Old 11-12-2015, 06:19 PM #1 (permalink)
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Default Frustrated!

Got an email from Duke saying that my insurance denied a BiPap for me because I didn't meet Medicare guidelines. Here's what's frustrating:
1. On October 16th Bcbs approved a trilogy for me, however they refused to pay the $1,450 per month and wanted a rent to own deal. DME company refused so no trilogy.
2. Neuro decided to change order from trilogy to BiPap so I could get a "device" to help with breathing.
3. As stated above, Bcbs denied BiPap due to not meeting Medicare guidelines

How in the hell could I be approved for a trilogy yet fail to meet Medicare guidelines for a BiPap? Furthermore, why are Medicare guidelines being used when my primary insurance is commercial Bcbs? I'd be willing to bet that the next denial will be placement of feeding tube, which I have a surgical consult for next week. I'm convinced they do no want Pals to be able to extend their lives. With all we have to deal with....what a punch in the gut.

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Old 11-12-2015, 07:23 PM #2 (permalink)
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Default Re: Frustrated!

I'm so sorry, Vince, that they are putting you through this.
It is so outrageous.
It's so hard to understand how these "powers that be" can do this type of thing
to us. To anyone.
I know I can't help any...I have no expertise in this area.
But you are in my thoughts.
And you have my empathy.
Laura.
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Old 11-12-2015, 07:38 PM #3 (permalink)
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Default Re: Frustrated!

It took me 6 months to get my BiPap through Blue Cross. My neurologist wrote two letters and called BC several times. My RT also was fighting for them to get me the BiPap.

Finally they made me get a sleep study, they really spin their wheels sometimes, then they approved it. I look forward to the day I can tell BlueCross to kiss my a$$. I am paying 2375.00 per month for my wife an myself. Don't dare look elsewhere because of my ALS>
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Old 11-12-2015, 08:06 PM #4 (permalink)
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Default Re: Frustrated!

Thank you Laura, you are very kind. Sometimes we just need to blow off steam. Mark, I'm about ready to tell them to kiss my a$$ right now! How can they justify approving the trilogy and be willing to pay $1,450 per month when the damned BiPap is only $3,500 to buy it outright? Just makes no sense. In January, I'll be completely on Medicare and will have a MediGap Plan F supplement. Don't expect it to be any easier but at least I can say "goodbye" to BCBS!

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Old 11-12-2015, 09:17 PM #5 (permalink)
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Default Re: Frustrated!

Duke may have your coverage wrong. They may be mixing you up w/ another pt. Blue Cross plans have various guidelines, and they are not Medicare's. Or they may be unhelpfully anticipating your coverage switch. Not sure what guidelines you don't meet. I would call Duke to clarify and (as you know) continue to reconsider clinics given your distance and all these issues.

As an alternative, just reiterating for others, too, you can bypass insurance and DMEs by buying a BiPAP on line using a simple prescription from any doc, including your local friendly PCP. You don't need a backup rate, as I recall (a lot of PALS never do, actually), so if you think you'd like a BiPAP in the near future, I notice that the [pressure, not volume-controlled, but still a very helpful machine] "new/open box" S9 VPAP S including heated humidifier is available from a reputable seller for $925. Just a fact. BTW, a BiPAP usually lasts 10,000-20,000 hours of use (turned on).

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Old 11-12-2015, 09:37 PM #6 (permalink)
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Default Re: Frustrated!

Thanks Laurie. Perfect advice as always. I sent Duke an email and specifically asked for an explanation of why they are citing Medicare criteria. Got no response. My wife will call in the morning (I was trying to do this myself via email so she wouldn't have to be burdened with it while at work). I'll start checking for used equipment online as I doubt this will get resolved.

Thanks again.

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Old 11-13-2015, 12:58 AM #7 (permalink)
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Default Re: Frustrated!

Vince and Mark, had the same problem as Mark with blue Cross. Blue Cross refused the first time around. Took months to get it approved. $1450/month and I pay $190/month. The Pulmonalogist was persistent. And I'm glad I have the trilogy because it definitely helps.
12/1, I'll say goodbye to blue cross and go on medicare with the F supplement. Now I'll see what happens. Or what changes.
Vince, since I go first, I'll let you know how it goes.
Marty
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Old 11-13-2015, 02:26 AM #8 (permalink)
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Default Re: Frustrated!

One more thing: don't ever let a clinic be the intermediary in the DME/health plan transaction chain. You're the patient/premium payer. Ask for a copy of the BiPAP prior auth denial, which the plan is supposed to send you anyway (if they don't, that's another clue that the clinic may be the weakest link) and follow the appeals process if you're so inclined.

