Medicare Advantage Plan denied basic DME supplies

[jencat824]

The reason my sis-in-law ended up with an Advantage Plan was her age. She is disabled & could not get a Medigap plan in our area. I'm told they do sell these to under age 65 Medicare recipients in some areas, just not in ours. I can't say the Advantage Plan is all bad, it covers some things she could otherwise not afford, but she does not have the ability to deal with them, that's were I come in, since she lacks patience (she had a brain injury), I deal with them.

Some days I feel like I deal with the entire family's 'issues' - well wait, I do! My mother-in-law, all her medical issues, my brother-in-law (I'm his guardian), my sis-in-law, deal with stuff like this, add on taxes for the entire extended family (around 25-30 people) & I' guess I am the go-to person. I thought I was tired from OSA, no I'm tired from 'family issues"!

Anyway, I digress, I'm just saying to those who think all Medicare Advantage Plans are useless & evil, sometimes you have to take the bad to get some good & I understand why some folks get themselves stuck with them - they have no other choices in their geographical areas.

To the OP - just keep trying to get them to provide services as contracted in a reasonable geographical area. 40 miles away is not reasonable to me, I think they need to make an exception here & pay a DME closer to your home, either the one you had been using, or another DME able to provide comparable services.

Good luck,
Jen

[Sheriff Buford]

[quote="MagsterMile. 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. [/quote]

Magster: I'm not going to weigh-in on the Medicare part of this discussion. When I deal with Apria (phone: 1-800-436-5147), I deal with the major-Apria warehouse place that sends you your equipment. I call them every 3 months and they will send me the same order (filters, hose, mask and humidifier tub) every time. Apria is not all that bad if you are getting equipment-supply refills on some frequent basis. When I have had problems with Apria, and as I understand from what other forum members have told me, is that if you are looking for Apria to treat you as a TRUE DME should.... then that's where the problems come in. Apria is not very good at offering TRUE DME service (giving advice, helping you with masks, and equipment issues, etc...). If you are ordering supplies, then they may worth dealing with if they can save you money.

Sheriff

[jencat824]

I do agree with Sheriff about the 'true DME part' because of CPAP equipment for my bro-in-law, they were NO help in trying to get him a mask that was workable. Because of that, he just didn't work with the CPAP & quit trying. I tried to get him other masks, but he found a reason to dislike them. Among his other problems he has untreated OSA - however at smoking 3-4 packs a day with severe COPD he's killing himself anyway & I can't get him to stop, he is a grown man. I'm his guardian for finances, he has mental issues & can't handle money, among other problems. I think if Apria had handled things better with him he might have used the CPAP & that would have made him more comfortable.

My big problem with Apria is the BILLING dept, they supply his oxygen & they are awful to deal with in terms of billing. Now his insurance is Medicaid, so that may be why, but they have to be called at least 3 times per bill to rebill Medicaid or rebill something properly, since they don't always use the right codes.

I think if Sheriff can vouch for them sending the supplies in an orderly fashion, they might be worth trying, just stay on top of their billing. By that I mean keep every piece of paper they send you - packing slips, notices showing were insurance was billed, bills that show amounts due or not due, etc. If you stay on top of that, it should be OK. I've found when dealing with them on billing having the packing slips & matching them to the bills helps me when I need to call on any issue relating to billing. They do a good job of delivering the oxygen promptly without having to be called.

Good luck,
Jen

[MagsterMile]

The latest update on my Humana Med. Advantage Plan: Talked with patient advocate for DME (which is affiliated with a big hospital) in this area that I use. The latest is that Humana has now approved all my EOB's for Jan, Feb. & Mar. that previously showed denial!!! How can this be you ask if I'm out of network? DME insists that I'm in network and rep from Humana said I'm not in network. Lovely! So, since I'm now in the network (per the DME), I won't need a 'waiver' from the Dr that would excuse me from traveling the 40 miles for cpap supplies. Not only will I not have to travel to get supplies, I won't need to submit a monthly referral from the family Dr and will now only do it quarterly. I'm also relieved of the responsibility of trying to get a different cpap machine at the new DME.

[Janknitz]

Awesome. The hoops have been jumped.

[Bobby269]

Information. My insurance is Humana Gold HMO.They have been paying for everything for 3 years. In Texas you have to use Apria as a DME. Apria goes by the medicare guide lines for ordering supplies.

[NateS]

The reason my sis-in-law ended up with an Advantage Plan was her age. She is disabled & could not get a Medigap plan in our area. I'm told they do sell these to under age 65 Medicare recipients in some areas, just not in ours.
Jen

Jen, you indicate that your general area is Jeffersonville, Indiana, so I arbitrarily plugged in Clark County Zip Code "47130" into AARP's UnitedHealthCare endorsed Plan pages and it reports that conventional Medigap (Medicare Supplement) coverage IS sold through them there:

https://www.uhcmedicaresolutions.com/he ... code=47130

You might want to check that out.

See also: How to Choose an AARP Medicare Select or Medicare Supplement Plan That Fits Your Needs and Budget

https://www.uhcmedicaresolutions.com/on ... 03INWB.pdf

Hope this may possibly help.

Best wishes, Nate

[Roger2]

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.

