DME providers for MAPD

[somarco]

I don't write MA plans but had someone ask if MA providers have a different DME list. One that is not the same as Medicare.gov.

A few people that have MA plans say they can use XYZ for their DME even though XYZ is not shown as a Medicare approved provider.

Is this true or do some of these folks need to up the dosage on their med's? Can an MA carrier include DME providers that are not approved and can they refuse to include those that are on the Medicare list?

 

[bpenn9]

I don't write MA plans but had someone ask if MA providers have a different DME list. One that is not the same as Medicare.gov.

A few people that have MA plans say they can use XYZ for their DME even though XYZ is not shown as a Medicare approved provider.

Is this true or do some of these folks need to up the dosage on their med's? Can an MA carrier include DME providers that are not approved and can they refuse to include those that are on the Medicare list?

MA plans have contracts with DME providers so yes they can refuse those that are on the Medicare list. I am not sure they can include those that are not approved? Just had a gal I enrolled, we will be switching her DME provider.

 

[somarco]

Thanks for the response.

Odd they can refuse CMS approved DME providers, but considering the carrier, not Medicare, is paying the claim I guess they can use anyone they want

 

[sshafran]

Thanks for the response.

Odd they can refuse CMS approved DME providers, but considering the carrier, not Medicare, is paying the claim I guess they can use anyone they want

The sticky/annoying thing is that the network extends beyond the docs/hospitals, which is what we tend to focus on.

I've had clients get the lab bills denied that their in-network PCP doctor ordered, because the lab the PCP sent them to was out-of-network. I'm sure the lab accepted medicare, but not the HMO. The client blamed the PCP... but it's not the PCP's responsibility to check the in-network status of a lab any more than it is the PCP's responsibility to check the in-network status of a Pharmacy when sending rx's out.

But...$0 premium is all some people see (and I partly don't blame them, as I've almost always chosen the lowest cost / highest deductible coverage available - but the networks can be annoying and they are becoming more annoying as I age).

 

[somarco]

becoming more annoying as I age

You should see life from my perspective . . .

MA plans from my perspective are a crapshoot. All the moving parts make it impossible to nail down your OOP costs.

For almost 40 years I dealt with the issues and challenges of managed care. Especially true with ER claims but labs are also sticky. Now you have to factor in all that and add DME providers to the mix.

I participate in an online forum for diabetics with pumps. Gave me an entirely different perspective even though I have a handful of insulin dependent diabetics.

Medicare pays for the pump and insulin is covered under Part B. However, the sensors are only covered as DME under original Medicare but only if you have a particular brand. Original Medicare will also pay for the sensors, but again, only if you have a specific brand. And now another wrinkle. If you use your smart phone to monitor your readings Medicare will not pay for your sensors.

Sensors come in a 4 pack at a discounted price around $260. Sensors last about a week.

As if this isn't enough, SOME MA plans cover the sensors, some don't. SOME MA plans include the cost of sensors in your max OOP but many throw insulin into Part D.

Only lately have I seem questions about how to find approved DME providers when evaluating DME providers. Because I assumed MA carriers used the same CMS approved list I considered the question to be unimportant.

Reading the responses from members who have pumps and MA plans led to posting this thread.

As we all know there is a LOT of misinformation among Medicare beneficiaries. And like Scott pointed out, many of them are sucked into the low $0 premium plans only to find out life as an insulin dependent diabetic on an MA plan is quite expensive.

But even if you don't have a pump, the montly cost of insulin under a PDP can easily set you back $400 per month and more.

Too often agents who peddle MA plans focus on the max OOP and claim most folks never hit the max. They sell cancer plans to offset part of the cost.

Diabetes is different in that it is neither a short term issue nor (in most cases) life threatening. Diabetics, including those who are insulin dependent can lead very long lives but the cost of staying alive can be signficant.

 

[VolAgent]

I've had clients get the lab bills denied that their in-network PCP doctor ordered, because the lab the PCP sent them to was out-of-network. I'm sure the lab accepted medicare, but not the HMO. The client blamed the PCP... but it's not the PCP's responsibility to check the in-network status of a lab any more than it is the PCP's responsibility to check the in-network status of a Pharmacy when sending rx's out.