Often, the clinic staff are so overworked/undermotivated that they make up their own denials, in essence (fail to correct the DME/plan/their own omissions/ errors that cause/constitute denials). DMEs can do the same thing. Unfortunately, it's often P/CALS that have to be the fixers.
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Old 11-19-2015, 09:27 PM #9 (permalink)
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Default Re: Frustrated!

Laurie I have no understanding at all but so very glad you are able to help sift through all this for everyone.
God bless, Janelle x
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Old 11-20-2015, 07:30 AM #10 (permalink)
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Default Re: Frustrated!

What you've run into really confuses me. We have BCBS (Covacare), and they approved the Trilogy no problem. We were told (at Duke) that with ALS the diagnosis, not condition, qualifies one for the bipap. BTW, hubbys numbers were still good, but I took in a recording of him snoring at night--very clearly obstructive sleep apnea. We didn't have to have a sleep study (perhaps because he had a many years earlier diagnosis?)
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Old 11-20-2015, 08:12 AM #11 (permalink)
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Default Re: Frustrated!

Quote:
Originally Posted by fionae View Post
I'm so sorry, Vince, that they are putting you through this.
It is so outrageous.
It's so hard to understand how these "powers that be" can do this type of thing
to us. To anyone.
I know I can't help any...I have no expertise in this area.
But you are in my thoughts.
And you have my empathy.
Laura.
Laura echoed my sentiments better than I could express. Thinking of the of you, Vincent, and sending you positive thoughts for a speedy resolution. Cee
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Old 12-01-2015, 01:12 PM #12 (permalink)
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Default Re: Frustrated!

Quote:
Originally Posted by mpnatx View Post
Vince and Mark, had the same problem as Mark with blue Cross. Blue Cross refused the first time around. Took months to get it approved. $1450/month and I pay $190/month. The Pulmonalogist was persistent. And I'm glad I have the trilogy because it definitely helps.
12/1, I'll say goodbye to blue cross and go on medicare with the F supplement. Now I'll see what happens. Or what changes.
Vince, since I go first, I'll let you know how it goes.
Marty
Marty,
I'm on florida Blue with my employer right now. I start medicare in February and was planning on getting the F Plan with Florida Blue Cross. Do you think I'll have trouble with BCBS Supplement? I know Mayo is Med non-participating clinic (in Florida) but I'm worried about which supplement to get. I found a good Part D for my drugs but was ready to pull the trigger on Florida BCBS Supplement because it was a little less expensive and a rich plan. I will say that Florida Blue with my employer has made some mistakes and denials but I've appealed them and won. The medical payments went well but counseling and drugs I've had to fight. I won't have the strength to fight as hard as I've fought throughout these past two years so I'm wondering if I've made the right decision.
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Old 12-03-2015, 02:05 PM #13 (permalink)
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Default Re: Frustrated!

Kim,
I started Medicare on 12/1. I haven't used it yet, so I don't know how it will work. I had BC/BS as my standard plan for many years and checked with them first for a supplement F. I also talked to several other companies and decided to go with the AARP United Health care supplement F. The benefits were identical, but the United Health Care plan was @$75 less per month with a guarantee that it can only increase so much a year for the next 10 years.
It was a learning experience for me, but got through it. I have a Dr appointment in two weeks, so I'll get to try it out for the first time. I've notified my DME that rents me the Trilogy and waiting to hear from them too.
I'll let you know how it goes. Good luck!
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Old 12-08-2015, 08:20 AM #14 (permalink)
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Default Re: Frustrated!

Marty,
In Florida the Florida Blue (BCBS) Supplement is cheaper for me than AARP United Health Care. Plan F with UHC for me (under 65) is $755.75 and Plan F with Florida Blue is $611.10. Interestingly, Plan G (which is everything in Plan F except the medicare B deductible) is $564.10 so I'll take Plan G. I met with someone at Florida Blue to question this and they said it was odd and it only works if you're under 65. So if all that is correct, the yearly difference between F and G for me is $564 and that's more than the Part B deductible. Every dollar counts for me. We did talk about increases in premiums and she didn't mention a guarantee but gave me a history of their premiums. Last year it increased 5% but that was the first increase in three years.
I have until February 1 and it's a crying shame I've devoted all my energy into this and other financial decisions, including fighting with my long-term disability company, the college, a lawyer's office, and even getting appointments at Mayo Clinic.
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Old 12-08-2015, 12:24 PM #15 (permalink)
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Default Re: Frustrated!

As a doctor, my wife spent many hours on the phone with insurance companies, persuading the insurance company's doctor to approve what was needed for her patients. Perhaps your doctor will do this, too.
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