Moments of Wonderful

…rather than a lifetime of nothing special. A diabetes blog.

Moments of Wonderful - …rather than a lifetime of nothing special. A diabetes blog.

Denied

binders full of

And you wonder why I keep every piece of medical and insurance paperwork I receive?!

I hesitated to even write about this because I feel like I complain about my insurance woes far too often. However in this case in particular, I am shocked at the behavior of both the parties involved and the way in which they both show very little care for their customers.

The very first thing I did when my new insurance started on March 1st was make an appointment with an endocrinologist. The very first thing I did when I walked into the endocrinologist’s office was ask for a prescription for the Dexcom G4. The endocrinologist quickly agreed and my paperwork was started the very next day.

The forms quickly went from Dexcom to my insurance company. I received a call from my Dexcom representative who explained that my insurance uses a third party supplier and that the supplier would call me in a few days to confirm my benefits.

I knew my new insurance policy practically word-for-word so when I finally received the phone call, I was just pennies off from the price that the third-party representative quoted. That price included my deductible and then the percentage that I owed on the balance according to my PPO insurance plan. Let me repeat this point because it is quite important for the rest of the story – my insurance company and this third party supplier communicated with each other to provide preauthorization and a price quote on this benefits claim. I paid the remaining balance and asked for a receipt for my tax records.

I received the Dexcom a few days later and happily began using it. I had no idea anything was wrong until about a month later when I was on my insurance company’s website looking for an eye doctor. The home page shows a list of the most recent claims. Under the Status column, most of the claims have the word Processed in green. One claim, however, lists Denied in bold black letters. I clicked to open the EOB and noticed it is the Dexcom claim. In the explanation, it states that the claim was denied because my insurance company did not receive an “itemized list of charges.” In addition, every claim after that one was paid out at the wrong amount based on the denied claim that should have met my deductible.

My first call was to the insurance company. They explained that they needed a manufacturer’s invoice, provided by the third party supplier, to process my claim. Obviously, my second call was to the third party supplier. I explain the problem and the representative on the phone stated that he would fax over the invoice immediately. He noted that it sometimes takes a week or so for the insurance company to catch up on the paperwork. I kept on eye on the status of that claim, and it continued to read denied.

When I called the insurance company again to check on the claim, I received the explanation that the third-party representative had sent over a packing slip, not the actual invoice that they needed. The insurance representative offered to initiate a three-way call with the third party supplier. During that phone call the representative explained yet again what they needed and the third party supplier representative agreed to send over the information. I finished that phone call with hope that the situation would be quickly resolved.

At this point it was now late June. Since the initial Dexcom order I had several other orders with the third party supplier and they had all resulted in difficulty and error. Out of extreme frustration, I took to twitter to complain. I was directed to write an email to their social media account.

My strongly worded email resulted in a phone call from the third party supplier. The representative explained that they have a contract with my insurance company. That contract determines the price for the Dexcom and the documentation needed for the claim to be processed (e.g. why PWD are sometimes required to provide BG logs). According to the representative, the contract DOES NOT include the requirement for a manufacturer’s invoice. Therefore, the third party supplier refuses to provide the invoice.

I asked my insurance company if I could just called Dexcom directly and get the invoice from them. The answer was no for the same reason that the third party supplier won’t produce the invoice to the insurance company. The contracted rate from the third party supplier is a different (likely higher) price than the actually price from Dexcom.

During that same phone call with my insurance company I mentioned that I had that receipt from the third party supplier that outlined my insurance coverage and my out of pocket costs. The insurance company representative asked for those details and said he will process the claim for the amount of money that I have paid. He said that if the supplier wants the rest of their money, then they will produce the invoice.

Granted that last conversation took place the first week of July, and that EOB still sits in my account – denied.

Category: Dexcom, insurance
  • PancreasticMom says:

    So, SO frustrating….I’m so sorry. There is definitely a love/hate relationship with insurance companies. I love, Love, LOVE it when it works as I expect and without any calls from me to hash things out. Love seeing those EOBs where they have paid and the “amount owed to provider” is $0. But when I DO have to call it can be so nerve-wracking and tear-invoking! Wish the best turnout for you…hope that’s a PAID EOB:)

    July 29, 2013 at 6:38 am
  • Stacey D. says:

    I feel so frustrated for you! I am actually contemplating switching to my husband’s insurance next year if my employer will remain with my current one. I have never in my life dealt with such aggravtaion before. Granted, I know that there can be MANY issues with insurance for us PWD, and in the scheme of things I have been fortunate. However issues like these should not exist. I hope it gets resolved for you soon.