I have yet to see a doctor in any way ask who I'd like to use for labs. The doctor, clinic or hospital selects the lab. I have always seen the doctor, clinic, etc. ask who I use for my pharmacy, while inpatient meds are handled by the hospital's pharmacy.

As long as labs can be in or out of network this problem will exist. Same with anesthesiology, no one comes in and asks who you'd like to use, you get whoever the surgeon or hospital uses and you better like it. And you can be almost certain the person won't be in network.

 

[LostDollar]

Some out of network anesthesiology problems can be solved by asking the surgeon for help.

Some out of network lab problems can be solved by careful review of the EOB and asking questions.

Local lab billed under corporate billing location.
Local lab (or other service provider) billed under different holding company name.
Lab service coded incorrectly for type of service in relation to the type of laboratory which provided it.
Lab in a doctors office submitted under incorrect provider id's.

Takes questions of both carrier customer service and provider a/rec person and sometimes a carrier appeal.

(edited-orig post too long)

 

[LostDollar]

becoming more annoying as I age).

You should see life from my perspective . . .

 

[somarco]

One clarification from post #5 above. I am not diabetic and don't have a pump. I kind of fell into this group by accident while researching information for a client who was on a pump. This forum, like every other consumer forum, is filled with a lot of well meaning people who have no clue about the subject but are quick to offer their opinions and answers.

No one asked if I was diabetic. Unless they check my profile they don't know I am an agent.

And I never solicit anyone.

Vol isn't old enough to be on Medicare so I assume he is referencing the challenges of mangled care for those with under 65 coverage. Dollar is on Medicare but apparently his wife is under 65.

Most docs have labs they regularly use. Easy enough to find out by asking the nurse or office staff. The labs my docs have used over the years have all been par providers.

PARE claims are the ones where hidden providers lurk and if you have a mangled care plan you have to be on the lookout for non-par providers. Unfortunately most folks don't think about the issue and if they do it is usually a situation where there is really nothing you can do.

Air ambulance is a biggie. I have seen consumers post they would have refused the air ambulance if they knew how much it was going to cost.

Wonder if they would likewise refuse anesthesia if the gas passer was non-par?

All of this is why my focus is now original Medicare and Medigap only. Less drama.

Some things I have learned about consumers.

They never read their policy . . . until after the claim is denied.

They assume everything is a copay and then complain when they get a collection notice.

They assume if the doc or hospital is in network everyone involved in the treatment is also a par provider.

They also assume the providers know which plan they have and know all the par providers for that particular plan.

Consumers almost never cross-check EOB's against provider bills. They have no idea who has paid what, if anything at all. They have no clue if they are liable for any balance. If something goes wrong it is because the provider and/or carrier screwed it up. Patient is never to blame.

Consumers don't know (nor do they care to know) about NPI numbers. Providers with multiple offices can have one location in network for some carriers and plans and non-par in other locations.

Networks are a PITA, especially PPO's. When I sold U65 health insurance and recommended an HMO (always KP) I made sure I addressed the challenge with my client before submitting the app.

Consider this plan to be like Private Benjamin.

You are not getting the plan with the yachts and condo's. You join the plan and play by their rules if you have any hope of getting your claims paid.

I never had any client complaints when they bought the HMO but more than I care to remember when they had a PPO.

I hate managed care.

 

[sshafran]

I have yet to see a doctor in any way ask who I'd like to use for labs. The doctor, clinic or hospital selects the lab. I have always seen the doctor, clinic, etc. ask who I use for my pharmacy, while inpatient meds are handled by the hospital's pharmacy.

As long as labs can be in or out of network this problem will exist. Same with anesthesiology, no one comes in and asks who you'd like to use, you get whoever the surgeon or hospital uses and you better like it. And you can be almost certain the person won't be in network.

I remember my wife's OBGYN talking to us about which lab... but I brought it up, not her. I think she was a little surprised that I asked for the name of the lab - but I wanted to be proactive. We tend to check network status of almost everyone.

Except the guy who did the epidural mid-labor - for some reason my wife didn't want me to stop the man with the big needle and look him up to confirm in-network status