a loss too. Neither will now submit a bill to Medicare for a denial letter. They, and Medicare, all say they are no longer doing this.
I called Byram Hl Care this morning and, even though I know they donā€™t have a contract with fed BC, I talked with (on the 4th transfer) a person in durable medical who seemed dense and had no clue if BCBS was a legit insurance company. He finally said that they would probably take out of network orders, assuming the insurance company agreed to pay. I reminded him they had been paying since 2011 but sheesh. I asked for a supervisor but he chose not to respond to that.

I really really, seriously need the 670G and guardian 3 sensor (eligible in Jan as a Medicare pt) for reasons too numerous to mention. This may force me, however, to go back to Dex in order to actually obtain supplies with less hassle. Less safe because another 1 to 2 years before it and Tslim do anything similar to the 670G. I have the 630G now that does suspend for lows but only because it is connected to the enlite sensor.
Way too much boring info but I am surely not the only one discovering and going through this.

By the way, it seems as if contracts have to be with the state fed system, not the federal as a whole. I am in NC so Byram, etc would need to have a contract with NC fed bcbs. I think.

OK, over and out. Will see if anyone else is caught in this conundrum. Thanks to all who replied.

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6

FYI for anyone interested. A second call to Medicare, and talk with a supervisor, resulted in this info:

  1. Medicare is no longer sending out denial letters but are sending out a summary statement that will take the place of the denial letter.
  2. Both Edgepark and Apria (my 2ndary insurance suppliers) are noncompetitive bidders and do not have to submit claims to Medicare. She told me that Byram is also a noncompetitive bidder. But they are not approved for my region anyway.
    All part of the joys of a non-single payer health care system.
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