Angelina has been on the Dexcom CGM since January 2014. For anyone that’s counting that’s 15 months. Two receivers, 3 transmitters, and 18 boxes of sensors. For every single one of these orders our medical supply company does not ship them to us until they have received authorization from the IPA (Defined as “An independent group of physicians and other health-care providers that are under contract to provide services to members of different HMOs, as well as other insurance plans, usually at a fixed fee per patient.”) that reviews these kinds of claims that are then billed to our insurance company. The IPA reviews the medical necessity of the device or service requested to determine if it meets the HMOs pre-determined guidelines. Angelina’s Dexcom has been categorized and authorized as medically necessary since the first shipment (because otherwise we never would have had it shipped to us).
There is only one medical supply company that we are allowed to go through for it to be paid for by our insurance, which we have done since the first order – despite my better judgment and overwhelming frustration with the medical supply company. Despite this, every single order for Dexcom supplies is initially a denied claim when submitted to the insurance company. Every insurance company claim says “You do not have to pay this unless you signed a written agreement with your provider to pay it. Your plan does not cover charges for, or related to, services or supplies that we find to be experimental or investigational.”
And every claim I send a message saying “This was authorized on XX/XX/XXXX by XXXXX IPA” and attach a copy of the authorization form with dates and relevant claim information. And every time within about a week the claim is then paid by the insurance company. In the beginning I used to actually make a phone call to the insurance company and go “This claim was denied. I don’t know why this was denied. What can be done?” And almost every single time the member services representative would say “I see where this was paid on XX/XX/XXXX (previous insurance claim that I had already disputed/appealed) and I see the medical necessity documentation in our system. I’m not sure why this wasn’t approved. I will send it back to claims with a note. This shouldn’t happen again.” It was after about the third phone call like this that I realized that whoever is working in the claims department just must not be looking at Angelina’s file at ALL and is just denying the claims right off just to make sure we’re paying attention and hoping we will not appeal/dispute the claim denial and they won’t have to pay it.
For the past several months I have sent a fairly standard, concise, polite dispute email to the insurance company that simply says “Please see attached authorization from from XXXXXX IPA authorized on XX/XX/XXXX for 90 days, ending XX/XX/XXXX for item #AXXXX. Today, however, I got an email from our insurance company that says “View your recent claim” and has an fairly innocuous “You have a new claim! Click here to review your claim on our secure web portal” as well as other standard stuff about the insurance company, privacy policy, security, etc.
So, I click. And it takes me to the Explanation of Benefits that tells me our recent transmitter order/claim has been denied because “You do not have to pay this unless you signed a written agreement with your provider to pay it. Your plan does not cover charges for, or related to, services or supplies that we find to be experimental or investigational.”
Mind you that we had an authorization dated JANUARY 27, 2015 that authorized transmitter, receiver, and sensors for a three month period, expiring APRIL 27, 2015 (that’s tomorrow, in case you didn’t know). We got a new receiver the beginning of February. I sent them this authorization form. The beginning of March we got an order of sensors. Denied. I sent them the SAME scanned copy of the SAME authorization form. Today’s denied claim email was for a transmitter that was ordered the end of March, two months into that three month authorization. I sort of snapped a little.
This was the not so concise, polite, or to the point message I sent them today in response to the claim. And of course attached to this email was also the SAME authorization form I had already sent them two times before:
“This is the THIRD claim that has been denied, even though I have provided the same attached authorization for these items from XXXXX IPA. Medical necessity has been WELL established, as I’ve explained and provided documentation for every claim for the past 15 months that my child has been on the Dexcom Continuous Glucose Monitor System and still each and every claim continues to be denied until I send this member services communication and supply (AGAIN) the authorization letters, at which point they are reviewed and approved. I am beyond frustrated with having to appeal every single claim when all of the information has been provided repeatedly already and it seems that someone in the claims department is just checking to make sure we are paying attention to whether or not claims get paid.
When my daughter started on this life-saving medical device we were informed that we had to go through XXXXX Medical Supply as our ONLY option for this device. We have continued to order through this incredibly inefficient and disorganized medical supply company who can never seem to get a single order fulfilled correctly or in a timely manner because they are the only company contracted with [insurance company] and otherwise our claims would not be paid at all. So it is further infuriating that despite using this contracted company that the claims continue to be denied every single time.
Every time I’ve called regarding this same matter I have been apologized to and told that there is in fact medical necessity information in the system and the representative has no idea why the claim was not approved and assured that it shouldn’t be happening. So beyond requesting that this specific claim be reviewed and approved, as per the attached authorization, I would also like to request that future claims for this same medical device actually be reviewed along with my daughter’s likely extensive medical necessity documentation and be approved the first time, as they should be.
Yours,
Jessica Lastname – an incredibly sleep deprived, stressed out mother of a child living with a life-threatening chronic illness”
Now I just hold my breath and wait and hope that our insurance doesn’t mysteriously get cancelled. I do momentarily feel much less stressed out though. That is something I have wanted to say for the past year, at least.
This absolute lack of communication between the insurance company and the HMO group that is making the decision to cover the thing or not is absolutely ridiculous. And of course we are stuck in the middle trying to fix everything. I shouldn’t have to fix this. If the insurance company requires me to get authorization from the HMO group/IPA then they should pay the bills that come in that were already authorized by the IPA. If they aren’t going to pay the bills based on lack of medical necessity documentation submitted directly to the insurance company then they should change the way this whole authorization system works! Or at the very least, have the IPA forward the authorizations to the insurance company when they are approved.
UPDATE 4/27/15:
I received this communication today in response:
“Dear Ms. XXXXXX:
Thank you for using the secure member website to contact [insurance provider]. To help
protect your confidential information, please continue to use the secure
member website to contact us. This online form provides greater
security than standard Internet e-mail.Your claim question
This is in response to Angelina’s claim for date of service 03-26-15 in
the amount of $1,635.59 from XXXXX Medical Supplies.The claim was sent for reprocessing because it was denied in error.
Generally, claims are completed within 10 business days. A revised
Explanation of Benefits will be available shortly.I apologize for the inconvenience.
Your rights
You have the right to file a complaint.How to file a complaint
We need the following information:
1. Patient name.
2. Patient [insurance provider] ID number.
3. Date of service or date of incident
4. What you are reporting in your complaint, specifically. If your
complaint is related to a provider please provide the provider’s first
and last name, tax ID number, and address if available.
5. Whether or not you wish to remain anonymous in the investigation of
your complaint.How to submit a complaint
You can file a complaint one of four ways:
1. You can call the Member Services number on your ID card.
2. You can write a letter to the address on the bottom of your
explanation of benefits.
3. You can fax a letter to 866-XXX-XXXX. Please make sure your [insurance provider] ID
number is on each page submitted.
4. You can use the ‘Contact Us’ link and e-mail us with the details of
your complaint.If you have additional questions, send us a ‘Contact Us’ message or call
the toll-free number on your member ID card, if applicable.Sincerely,”
I appreciate the response. Now we just have to wait and see whether or not it makes any difference for our next order. However, this is the first time that I have ever received complaint filing information in one of these communications. I’m pretty sure the message I sent yesterday was a complaint.
Chasing Lows 