    July 29, 2013 at 6:43 am
  • Lisa says:

    I think insurance companies do this to see if you will just give up and pay the bill out of pocket. DON’T EVEN CONSIDER IT! My insurance company does it at least once a year to me. At present they are wanting me to pay the full price of the radioactive ion used during a neuclear stress test. They say that it was coded as a pharmaceutical that I took home with me, so it should be covered under my drug plan. Let me just run over to the pharmacy and pick up a radioactive drug…that will never happen! Unfortunately, I don’t think things are going to get any better any time soon.

    July 29, 2013 at 6:51 am
  • Laddie says:

    So sorry you’re going through this. Maybe you can get your Dex to graph how much your BG with the stress of dealing with insurance companies and supply distributors. Hope it get resolved sooner rather than later.

    July 29, 2013 at 7:06 am
    • Laddie says:

      Oops. I mean to say how much your BG goes up with the stress…

      July 29, 2013 at 7:07 am
  • Sarah - Sugabetic (@SugabeticMe) says:

    dafaoietuaeblakjgapoiudtaetekt!!!!!!!!!!!!!! I’m angry FOR you too!! GEEEEEEZZZZ….. 🙁 I have a feeling this is the same crap I’m going through with my supplies? Do they not realize that they aren’t getting PAID because of their stupid contracts???

    July 29, 2013 at 8:46 am
  • Scott E says:

    Ugh. I think I might be facing a similar situation as you soon. My wife’s company supplies my medical benefits. Her company recently spun off from its (former) parent, so everything changed in terms of plan/coverage — but the administrator is the same. My first “transaction” with the new company was for test strips; I believe through the same distributor you dealt with. After plenty of hassles with them (and their unexplained switching of my insurer to a completely different company), they finally processed the order, acccompanied by a slip that says I owe them ZERO.

    Last night, my wife goes online to check her benefits status, and finds out the claim was denied and I’ll owe in excess of $1000. Meanwhile, this may get passed on to the flex spending account and I could get automatically reimbursed (from FSA, to the extent there’s enough to cover it), which means if the first thing gets straightened out, there’s a second complicating issue to straighten out.

    Ugh… I feel for you.

    July 29, 2013 at 9:55 am
  • Joanne says:

    Ugh… Sorry to hear this. Hate the run-around, but don’t give up… Like someone said I the comments earlier, I think they do this to make you give up. He it gets resolved… And SOON!

    July 29, 2013 at 10:16 am
  • Denise aka Mom of Bean says:

    beyond ridiculous!

    we are dealing with third party supplier for the first time and it’s been a nightmare…six weeks and still no sensors. thankfully dexcom has sent us two to tide us over, but still, the frustration is maddening!

    July 29, 2013 at 1:46 pm
  • sarah says:

    Sorry this is happening to you. I’ve been fighting about my CPAP machine for 5 months. Insurance wants it billed as a purchase, medical co bills as rental. Medical co bills as purchase, insurance denies saying proper authorization was not gotten. Last week I told both companies I was going to take the machine back, medical co would not get anything and brain damage due to lack of oxegen in my sleep is going to cost insurance alot more than a $1200 machine……. I didn’t get anywhere with that…….

    July 29, 2013 at 6:30 pm
  • Scott K. Johnson says:

    How very frustrating. I hate that we often have this sort of added stress on top of diabetes itself.

    July 29, 2013 at 6:47 pm
  • katy says:

    I’m torn—I hate that this is happening, but love that you turned your medical billing records into shabby chic scrapbooks.

    July 29, 2013 at 7:49 pm
  • Kelly Rawlings says:

    Empowered patient unity, sister! Every time I read accounts like this, I think: “What if the person receiving the service or product has literacy issues. Or numeracy issues. Or is in pain?” Why does the buck (literally and figuratively) always get passed back to the patient? Something in this system of patient, provider, and payer needs fixin’. And it shouldn’t have to be paid out of our blood, sweat, and fears.

    July 30, 2013 at 12:34 pm

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