Originally posted on my HealthInsuranceBitch blog.
It has been more than a year since I got my last pair of compression garments for my lymphedema. One pair. I should get two pair every six months. Since I should have a pair to wash and a pair to wear each day and the elasticity begins to wear out after six months. But as hard as it is to get one pair I have NEVER gotten four pair a year. Instead I wear the one pair I have over again for several days and then wash them and hope they are dry by the next morning. At least at this point in time I have some old pairs that I can wear, even if it means the worn out elasticity will allow my legs to swell, it’s still less than swelling than if I wore no garments at all.
I bring this up because I’ve had my garments for a year and yet my DME provider has yet to be paid. I’m past due for a new pair and yet I how can I get another pair when the provider hasn’t been paid from last year?
Oh sure, I could just pay out pocket. However, I’m currently paying COBRA out of pocket because I’m out of work. It’s more difficult to find a job when you have a chronic condition affecting your legs. If I could go work at Target or Home Depot and be on my feet all day I would. But I cannot.
The better option would be if my insurance company would follow their OWN policy and pay the claim.
Here’s the issue…and your lesson for the day, so get a pen and paper.
NETWORK GAP COVERAGE
Since my insurance company has no in-network provider within a 50 mile radius of my home that can provide the medically necessary treatment my doctor prescribes my insurance company has to cover an out-of-network provider at my in-network benefit level.
Understand? I do. Obviously they don’t. Despite going over it EVERY YEAR…they still don’t seem to understand.
Due to the size and shape of my legs, my compression garments have to be custom fitted. Once made custom fitted garments cannot be altered. So if the measurements are not taken correctly, the $300 pair of garments are a waste of time and money. For this reason, the company only takes orders from certified fitters whom they train. So if a provider has no employees who are certified fitters, they cannot provide my garments for me.
My search begins with cross referencing the garment company’s list of certified fitters with my insurance company’s list of DME providers within a 50 mile radius of my home. That list indicated there were no DME providers in my network that could provide the garment I needed. To double check I called every DME provider on my insurance company’s list. I documented who I spoke with, and asked if they were able to provide the specific custom fitted garment I need. They all said no.
So then I contact my insurance company and request that I can go out of network at in-network benefit level. This process has gone different ways. A previous insurance company agreed and my out of network provider filed the claim and was paid. My current insurance company would not authorize, and the provider was leery of accepting direct payment because of past issues with the company. So I paid out of pocket and with the assistance of the provider filed the claim with all my documentation for reimbursement from the insurance company.
Last year, well about 13 months ago, in the hopes of saving the round-a-bout hassle that every time comes back to “there is no in-network provider”, I asked if the insurance company would just pre-authorize me to go out of network. I was told I would have to file the claim and appeal.
An appeal only costs me time and a stamp, while it costs the insurance company time and an hourly wage to pay some to process it. When in the end I will win, it’s been established, I am right in this matter. So since my employer is self-insured I asked if the Benefits Administrator could order my insurance company to give the pre-authorization. I was told yes.
So I spoke with the Benefits Administrator about the issue. She knew me well, as I have filed and won other appeals. She knows I know my stuff and I’m not asking for anything unnecessary. She said “send me and e-mail”. I sent her the details. And within a few days I had a case manager calling me to set things up with authorization and wanting to make sure I got exactly what I needed. I should have known NOTHING IS THAT EASY.
That was March 2009, fast forward to February 2010, I get a phone call from my garment provider stating my insurance had denied the claim, and all their appeals…even though they had an authorization number.
I was pissed.
I immediately call the insurance company and was told that the claim was processed as out of network and therefore I would owe my out of network deductible. I corrected them and explained the authorization from the Benefits Administrator indicated it had to be processed as in-network. The woman claimed the authorization never specified in-network. WTH, there would be no need for the Benefits Administrator to intervene in the matter if this was a normal out of network claim.
So I e-mail the Benefits Administrator, recap the entire situation. She replies back the next day and cc’d someone from the insurance company. The next day the woman from the insurance company replies and apologizes for the mistake and states the claim will be reprocessed correctly and the provider paid. That was February 2, 2010.
I wait a couple weeks and checked my claims online. No changes. I call the provider; they state they did receive the information but still no payment.
So today, I check my claims online. No changes. I call the provider. No payment.
I fired off yet another e-mail to Benefits Administrator and woman from the insurance company. I remind them that by wearing my compression garments I SAVE them money because the garments have reduced my hospitalizations due to cellulitis.