Medicare Advantage Plan denied basic DME supplies

MagsterMile wrote:I was just denied coverage of my DME supplies - mask cushion,tubing, headgear - I just switched over to Humana Medicare Advantage Plan as of 1/1/13 and they have denied my claim for typical DME equipment supplies. The reason code: 08Z read as following 'Payment has been denied because these services were not urgent/emergent, nor have we received a referral approving services in advance from the Primary Care physician'.

I'm waiting breathlessly to see if they will or will not deny coverage for rental of my Vpap Adapt machine for the same reason.

Insurance claims are processed by computer, which will kick out the claim if the right info isn't in the right column. More than likely your eligibility for the supplies did not get input when you transferred your coverage to them, and your previous claims for the sleep study, initial machine rental, etc., were not processed by them, hence that column is blank in your Humana file. I'm sure that up to this point no human has seen, or is even aware of, your claim. A phone call to their customer service rep should get it fixed.

idamtnboy wrote:

MagsterMile wrote:I was just denied coverage of my DME supplies - mask cushion,tubing, headgear - I just switched over to Humana Medicare Advantage Plan as of 1/1/13 and they have denied my claim for typical DME equipment supplies. The reason code: 08Z read as following 'Payment has been denied because these services were not urgent/emergent, nor have we received a referral approving services in advance from the Primary Care physician'.

I'm waiting breathlessly to see if they will or will not deny coverage for rental of my Vpap Adapt machine for the same reason.

Insurance claims are processed by computer, which will kick out the claim if the right info isn't in the right column. More than likely your eligibility for the supplies did not get input when you transferred your coverage to them, and your previous claims for the sleep study, initial machine rental, etc., were not processed by them, hence that column is blank in your Humana file. I'm sure that up to this point no human has seen, or is even aware of, your claim. A phone call to their customer service rep should get it fixed.

One more good reason to stick with genuine government Medicare plus a Medigap policy. Then your records are always there in the same place and never have to be transferred by you or by a third party upon whom you must rely to make the transfer.

And even though the Medigap portion is written by those same insurance companies that try to sell those (Dis)Advantage plans, if you have genuine Medicare, its the government that submits your claim to the Medigap carrier, not you, and the company relies on the government's information and decision as to payment, so you don't get whipsawed. Unlike their (Dis)Advantage policies, the insurance companies do not second-guess claims passed onto them through your government Medicare program. If Medicare said it's covered, it's covered. Period.

Regards, Nate

I agree with Nate on this one...you don't find out about how your insurance works (or not) until you try to use it *smile*. So those who are choosing between Medicare Supplement (Medigap) and Medicare Advantage plans, please take this as advice to be considered. I could have saved some time and money if I had known these things before I signed up for a Medicare Advantage plan.

I Don't think you can poo poo all Medicare Advantage Plans. They differ by issuing company and by state. I have the AARP plan thru United Health Care. There is NO out of pocket premiums. The plan covers everything including prescription drugs. We do have a co-pay for doctors and for some drugs (Most generics are free). The plan follows the Medicare guidelines for CPAP supplies with a 20% co-pay. I am EXTREMELY happy with the plan.

My eldest sis-in-law has a Medicare Advantage Plan & it is quite difficult to 'jump thru their hoops' but if you are patient & get EVERY piece of data they require, they have to live up to the contract and pay according to that contract.

First obtain a copy of what you signed with them when you contracted them as your plan as of 1/1/13. Then determine what they SHOULD be paying. Next work with your PCP to get whatever data they are asking for, such as copies of your original sleep study, copy of what your DME provides & how often, etc. After going thru the steps & making sure you give them EVERYTHING they ask for, they should pay for supplies you need. Be meticulous in making sure you complete each step they require, they will deny the claim for so much as a line the PCP leaves un-filled out (no kidding!).

I've been the one dealing with my sis-in-law's plan & they are a BI**CH! They have to pay as they say they will, but when you take out the policy they neglect to tell you that they are difficult to deal with. Its usually a nice person selling something that sounds like a good, sound plan. It is probably good & sounds, just a PITA. Anyone approached by Humana or any other insurer about these 'Advantage" plans beware.

