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archangle wrote:Be sure to complain to your Congress representatives. It may not do any good, but NOTHING will happen if enough people don't complain.

I keep telling my husband this. Until enough people start speaking out about all these injustices, screaming "No More!!" -- nothing will ever change.

My mail order pharmacy has switched one of my medications from coated tablets to NON-COATED tablets. When the bottle arrives, the inside is coated, and I do mean coated, in white powder. Plus, I have to cut some of the tablets in half. By the time I'm done, it looks like someone sneezed in a cocaine factory. Worse off, these non coated tablets are harder to swallow and I choke on them, especially the ones that are cut in half.

At lunch one day, one of those half tabs got stuck in my throat. I had to force it back up and with it came my lunch, which included a fruit punch -- all over my kitchen table.

I've complained over and over again about these non coated tablets. Their answer? If I don't LIKE their product, I can go get my prescription locally, at over 100% more cost to me.

I am screaming at them "NO MORE!" This is ridiculous that because they want to save money (so their shareholders can get a bigger bonus) I am risking my life 3x a day taking their stupid pills.

The first order I got from them was the COATED tablets. They switched to non coated the second quarter of 2012. And I've been arguing with them ever since.

NateS wrote:I use MyMedicare to check up on provider claims by reading what is listed, but I have never done a "review" - could you please elaborate on that process?

Thanks, Nate

The ''review" option applies ONLY to my BC/BS insurance which used to be my one & only insurance but is now secondary to Medicare.

SORRY for confusing everyone!

Sir NoddinOff wrote:

StuUnderPressure wrote:You can sign up for a "My Medicare" account.
With that account, you can submit a "review" of the claim submitted by each medical professional. In that review, you can opine about the lack of necessity of any tests, etc done. You can also report those excessive tests, etc. to Medicare as part of their fraud reporting initiative.o occur.

Thanks, StuUnderPressure. Interesting info: I'm not sure how good my word would be against my doctor(s) or If I want to upset/challenge my medical team like that, however I'm glad to hear there is a complaint process. I'll covertly check it out. I'll admit I haven't really explored the options in 'My Medicare" but I agree with NateS, maybe a bit more detail and a non-gov't how-to link or URL might help one understand the process. Youtube video etc.

The ''review" option applies ONLY to my BC/BS insurance which used to be my one & only insurance but is now secondary to Medicare.

SORRY for confusing everyone!

I'm not quite sure why this problem is being caused by anyone other than the DME? What am I missing?

The doctor has written a script for an ASV, correct? Even better (but not fully necessary) if he wrote the script for the specific machine you want.

The insurance company has approved of an ASV for you, correct? Most insurance companies don't care WHICH model of ASV you are getting, if you need an ASV and meet their criteria then they are going to pay X amount of dollars whether the DME gives you the cheap, outdated brick or the newest latest and greatest. Does yours pay by model?

The DME is the likely holdup. They'd rather give you the cheap, old brick and pocket the difference.

I understand that you switched to a new DME because the old one insisted on giving you the cheap, old brick but the new one has promised you what you want. So is the old DME holding up the works because they want the money so that your new DME can't get insurance approval. If that's the case, then your insurance company OR a state DME regulator, or even your doctor can light a fire under them. Or is the new DME really playing games so they don't have to give you the latest and greatest after all? Either way, the problem still lies with a DME, not your insurer or doctor.

So the medical center just called about 15 minutes ago and the insurance company, horizon BC/BS refused to pay the DME once again. The deal is this: I call Horizon and spend about a half hour getting through to someone (give them my birthday about eight times) , i explain everything and they always agree that i'm entitled and have been approved for an asv machine but claim each time that someone else has done something wrong: the doctor needs to reapply, the new DME hasn't filled the right paperwork, the old DME hasn't dropped the case - so then I call each of the above and explain and it sets off a new round of motion but nothing happens because AT THE MOMENT the DME actually needs whatever code guarantees them payment, horizon refuses.

So it was supposed to go through today, everything was cleared but when the DME put the request through, Horizon turned them down again. The person at my doctor's office ( who i need to get a great gift for - recommendations requested) called horizon and refused to deal with the person answering but demanded to talk to a supervisor. The supervisor claimed that there should have been no problem, but the dr.'s office had the name of the person at Horizon who turned it down - supervisor then said: " oh, yeah, let me look into this".

So after an hour or so of getting switched between various departments at Horizon, once again they've agreed that i'm entitled to a machine and it should go through tomorrow without any problems. I'm not holding my breathe.

To bad you don't get paid for the hours of frustration you have spent trying to get this worked out. I will look forward to hearing how this works out for you. You will have certainly earned the machine by the time you get it.

STL Mark wrote:To bad you don't get paid for the hours of frustration you have spent trying to get this worked out. I will look forward to hearing how this works out for you. You will have certainly earned the machine by the time you get it.

and I'm basically in perfect health and able to fight this everyday, for very sick people it's basically impossible to battle the system unless they have family members willing to do it for them. But i'm in terror every second that obamacare might ruin this wonderful system.

I'll avoid the tempting soapbox other than to make the following observation:

Insurance companies are in the business of not paying claims.

