Insurance Hassles (bait and switch I say)

princessbelle · Post by **princessbelle** » Fri Apr 10, 2015 2:20 pm

I have employer BCBS of Illinois because corporate office is there. I live in Michigan and the factory my husband works at is in Michigan. Illinois cpap benefits are after 3 months or rental compliance then a purchase can be submitted and they make exceptions if the new machine is a replacement and will the the out right purchase with no rental period. I called my insurance BCBS IL to find out what the benefits are regarding a new cpap machine. When I got to the DME, they informed my insurance does a 10 month rental. BCBS IL says they should bill it as a purchase and the DME claimed they can not do that. DME said they have to bill per what the contract is they have with BCBS MI (10 month rental). I have went back and forth with the DME and BCBS of IL (BCBS of MI will not talk to me because my policy is BCBS IL)via email after the first few conversations. I finally got fed up and told the DME if they can not get this figured out by 4/15 to schedule someone to come get the machine. Guess what happened? The DME is reversed all but the first rental charge and once that is cleared up they are going to bill for a purchase. From what I can find on the internet BCBS MI has cheaper co-pays for office visits and prescriptions but I didn't get those it went by my BCBS IL policy. It seems I get the benefits that help BCBS's bottom line not mine. I told them this was bait and switch I have an Illinois policy that we and the employer pay for but get the benefits of the sate we live in (if it saves BCBS money). Here is the kicker there is no way to know what the benefits are, I have to go by what the providers tells me because I am not a BCBS MI member I don't have access to the policy that is in Michigan. I can't help but wonder how many people have been duped. I got my new machine in November and my yearly deductible had been met so it would have just 20% of the insurance contracted price. If you have an out of state policy, you might want to know what your policy benefits are vs what you are getting in your home state.

postitnote · Post by **postitnote** » Fri Apr 10, 2015 3:14 pm

I have BCBS IL though its a private policy. PPO 01. My deductible is around $6000 before they will cover any DME. Barring a heart attack or something no way will I meet that deductible so no DME coverage for me. $500 a month but fabulous prescription benefits!

princessbelle wrote:I have employer BCBS of Illinois because corporate office is there. I live in Michigan and the factory my husband works at is in Michigan. Illinois cpap benefits are after 3 months or rental compliance then a purchase can be submitted and they make exceptions if the new machine is a replacement and will the the out right purchase with no rental period. I called my insurance BCBS IL to find out what the benefits are regarding a new cpap machine. When I got to the DME, they informed my insurance does a 10 month rental. BCBS IL says they should bill it as a purchase and the DME claimed they can not do that. DME said they have to bill per what the contract is they have with BCBS MI (10 month rental). I have went back and forth with the DME and BCBS of IL (BCBS of MI will not talk to me because my policy is BCBS IL)via email after the first few conversations. I finally got fed up and told the DME if they can not get this figured out by 4/15 to schedule someone to come get the machine. Guess what happened? The DME is reversed all but the first rental charge and once that is cleared up they are going to bill for a purchase. From what I can find on the internet BCBS MI has cheaper co-pays for office visits and prescriptions but I didn't get those it went by my BCBS IL policy. It seems I get the benefits that help BCBS's bottom line not mine. I told them this was bait and switch I have an Illinois policy that we and the employer pay for but get the benefits of the sate we live in (if it saves BCBS money). Here is the kicker there is no way to know what the benefits are, I have to go by what the providers tells me because I am not a BCBS MI member I don't have access to the policy that is in Michigan. I can't help but wonder how many people have been duped. I got my new machine in November and my yearly deductible had been met so it would have just 20% of the insurance contracted price. If you have an out of state policy, you might want to know what your policy benefits are vs what you are getting in your home state.

princessbelle · Post by **princessbelle** » Fri Apr 10, 2015 4:26 pm

I have not figured out the prescription crap but for some reason that has changed, we can no longer get 90 days meds at local pharmacies, we can do online for the same as 3 months at local. No cost savings for us plus when I checked it out they wanted my card information before giving me a price of what I had to pay, no thanks. I have a $500.00 deductible that has to be met before insurance pays a dime then it is the 80/20 split and then a $3000.00 out of pocket max then insurance covers at 100%. If prescriptions medications were still counted toward those it would be great but that has changed. My point was I pay for an Illinois policy but when it the Michigan plan saves them money that is what they were trying to force me to use.

chunkyfrog · Post by **chunkyfrog** » Fri Apr 10, 2015 4:26 pm

When I was a tadpole, my parents had Blue Cross, and they had no complaints.
In the fullness of time, though, Blue Cross/Blue Shield has changed.
No longer a single company, responsible to subscribers and decency,
they are now a big, faceless corporation, answerable to no one.
They rent out the good name left them by decades of decent business practices, to the highest bidder.
Often that bidder is the lowest form of greedy scum, and no one seems to care.
Nothing they do can surprise me.
When I chose my Medicare supplements, guess what company was never even considered?
Oh, yeah, United Health Care was also left out. I do not recommend either to anyone.
--(can somebody lean a ladder up against this soapbox? Please?)

palerider · Post by **palerider** » Fri Apr 10, 2015 4:50 pm

chunkyfrog wrote:--(can somebody lean a ladder up against this soapbox? Please?)