Good lucky & PM me if I can be of any help.
Jen

LSAT wrote:I Don't think you can poo poo all Medicare Advantage Plans. They differ by issuing company and by state. I have the AARP plan thru United Health Care. There is NO out of pocket premiums. The plan covers everything including prescription drugs. We do have a co-pay for doctors and for some drugs (Most generics are free). The plan follows the Medicare guidelines for CPAP supplies with a 20% co-pay. I am EXTREMELY happy with the plan.

It will always seem like a great plan until you get bitten by the difference somewhere down the road, but I hope it never happens to you.

See:

The Fraud of Medicare Advantage Plans

http://www.timegoesby.net/weblog/2007/0 ... of_me.html

Medicare ‘Rip-Off’ Hits Elderly

http://www.bloomberg.com/apps/news?pid= ... J36nhLHGck

Update on Medicare Advantage Plans

http://www.cjr.org/campaign_desk/update ... tage_p.php

Regards, Nate

NateS wrote:

LSAT wrote:I Don't think you can poo poo all Medicare Advantage Plans. They differ by issuing company and by state. I have the AARP plan thru United Health Care. There is NO out of pocket premiums. The plan covers everything including prescription drugs. We do have a co-pay for doctors and for some drugs (Most generics are free). The plan follows the Medicare guidelines for CPAP supplies with a 20% co-pay. I am EXTREMELY happy with the plan.

It will always seem like a great plan until you get bitten by the difference somewhere down the road, but I hope it never happens to you.

See:

The Fraud of Medicare Advantage Plans

http://www.timegoesby.net/weblog/2007/0 ... of_me.html

Medicare ‘Rip-Off’ Hits Elderly

http://www.bloomberg.com/apps/news?pid= ... J36nhLHGck

Update on Medicare Advantage Plans

http://www.cjr.org/campaign_desk/update ... tage_p.php

Regards, Nate

It's all well and good to say get a Medigap plan and stay on regular Medicare, and avoid the Advantage plans, but for a lot of folk it's impossible. What people forget is that in some cases, Medigap plans do not have 'guaranteed issue' -- they do not have to take you. So unless you sign up for a supplemental Medigap plan from a private insurance company exactly when you first become eligible for Medicare, during the guranteed issue window -- and pay continually from that day forward, you may not be insurable later on. You will have to go through underwriting and/or pay much more to get a Medigap plan. And even when done right, Medigap plans can be prohibitively expensive, especially when you consider the fact most do not include drug coverage and that has to be bought separately.

My parents for years had AARP Medigap plans -- however while the plans paid for everything, it was far too costly and they eventually lost their coverage (for two months). My mom got it back, but my dad they wouldnt take back. So we got him on a Medicare Advantage HMO plan from AARP. Advantage plans have to take people regardless of pre-existing conditions. There are HMO hoops to jump through and co-pays, but the monthly premium is $0 and the plan includes drug coverage. I know they do pay for my dad's CPAP equipment.

The biggest problem with Advantage plans are that they don't have any mandate to sell or price uniformly - one county may offer certain Advantage plans while a county next door has wildly different, more expensive plans. ($0/mo Advantage HMO in County A vs. $150/mo Advantage PPO in County B....) This is exactly why the Paul Ryan Vouchercare plan was so horrible. Because the private insurance companies could sell pretty much whatever style products they wanted, or even choose to not sell policies in certain locales altogether -- just like the current Advantage plans now do. A luck of the draw depending on where you live. A violation of Medicare's purpose to offer uniform, guaranteed benefits and costs to Americans no matter where they live in the nation.

NateS wrote:

LSAT wrote:I Don't think you can poo poo all Medicare Advantage Plans. They differ by issuing company and by state. I have the AARP plan thru United Health Care. There is NO out of pocket premiums. The plan covers everything including prescription drugs. We do have a co-pay for doctors and for some drugs (Most generics are free). The plan follows the Medicare guidelines for CPAP supplies with a 20% co-pay. I am EXTREMELY happy with the plan.

It will always seem like a great plan until you get bitten by the difference somewhere down the road, but I hope it never happens to you.

