Question about Insurance Billing and Yearly Amount Limit

Hi Everyone,

I just recently got Anthem BCBS insurance. They have been AMAZING at paying for all of my pump supplies and Dexcom supplies. I have a $300,000 year maximum that insurance will pay.

My question is this....

I order supplies from Edgepark. They bill my insurance company nearly $2000 for three months of pump supplies. My insurance pays the claim at the contracted rate of $1000 for everything. So, does the crazy Edgepark rate of $2000 count toward my yearly insurance maximum or does the contracted rate of $850 count?

Very confused here and worried!

Thank you!!!

I'm on BCBS of SC and they don't work with Edgepark (at least my company one doesn't)...very frustrating. Though Edgepark has told me that it will be $438 for a three month supply of insulin pump supplies. That being said when I had Cigna, Edgepark billed $1000 for 3 month supply. So I guess they bill whatever the company will pay.

As a side note with BCBS of SC I had to go back to using Medtronic for supplies who is my supplier for my pump.

Only the paid amount counts toward the maximimum. Sometimes the billed amount is just totally crazy. I've had stuff billed at $2400 that was paid at $75. I had a vitamin D test that was billed at $240 and paid at $2. This is an artifact of a totally messed up health sustem. BCBS isn't an insurance company, it is a payer. And there isn't competition in pricing, there is collusion.

I don't have a response to your question but I'm curious about your insurance policy containing a $300,000 annual limit.

Here's a cut and paste from the US Health and Human Services government web site:

The Affordable Care Act prohibits health plans from putting a lifetime dollar limit on most benefits you receive. The law also restricts and phases out the annual dollar limits a health plan can place on most of your benefits — and does away with these limits entirely in 2014.

It is the contracted rate (or the amount paid) that is applied to your limit.

Question to any pumper participating in this discussion, not using the Omnipod: What, specifically, does that $1000 buy?

I'm curious because I'd always "heard" the overall cost for the omnipod as compared to tubed pumps over typical usage life was about the same. Less cost up front for the controller/pump (called the PDM for the Omnipod, and only the wireless controller -- the pump is integrated with the pod), while more expensive for the recurring supplies (pods).

However, I pay just a little more for 3 months of pods ($1300 for 5 boxes, 45 pods, I change every two days), and if I were not T2 but like most T1's, I'd be wearing the pods for three days and only buying 3 boxes every quarter. so, ~$800.

So, with the PDM costing $500, a 3 year life of the pump (insurance let's you get a new pump something like every 3 years IIRC), total cost is 500 + 12*1000 = $12,500.

A tubed pump, IIRC, runs around $5k up front. So 3 year cost would be 5000 + 12000 = $17,000!!!

I've got to be missing something here... I know these numbers aren't right in some way.

Hey Dave,

I use the Medtronic Revel 723 and love it. The amount that Edgepark tries to bill my insurance company for is outrageous. However, I've looked at the contracted rate and it is MUCH more feasible. With that said, here is what my 3 months supply cost looks like.

3 Boxes of Reservoirs


3 Boxes of Infusion Sets


Total= $531.00

So for the year - $2124 for supplies.

Hope this helps. Of course every insurance company is different.

3 Boxes of Quick Set Infusion Sets

Thank you Terry for bringing this to my attention. My insurance program is partially state funded....not sure if that makes a different or not for what they can get away with but my handbook says a max of 300,000 a year and 1 million for lifetime max.

Thanks Brian! Yeah, the numbers are insane! I got billed $4500.00 for an ER visit and insurance paid a whopping $410.00. It's crazy that if I hadn't had insurance I would have been expected to pay the full $4500!! Healthcare and insurance just doesn't make sense to me in the slightest!

Thank you all so much for your comments! I will rest much easier tonight knowing that with these outrageous prices I"m not going to reach my yearly max in like two months! I am just floored every single time I look at a claim statment!

Its the paid amount. I used Edgepark for many years but had to drop them because they woudl bill my secondary. Medicare is me primary and I use sensors so Edgepark would bill medicare for the sensors, but as we know medicare will not pay for the sensors. Upon billing they then wanted the non discount rate paid immediately by me then I would seek reimbursement from Anthem but then anthem would pay at the discounted rate. I would then need to go back to Edgepark and convince them to discount my account for the anthem amount.

I really liked Edgepark but they were so difficult to deal at the end that I had to drop them. I wish you the best.