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Insurance "approved" my CGM but is refusing to pay

Discussion in 'Insurance Issues' started by SaltyAndSweet, Jun 25, 2008.

  1. SaltyAndSweet

    SaltyAndSweet Approved members

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    Help!
    I don't know what to do. After several appeals and 6 months later, my insurance company approved a Minimed Insulin Pump AND a continuous glucose monitor (I'm not exactly Type 1, and Type 1's are the only folks who get approval usually with my insurance).

    I got the pump, but the medical supply was told that the CGM will NOT be paid for even though it was approved and deemed medically necessary. How can they do this?!

    Has anyone ever had this happen before? Any advice as to what to do about it? I am just sitting here because I have no idea what to do.
    Thanks in advance!
     
  2. Abby-Dabby-Doo

    Abby-Dabby-Doo Approved members

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    Do you have anything in writing? If you don't I would start there. Then you have to fight the reasonings they're giving.
     
  3. SaltyAndSweet

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    I have my approval in writing. Something seems funky between the supply company and my insurance. The supply company has yet to submit the claim, but has already been told by insurance (I have no proof of that conversation) that the CGMS is experimental / investigational / unproven and will not be paid for despite the approval. This was what my FIRST denial said. BUT the first denial was overturned.

    The insurance told me they can not deny a claim until it has been submitted and the supply company is being silly. Which, knowing that the supply company is trying their hardest to make a sale, that isn't true.

    I am running in circles! They are each pointing fingers at each other and the insurance is making things even more difficult by saying to me that they can not discuss the details of my issue because of HIPPA. Which makes ABSOLUTELY no sense. It is my policy, my stuff, it is all about me, so I have no idea how HIPPA can keep them from talking to me about me. How can that be?!
     
  4. Mama2H

    Mama2H Approved members

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    Do you have to go through the medical supply or can you go directly to the cgms company? Sounds to me like your supply place has already heard a no before so they do not want to hassle with it. I would skip the supply and go directly to the cgms manufacturer.
     
  5. SaltyAndSweet

    SaltyAndSweet Approved members

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    Hi Nicole,
    I am getting the Minimed system. I have no idea why I have to go through this supply company. My doc/I tried to go directly through Minimed but they said something like they do not sell in our area and I would have to go through this supply company. It was 6 months ago when that was stated, so I am a bit fuzzy with the ol' memory, but I think that is what the deal is.
    I have a feeling I am not the only difficulty that my insurance has caused the supply company. :( The supply actually sent a rep out to talk to the medical director a few weeks ago. Still waiting to hear what that resulted in, but I doubt it is positive otherwise I am sure they would have told me right away.

    Thanks for your reply.
     
  6. moco89

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  7. SaltyAndSweet

    SaltyAndSweet Approved members

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    Thank you! I love you! I completely forgot about the Insurance Commission!
    My memory just isn't with me anymore.
    Thanks again!
    :D
     
  8. moco89

    moco89 Approved members

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    You're welcome! Good luck with everything!
     
  9. JamieTheTiger

    JamieTheTiger Approved members

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    In my experience, a vendor that doesn't actually submit a claim is trying to not have to accept the allowed amount as payment. They think if they create enough problems, you'll just pay the bill.

    If they haven't submitted a claim, then the insurance company is correct and there isn't anything they can pay. HIPAA is such a huge PITA. I get WHY it was created, but it was done so VERY poorly. It is a huge, massive block to getting things done in the healthcare. Gah.

    Is your insurance via an employer?

    You know, my suggest would be to ask the supplier for the actual claim they should be submitting. Submit it with a copy of the approval yourself.
     
  10. Stacey Nagel

    Stacey Nagel Approved members

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    The letter we got from our ins co. had a disclaimer. It said that the Navigator was approved. BUT that approval didnt mean that they would pay... Its just messed up insurance talk.... Edgepark had to negotiate a price with my ins company before they would agree to pay.. and they did... . Try to see if MM will start that process for you...
    Stacey
    Stacey
     
  11. Stacey Nagel

    Stacey Nagel Approved members

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    we had the same thing going on at first between Abbott and Edgepark...
    Abbott wouldnt send our claim over because they said GHI doesnt pay..
    So, I spoke to our endo... and he faxed the prescription papers etc DIRECTLY to Edgepark... and the rest is history.
    have your endo send the prescription directly to the supply company... and see what happens...
     

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