See:

The Fraud of Medicare Advantage Plans

http://www.timegoesby.net/weblog/2007/0 ... of_me.html

Medicare ‘Rip-Off’ Hits Elderly

http://www.bloomberg.com/apps/news?pid= ... J36nhLHGck

Update on Medicare Advantage Plans

http://www.cjr.org/campaign_desk/update ... tage_p.php

Regards, Nate

Nate ...I have had this plan for 4 years without problems...however...as mentioned they differ by state/county.
Your articles are dated 2007-2009. There have been lots of changes.

LSAT wrote:

NateS wrote:

LSAT wrote:I Don't think you can poo poo all Medicare Advantage Plans. They differ by issuing company and by state. I have the AARP plan thru United Health Care. There is NO out of pocket premiums. The plan covers everything including prescription drugs. We do have a co-pay for doctors and for some drugs (Most generics are free). The plan follows the Medicare guidelines for CPAP supplies with a 20% co-pay. I am EXTREMELY happy with the plan.

It will always seem like a great plan until you get bitten by the difference somewhere down the road, but I hope it never happens to you.

See:

The Fraud of Medicare Advantage Plans

http://www.timegoesby.net/weblog/2007/0 ... of_me.html

Medicare ‘Rip-Off’ Hits Elderly

http://www.bloomberg.com/apps/news?pid= ... J36nhLHGck

Update on Medicare Advantage Plans

http://www.cjr.org/campaign_desk/update ... tage_p.php

Regards, Nate

Nate ...I have had this plan for 4 years without problems...however...as mentioned they differ by state/county.
Your articles are dated 2007-2009. There have been lots of changes.

Believe me, I am glad you have not had any problems. I wish friends and relatives of mine who chose Medicare Advantage could say the same.

Where can I go to read about these changes, written by an independent source, not on an insurance company sales piece?

(Also, isn't your insurance company taking the Part B premium which is being subtracted from your Social Security check, plus collecting a 14% subsidy out of the Medicare general fund which supports traditional Medicare? I don't have any support for that in front of me, but that is my general recollection. I will stand corrected if I am wrong about the part B premium and/or the subsidy being taken from the fund which supports the traditional Medicare plan.)

Regards, Nate

NateS wrote: if you have genuine Medicare, its the government that submits your claim to the Medigap carrier, not you, and the company relies on the government's information and decision as to payment, so you don't get whipsawed. Unlike their (Dis)Advantage policies, the insurance companies do not second-guess claims passed onto them through your government Medicare program. If Medicare said it's covered, it's covered. Period.

Not a foolproof system though. We had a dental surgery claim problem a while back. Medicare and BCBS paid the contract amount as usual. But then Medicare retroactively increased the allowable charge, paid the dental office 80% of the difference, and sent the remainder to BCBS for processing. BCBS computer kicked out the claim because it had been more than one year between the services provided date and the date of the reprocessed claim. I didn't know about the problem until the dental office sent me a bill for less than $2.00. I called BCBS, they looked it up, found the problem of timing and retroactive adjustments, overrode the computer settings, and paid the claim!

NateS wrote:[(Also, isn't your insurance company taking the Part B premium which is being subtracted from your Social Security check, plus collecting a 14% subsidy out of the Medicare general fund which supports traditional Medicare? I don't have any support for that in front of me, but that is my general recollection. I will stand corrected if I am wrong about the part B premium and/or the subsidy being taken from the fund which supports the traditional Medicare plan.)

I don't know about the subsidy part, but the insurance companies do get the Part B premium. They then offer whatever plan they want to for zero additional cost to the Medicare recipients, or for whatever additional premium they want to charge. The myriad bunch of plan coverages and premiums is what makes the Advantage system so difficult to choose from. It's called competition, which supposedly leads to lower cost and better service. If you don't believe it, I'll arrange a personal visit from Santa Claus to explain it all!

Janknitz wrote:Chunky is mentioning SHIP and I want to be sure everyone understands what it is. If you are on Medicare you receive a booklet every year called "Medicare and You" and on the back of that booklet is a phone number for SHIP or HICAP (California). This is FREE Medicare counseling by certified and dedicated volunteers who know their stuff. They can definitely help in situations like this.