*offers a hand down from the soapbox*

Janknitz · Post by **Janknitz** » Fri Apr 10, 2015 5:56 pm

Many moons ago I lived in the state of Hawaii, but my husband's employer's main office was in Oregon. So our insurer was an Oregon insurer. BUT, we were trying desperately to conceive a child, and our only chance was In Vitro Fertilization (IVF). Now, the Oregon company did not cover any fertility treatments at all. BUT, state law in Hawaii required insurers to cover one IVF procedure for couples who met the criteria (age, marital status, diagnosis, etc.) and we met the criteria.

Of course, Oregon insurance did not want to pay, but I appealed and pointed out that by law they must.

There was something or other about "qualified plans"--that means that an insurer can only cover you across state lines if the plan is federally qualified (meaning the federal government approves the plan so they don't have to be licensed in each individual state). That was supposedly bad for me in Hawaii, because it excused them from specific state coverage requirements--they only had to follow a more general federal plan. But somehow, it turned out they were not federally qualified for that particular plan, so they had to comply with Hawaii state law. And I got my IVF procedure prior authorization after all (although when the bill was submitted, they tried to deny it because "it's not covered under our plan"--$14000 later. I appealed, they paid).

You are in a bit of a different situation, because you have a BCBS MI plan in IL and you want to be treated as if you are in MI. I don't think in your case there are state regulations requiring CPAP be purchased according to particular rules in IL for all people on CPAP. I think in your case, you have an MI plan which pays one way, but your IL providers (not your insurer) can't wrap their heads around it because they think you have the IL plan when you don't. Ultimately it was the provider that gave in and billed according to the terms of the MI insuerer.

It's like you have Acme Brand Insurance and everyone in IL has Titan Brand Insurance, but since they are unfamiliar with Acme Brand they keep trying to treat you like you have Titan. Only it's more confusing because they both have the SAME name, but are different entities.

So you need to be really clear with providers. "I do not have BCBS of IL, I have another plan you may not be familiar with and this is what they cover and how." And then they still won't know.

It may be difficult also because DME's are likely to have CONTRACTS with BCBS IL to provide a CPAP machine for X rental price monthly for 10 months. They do NOT have a contract with BCBS MI for ANY provision of equipment, but BCBS MI is your insurer (You have Acme, their contract is with Titan). Same with your doctors, labs, X-rays, pharmacies, and hospitals who may provide you care. And you are stuck in the middle with all of the providers clueless as to what to do.

I hate to say it, but in a way you may be better off with a national chain DME like Crapria, because if you deal with them online and on the phone they won't mistake that you are BCBS IL, they have contracts with BCBS MI and know what to do via their centralized system. But dealing with the local office may still be a nightmare.

princessbelle · Post by **princessbelle** » Fri Apr 10, 2015 8:39 pm

I don't see what the big deal is, the plan we pay for should honored no matter where we live. I live in Michigan and have Illinois BCBS. I too had BCBS as a youngster and it was the best company around. They say they are not connected and separate entities then how can they bill across states lines. How does BCBS of Michigan know I am actually insured through BCBS of Illinois? Instead of Michigan processing the claim it should be sent to BCBS of Illinois for processing and payment. I am dealing with Carelinc. I told BCBS I can do business with an Illinois DME and they said that would not be covered I have to use providers in my "home" state which is Michigan. If we are not going to get the benefits we pay for shouldn't we be told upfront?

palerider · Post by **palerider** » Fri Apr 10, 2015 8:52 pm

princessbelle wrote:I don't see what the big deal is, ... They say they are not connected and separate entities then how can they bill across states lines. How does BCBS of Michigan know I am actually insured through BCBS of Illinois? I

the only deal that I see is that it *seems* that you haven't figured out that they are separate companies. think of them like state farce vs aetna... you keep saying bcbs like it's company with divisions or something.

previous job I had, in texas, for a virginia based company, had picked bcbs alabama, presumably because they were cheapest. (and crappiest)

state lines got nothin to do with it.

postitnote · Post by **postitnote** » Fri Apr 10, 2015 9:01 pm

And to think I thought BCBS IL was the best of all the policies I looked at. In all fairness they really were DME aside.

cathyf · Post by **cathyf** » Fri Apr 10, 2015 9:43 pm

I am familiar with the chaos... I have insurance through my husband's employer, which is in IL, where we live, but I work in IA, and my DME is in IA because it's the closest in-network DME to me. To add to the confusion, my insurance is a self-insurance plan with a 3rd-party administrator, and they use CIGNA for their network, but it's not a CIGNA plan. The plan rents for 2 months and then buys, while CIGNA rents for 13 months and then you own it at the end.

