I received my pump supply order from Medtronic yesterday and noticed that they only sent me supplies for 3 months, all other orders had been for 4 months. I called the company to inquire about the quantity change and was told that was the rule per Medicare Guidelines. When I told the rep I was not on Mediacare, she replied that was how my policy was marked per the insurance company.
Then I called the insurance company and was told by a rep that I was under Medicare Guidelines. After stating again that I was not on Medicare, the rep stated "Medicare" is the term used for government medical rules. She also said "a few things changed this year".
After trying to find these generic "Medicare Guidelines" online and coming up empty I called the insurance company back. The gentleman I spoke with this time, again confirmed my status and stated he had only seen this apply to people on retirement plans. (I'm 37 and not retired) He seemed just as confused as I was and said he need to talk to the Medicare Specialist, who had already left for the day.
I'm supposed to be getting a call back and hopefully some answers. Specifically why am I under these guidelines and what else in my coverage has changed because of it.
Many insurance companies use Medicare as a default on the minimum level of coverage that they can defend. They are money grubbers and if they can cut back coverage in any area, they will. But the line stops at Medicare. If they provide less coverage than medicare, then they are open to criticism. So many insurance companies simply adopt medicare coverage guidelines.
That would make the most since. I just don't understand why the first insurance rep told me it was new government rules. Maybe just trying to pass off decreased coverage?
Most insurance companies are now following what they call the medicare guidelines. It's a lot of crap and causes a lot of headaches and royal pains. A lot of tweeking by insurance companies happened as well first of the year I think due to the fears of Obama Care. I don't know much about it myself. Just know that my insurance company uses medicare guidelines for a lot of stuff.
who is your insurance company? is provided by the US government? I am using tri-care which is the military's retirement insurance and they basically follow medicare guidelines for quantities paid for.
I can't remember any doctor giving me a Rx for more than a three month supply. It's 30 days or 90 days and the Rx is good for a total of 365 days I think this has been a industry standard for a long long time.
So far my insurer (HCSC/ BCBSIL) sends a letter every year to say "you are only entitled to what Medicare allows." SO FAR, they have agreed to cover what my doctor recommends but they are always trying to chisel it, insulin, supplies, strips, whatever. I may not entirely use that many all the time but I can't stand having to deal with it once/ year and then every year. The whole process is imbued with stupidity ("If your doctor asks us to make it 'urgent', we can make it 'urgent'" "I'm requesting you make it urgent" "You can't..." WTF!).
I just get their reps on the phone and, without screaming or cursing (although that has come up in the past when I've flipped out, mostly screaming...), grill them in lengthy, circular calls, demanding to know who's in charge and who's making the decision. Which they answer with things like "the nurse making the decision..." so then we feud for 5-10 minutes about what the nurse's phone name and phone number are.. While I'm on the phone, I like to look up their office on Google Earth and plan hitting golf balls at it. Or the houses of the people who sign the letters, who are not, of course, the people on the phone. Total creepy psycho behavior which, of course, they will be aware that I'm not taking any psych meds.
The Google Earth of Chicago doesn't actually give you a good view of the "approach shots" to the office (showing the lower level, I wonder if they have paid for that?) however I'm very familiar with the neighborhood and there's all kinds of good angles with easy access to bike paths and/ or parking garages to scoot on out.
I also like to point out that I think that the whole issue is ripe for a class-action suit, making decisions about treatment without medical contact, cutting medical records, etc. The "damages" aren't huge on a case-by-case basis but I suspect they could be quantified. It also would help a case that we don't really care about $$$$ as much as getting coverage, in which case the only people making money on it would be the attorneys, which would likely enhance their interest in the case. I suspect that the Medicare guidelines and the weak and conservative AMA guidelines for supply needs stem from budgetary shortfalls but I am certain that were the issue to be explored, there's a significant probability that actionable graft and corruption that would be a hook for the case.
Then they give in and I go back under my rock for another year.