I had the same problem and I also changed to Humana the same date this year. I made a complaint with CMS and was able to get what I needed on load until they got it straightened out. They pulled the same crap on most of my medications and had an attorney call them. I would never recommend that company.

pax
Roger

[Madalot]

The reason my sis-in-law ended up with an Advantage Plan was her age. She is disabled & could not get a Medigap plan in our area. I'm told they do sell these to under age 65 Medicare recipients in some areas, just not in ours.
Jen

Jen, you indicate that your general area is Jeffersonville, Indiana, so I arbitrarily plugged in Clark County Zip Code "47130" into AARP's UnitedHealthCare endorsed Plan pages and it reports that conventional Medigap (Medicare Supplement) coverage IS sold through them there:

https://www.uhcmedicaresolutions.com/he ... code=47130

The critical point here is being on Medicare, but under 65 and disabled. I'm in the same boat. AARP offers Medigap plans where I am, but NOT for disabled and under 65.

My mother-in-law was at the mall and AARP had a booth set up. She talked to the woman about me, told the woman my situation and she assured my MIL I COULD get a Medigap plan through them. I called her a day later and she had checked further and sure enough -- NOT for the disabled and under 65.

[NateS]

…

The critical point here is being on Medicare, but under 65 and disabled. I'm in the same boat. AARP offers Medigap plans where I am, but NOT for disabled and under 65.

My mother-in-law was at the mall and AARP had a booth set up. She talked to the woman about me, told the woman my situation and she assured my MIL I COULD get a Medigap plan through them. I called her a day later and she had checked further and sure enough -- NOT for the disabled and under 65.

Thank you for explaining that. Chalk one more up for our "wonderful" private health insurance industry.

Regards, Nate

[Madalot]

…

The critical point here is being on Medicare, but under 65 and disabled. I'm in the same boat. AARP offers Medigap plans where I am, but NOT for disabled and under 65.

My mother-in-law was at the mall and AARP had a booth set up. She talked to the woman about me, told the woman my situation and she assured my MIL I COULD get a Medigap plan through them. I called her a day later and she had checked further and sure enough -- NOT for the disabled and under 65.

Thank you for explaining that. Chalk one more up for our "wonderful" private health insurance industry.

Regards, Nate

No problem. Obviously, not even the AARP Representatives understand this. I joined AARP when I turned 50 partly because of their Medigap plans, hoping I could get one. Pretty annoyed that they advertise them, but do NOT clarify that Medicare recipients, disabled and under 65 are not eligible (at least where I am). Having dealt with it so much myself, I know about it.

All other Medigap Plans I looked at were horrifically expensive, much more than what my out of pocket expenses are with the Humana Advantage Plan.

[NateS]

A book worth a read:

Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans
Wendell Potter (Author)

http://www.amazon.com/Deadly-Spin-Insur ... eadly+spin

"Book Description
Release date: September 13, 2011
In June 2009, Wendell Potter made national headlines with his scorching testimony before the Senate panel on health care reform. This former senior VP of CIG NA explained how health insurers make promises they have no intention of keeping, how they flout regulations designed to protect consumers, and how they skew political debate with multibillion-dollar PR campaigns to mislead the press and public. Potter had walked away from a six-figure salary and two decades as an insurance executive because he could no longer abide the routine practices of an industry where the needs of sick and suffering Americans take a backseat to the bottom line-leading Michael Moore to call him "the Daniel Ellsberg of corporate America."

Regards, Nate

[IrishSpike67]

Hi! This topic is EXACTLY what I was hoping to find! I recently switched from Care Improvement Plus (Medicare Advantage for Diabetics and Heart Failure patients) to Humana Gold Plus and can't figure out WHAT vendors/companies supply CPAP equipment to Humana beneficiaries. Trying to navigate the Humana website is a lesson in futility. That's one thing I really hate about Humana. The Care Improvement Plus webpage is so much easier to navigate and when you call them, you get a real live human on the phone... but that human usually doesn't speak very good English, so I guess it's sort of a crap shoot.

Anyway, I was hoping to get a list of companies that accept Humana but so far I've run into a brick wall. Can you fine citizens of planet Earth guide me in the right direction? Sorry for the flowery phrases and speech... on top of being in dire need of a new mask and hose (my cat punctures every hose I get--might have to wrap the d*mn thing in STEEL pipe!), my jaw is infected and I have to have a tooth yanked or have a root canal! When it rains, it pours! I'm on Tylenol with Codeine, so my speech is peppered with more than the daily allowance of sarcasm and long, drawn out paragraphs!

[ChicagoGranny]

I was hoping to get a list of companies that accept Humana

Humana does not have contracts with DMEs. They "deem" a DME to have a contract with them when the DME meets some simple basic requirements.

You have to call the DME (equipment provider) and ask them if they accept Humana Gold Plus.

Just call the supplier you prefer. If you don't know a supplier, look up one convenient to you on the internet.

[Jeannh]

A Medicare Advantage plan is basically an HMO. An HMO plan is a 'gatekeeper' model, meaning your PCP (the gatekeeper) has to refer for everything but emergencies and meds.

My guess would be that your PCP Needs to refer you to the sleep doc (this should only be a phone call), then the sleep doc has to authorize supplies for the DME via fax. I'll bet those 2 auths will handle it if you have DME coverage.

Ask the sleep doc's staff to get these ducks in a row for you-they do it all the time.
Jean