So my DME billed them for Oct, Nov & Dec. The insurance paid Oct & Nov and rejected Dec with a note to resubmit for the purchase. After awhile the DME sent me my bill for my co-pays which I paid. Then the DME then billed for Jan, and somehow the insurance got confused and paid that one. Then they billed in February, insurance company rejected it telling them to rebill as purchase. Did it again in March. Then last week they re-submitted December. Apparently no human being actually READS the reasons that the bills are rejected and they just keep hitting the "submit" button! I made copies of all of the paperwork I had and highlighted the reason codes on each one and mailed it to them earlier this week. Anybody want to make book on whether they will re-bill the insurance for an April rental next?

Also, princessbelle, your problem may be Carelink. When I was going around in circles trying to find an in-network DME I had a CIGNA person tell me that I should use Carelink. I researched them here, and discovered that they are bozos. I called CIGNA back and got another person, extremely helpful, who warned me off of Carelink. Told me that their business model for controlling costs was to be totally incompetent and that they just didn't pay the bills that they are supposed to pay. This is why Lincare is no longer in CIGNA's network -- they got so fed up with being jerked around by Carelink that they ended their contract. That's the scam with Obamacare -- the insurance companies have these OCare plans which are cheaper, and they have these "narrow networks" to keep the price down, but they go through these crooked outfits that don't pay the bills and then all of the providers exit the networks. After your network disappears you have "insurance" but can't actually use it to pay for health care anywhere.

Krelvin · Post by **Krelvin** » Fri Apr 10, 2015 11:18 pm

Have BCBS out of IL, though we are in Arizona.... had them convert the rental to purchase. Note I had already had 4 payments starting in Sep with previous insurance already.

princessbelle · Post by **princessbelle** » Sat Apr 11, 2015 1:12 am

Palerider If they truly are seperate companies then BCBS of Michigan would not be processing my claims for BCBS of Illinois (edit not Michigan). Using your example, State Farce (BCBLS MI) is not going have anything to do with a claim to Aetna (BCBS IL). State Farce will say you are not insured with State Farce please submit your claim to your insurance company. My claims should be handled by BCBS of IL, not BCBS MI.

Like I said before I can call BCBS IL to find out what is covered and what that coverage is but if I have to use my home state (MI) contracted benefits I have no way to know what they are. I have to go by what the providers tell me as I have no access to BCBS of MI.

Cathyf I have figured out Carelinc is a scam since they have sent me 3 wrong mask and have billed the insurance but assured me I will not receive a bill for the wrong mask.. I don't trust them enough to mail them back. I want a receipt for the returned mask. Carelinc is the one saying they have to go by their contract with BCBS of Michigan. I even asked them to do a direct bill to me that I would then submit to BCBS of IL they told me I would have then pay full price not the insurance negotiated rate. I think my only other choices are Sparrow (not happening) and Airway Oxygen. It is hard to know if the DME is in network as the provider search for DME gives me only optical. We used Airway for most of my Mom's stuff and they were good but that was years ago. It seems there are no good DME's around anymore.

BlackSpinner · Post by **BlackSpinner** » Sat Apr 11, 2015 9:28 am

princessbelle wrote:Palerider If they truly are seperate companies then BCBS of Michigan would not be processing my claims for BCBS of Michigan.

Yes they would. This is far more common then you think. I have written tons of software for inter company accounting transfers. You can have one company that buys for all the others or a couple who sell for the others. For example if you order fish for your restaurant from Newfoundland you are actually get fish from a dozen different companies. If you get a burger from a fast food outlet, chances are the ingredients were bought by one of them and used by several outlets( I was always happy the returns of goods are not possible with food,it is difficult to put a lettuce leaf back into inventory )

palerider · Post by **palerider** » Sat Apr 11, 2015 10:11 am

princessbelle wrote:Palerider If they truly are seperate companies then BCBS of Michigan would not be processing my claims for BCBS of Michigan.

here, dear, read this: http://en.wikipedia.org/wiki/Blue_Cross ... ssociation and re-evaluate, because it sounds, from what I can interpret in your posts, like you're confused about not only how things should work, but how things ARE working.

fair point, your story has confused others too.

princessbelle · Post by **princessbelle** » Sat Apr 11, 2015 12:50 pm

I am sorry if I have confused anyone that surely was not my intent. I just want the benefits of the plan I pay for. I don't think that is unfair.

Insurance Hassles (bait and switch I say)

Insurance Hassles (bait and switch I say)

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