(Now I'll let others argue about why they have a role in healthcare.)

-SWS wrote:

johnthomasmacdonald wrote: The part that always gets me is how many americans will still try to defend this system as " the best in the world" which is just beyond belief.

Well, I don't find indoctrination, dogma, delusion, or dishonesty beyond belief. Any of those might lend the statement that we Americans have the best healthcare in the world.

I couldn't agree more, -SWS, my good friend.

sawinglogz wrote:... Now I'll let others argue about why they have a role in healthcare. ...

'Cause it'ld be un'Merican to have the government provide and coordinate healthcare for all citizens!

I have worked in DME for years. I can count on both hands the number of ASV machines that I have set people up on. Yes, insurance companies do look down on you when you refuse equipment from a DME no matter what the reason. When I had a refusal I would have to send a statement to the insurance company and the prescribing MD. Another issue would be what was determined in your sleep study. If your sleep study determined that you didn't require a ASV machine the insurance will not pay for one no matter what. It does not matter what your MD prescribes. If you have not met the insurance guidelines then they wont pay. Sometimes they will make you "work" your way up to a ASV by going through CPAP, BIPAP ect... I have once gotten an insurance company to pay for a ASV because the pt. had cardiac issues. You might qualify with heart failure or atrial fibrillation who have central sleep apnea - with or without obstructive sleep apneas.

sawinglogz wrote:I'll avoid the tempting soapbox other than to make the following observation:

Insurance companies are in the business of not paying claims.

(Now I'll let others argue about why they have a role in healthcare.)

You forgot half the equation. They are also in business to collect premiums!

My insurance is wasting money to keep from giving me the supplies for the machine I already have. They want to send me another cpap then another SS then a bipap. All I need is filters and hoses. I had 3 calls from my insurance company today and two last Friday. Now I have to go to a sleep specialist so they can talk some sense into me.

Stormynights wrote:My insurance is wasting money to keep from giving me the supplies for the machine I already have. They want to send me another cpap then another SS then a bipap. All I need is filters and hoses. I had 3 calls from my insurance company today and two last Friday. Now I have to go to a sleep specialist so they can talk some sense into me.

Hi Stormy,

This probably won't work but I wonder just for the heck of it if you should try this. Explain you need the name of a supervisor to write to and in it include this information. The cost of the hoses and supplies you need for your ASV vs. how much it would cost to see a sleep specialist, have a ss, try a cpap, and then a bipap.

Also, show the statistics of how well you have slept on the ASV machine even though it will be over their head. And explain how being able to do so is preventing potential healthcare problems that would be costly to the insurance company down the road.

Then send a copy to Senator Coburn since he is a doctor to see what happens. And maybe send a copy to the head of the agency in Oklahoma that regulates insurance companies. As I said, it probably won't work but what do you have to lose and it will help you release many, many frustrations.

49er

Madalot and Archangle,

I definitely don't disagree with you. And before my sleep issues became alot worse, I did complain.

Many years ago, the insurance company wanted to charge me from the beginning of the month even though my coverage would have been effective mid month. When I protested, they said they would be happy to delay starting coverage until the next month which was totally unacceptable.

In spite of being told by the benefits officer of my former company that this was how things were done, I refused to accept that. Well, after writing several letters to various people, the insurance company made some type of deal that gave me an even better deal monetarily and still enabled them to start coverage at the beginning of the month. Can't remember the exact details but I was happy.

But sadly, I doubt my protesting did anything to change the situation as I am sure many people are continuing to be ripped off in the manner that I was.

It just seems like there are so many injustices that it is overwhelming as to what to protest. Perhaps that is why people don't complain. But yet when I hear about an 11 year old kid complaining that title nine was being violated, I felt ashamed that I hadn't been doing enough even though I am doing the best I can.

Also, the drug companies contribute heavily to both political parties so I question how much it helps to complain to Congress. Sorry, I am really being a naysayer, aren't I? You definitely make some good points for me to consider.

49er

Madalot wrote:

archangle wrote:Be sure to complain to your Congress representatives. It may not do any good, but NOTHING will happen if enough people don't complain.

I keep telling my husband this. Until enough people start speaking out about all these injustices, screaming "No More!!" -- nothing will ever change.

My mail order pharmacy has switched one of my medications from coated tablets to NON-COATED tablets. When the bottle arrives, the inside is coated, and I do mean coated, in white powder. Plus, I have to cut some of the tablets in half. By the time I'm done, it looks like someone sneezed in a cocaine factory. Worse off, these non coated tablets are harder to swallow and I choke on them, especially the ones that are cut in half.

At lunch one day, one of those half tabs got stuck in my throat. I had to force it back up and with it came my lunch, which included a fruit punch -- all over my kitchen table.

I've complained over and over again about these non coated tablets. Their answer? If I don't LIKE their product, I can go get my prescription locally, at over 100% more cost to me.

I am screaming at them "NO MORE!" This is ridiculous that because they want to save money (so their shareholders can get a bigger bonus) I am risking my life 3x a day taking their stupid pills.

The first order I got from them was the COATED tablets. They switched to non coated the second quarter of 2012. And I've been arguing with them ever since.