Also, if you are new to Medicare or if you are thinking about switching plans, it always pays to check in with your local SHIP/HICAP people because they can help you understand and break down the terms of each supplemental policy.

Medicare Advantage still has to follow Medicare guidelines. They can't deny coverage for things that are covered by "traditional" Medicare. So the refusal to provide the supplies because it's not an emergency is just bunk. But they can make you jump through that particular plan's hoops BEFORE they have to supply anything. Unfortunately, that may mean a new sleep study with a plan-approved sleep clinic and physician, and your equipment and supplies MUST come from their own approved providers, NO chance of coverage for a provider that's not part of their plan. So if you have a capped rental ASV from a provider that's not approved by your new Advantage plan, you may have to switch machines and providers. And in my experience, Advantage plans often DO specify the make and models of machines they cover in their formularies, rather than going by HCPCS codes.

It is a cautionary tale that if you already have OSA or more complex apnea, you need to check things out VERY carefully before switching to an Advantage plan or an HMO if you're not on Medicare.

Just got off the phone with Humana. Found out that the DME is not authorized (<10 miles from the house). Could that be since they didn't win the Medicare Bid? I can continue to go thru my DME but then I pay the out-of-network rate of 50%. If I switch to the in-network-provider they will pay 80% - the in-network provider is over 40 miles from my house. One of the in-network providers is Apria. I've yet to hear anything positive about them. However, found out that if I can get a 'waiver' letter from my Dr. and a referral, Humana will keep it on file and I will get in-network rates. My DME also told me that I can be 'grandfathered' in. I'm not too worried about the cpap machine since I'm primary CSA and have to use an ASV device. However, if I need to get retested (40 miles from my house!) I might not present with CSA. This could end up being a nightmare.

I'm almost hesitant to chime in here, but I'm too tired to get up and just sitting here would be boring. So....

I have had Medicare Advantage Plans since 2007. I was with Anthem BC/BS until the end of 2011 when they cancelled their plan in my area. I went with Humana after that and have had minimal issues.

When you consider that Humana inherited me and the Trilogy Ventilator monthly rental and my current DME is OUT of network - it's pretty impressive that I can say "minimal issues."

But...I did a thorough investigation BEFORE I signed up with Humana, making sure about my doctors and the DME. I knew they were out of network, but I bought the plan that paid the same for in & out of network providers. I also contacted most of my doctors FIRST to make sure they would still see me with the plan.

At one point the DME tried to dump me saying I was out of network, but a quick call to Humana to ask, then to the DME to tell them how to handle it -- everything is fine.

I think the poster that said it depends on the plan and the state, and how much investigation the person does before signing up, is correct.

A blanket "All Medicare Advantage Plans are bad" statement isn't really accurate.

I looked into sticking with plain Medicare and a Medigap plan -- a Medigap plan, for me, was over $800 a month. There was no way.

I agree that it depends on which plan you get, or the luck of the draw.

But here's what AMA doctors thought of Advantage when last surveyed:

The AMA conducted a survey of 2,202 physicians
about their experience with MA. Of the surveyed phy-
sicians who have treated patients covered by MA plans
like HMOs and PPOs:
> Half indicated that they have received payments
that are below the Medicare FFS rate
> Three out of five reported excessive hold times
and/or excessive documentation requests
> Contrary to the widely reported claim that they
provide more benefits to patients, half have
experienced denial of services typically covered
in the traditional Medicare plan.
• There are widespread reports of abuses and deceptive
marketing by agents trying to enroll seniors in MA plans.
The National Association of Insurance Commissioners
recently reported that 39 out of 41 states received com-
plaints about misrepresentations by insurance agents or
companies in marketing Medicare-related products.

http://www.ama-assn.org/ama1/pub/upload ... afacts.pdf

That too was several years ago, but I looked to see if they have updated their survey to reflect an improvement and I did not find one. And of course the AMA does not reflect the opinions of doctors who choose not to belong.

And here are some good tips for those wanting to try to find a good Medicare Advantage Plan. This was published only 5 months ago:

5 questions to ask about Medicare Advantage plans
By TOM MURPHY
AP Business Writer / November 7, 2012

http://www.boston.com/business/personal ... story.html

Regards, Nate