Insurance coverage - cuvettes

[mommywri]

Our insurance covers 26 cuvettes at what they say is a usual and customary fee of $190.00 but QAS charges $300.00 for the cuvettes. Does anyone know why the large discrepancy between the actual charge and the insurance allowed amount? Because our insurance pays a percentage of the $190.00 instead of the $300.00 it is still costly. (Given that we have to test frequently because my daughter is still growing and changing alot of meds)
How do insurance company's figure out what is usual and customary? [I know we should be greatful that the insurance co is paying anything at all but I thought I would ask because it would cost the ins co so much more if we had to do blood draws at the hospital]

Martha (mom to Christina, 14 aortic mechanical valve --St Jude--truncus arteriosus, pace maker etc.)

 

[RobThatsMe]

Hi Martha,

I had the same problem. It came down to the fact that BC did not know the proper code to use for the couvettes and processed them as diabetic test strips. It took many phone calls to them and with QAS's help we got them to code these as durable medical supplies with an open type code. They then paid at 80%.

Check with your insurance company and see if they are using the proper codes. Also, Debbie Tan, of QAS, was extremely helpful in working with both me and the insurance company on this issue.

Hope this helps, Please let me know if I can be of any further help.

Rob

 

[Birky]

prices

prices

I think they use what is reasonable and customary for the area that you are in. We now have Blue Cross and we don't have to deal with this anymore. They have a prepaid amount they will pay the provider. Prior to this, this was always an issue. Is it possible to get the cuvettes somewhere else? I am looking into a machine so I guess this is something I need to look into also. I didn't realize that they were so expensive. Did the company pay for the machine itself? You are right about more at the hospital. I too have a St. Jude valve but in the mitral position. This will be a lifetime thing for me as well. If you test every week, 26 would last you 6 mos. It is costing about $55.00 every time I go. I am on a 3 weeks basis at this time. Figure this over a lifetime and the machine is saving them money and also your arm from getting stuck so many times. Good luck,

 

[mommywri]

Thanks for your advice! I looked at the EOB to see how they figure the $195. It says: "Maximum amount. Based upon the data gathered by the Health Insurance Association of America and/or other sources, the maximum amount fee is arrived at the[sic] compiling the prevailing fees in a geographical area and applying the reimbursement percentage purchased by a group/member. Provides[sic] are then rembursed according to this percentile."

Can anyone figure out what this statement means? Does anyone know what the reimbursement rates for cuvettes is from Medicare? Or any other insurer? Would you be willing to email me privately to let me know?

Thanks so much for all your help!
Martha (mom to Chrissy mechanical aortic valve St Jude, Truncus Arteriosus, pace maker, 3 open heart surgeries etc.)

 

[RobThatsMe]

Hi Martha,

The EOB and Max Amount allowed is based on the code they used for the cuvettes. You need to make sure that they are using the right code for the covettes. If they used a wrong code, this could explain the lower allowance. I have BC insurance and they originally processed my claim using the wrong code. Once they reviewed this, they changed the code and my claim was processed correctly.

Rob

 

[mommywri]

The code they used was E1399 which says Durable medical equipment mi[sic]. Perhaps that means miscellaneous.

Martha (mom to Christina Aortic mechanical valve St. Jude, truncus arteriosus, pace maker etc.)

 

[mbalfour]

Another thread has more info

Another thread has more info

Please read the thread: Insurance: Empire BC/BS in this Forum. More info on the same subject.

 

[Gisele]

Martha

Martha

I don't get to boards as often as I used to so I just saw your post. If you recall I have BCBS of MA. I was getting re-imbursed at 100%, but not too easily. It seems as though because it was so new no one knew how to handle it. I was told to attach a letter saying to review this claim manually. Also do not use DME in your claim (durable medical equipment). Use the code E1399 mentioning your purchase is from an out of state provider for an Rx item. My cover letter also included referrences to previous claims that were paid for at 100%.

If you have any questions you can e-mail me. I still have all my paperwork on my claims even though I am no longer on Coumadin.

Good luck.

Gisele

 

[ALCapshaw2]

BCBS coverage for Couvettes

BCBS coverage for Couvettes

I don't get to boards as often as I used to so I just saw your post. If you recall I have BCBS of MA. I was getting re-imbursed at 100%, but not too easily. It seems as though because it was so new no one knew how to handle it. I was told to attach a letter saying to review this claim manually. Also do not use DME in your claim (durable medical equipment). Use the code E1399 mentioning your purchase is from an out of state provider for an Rx item. My cover letter also included referrences to previous claims that were paid for at 100%.

Good luck.

Gisele

BCBS of ALA tells me that Couvettes are DME and DME for my (out of state) employer is handled in the Home State for the entire USA so I get to start all over again trying to get coverage for my Couvettes. Oh yes, they tell me that E1399 is NOT a covered code so I must first place an order, which will of course be rejected, and THEN I can write an Appeal to BCBS in the company's home state. FUN! Naturally, NONE of the claims representatives have a clue as to what Prothrombin Time is or how it is tested. More FUN! Did I mention that DME can ONLY be obtained from an already approved provider? At least I did eventually find a provider (in the company's home state) who knew what PT is but they only carried Coaguchek machines and test strips. At least it's a start. Sometimes I think fighting the Insurance Companies is a BIGGER MOUNTAIN than OHS / AVR ! I know, they WANT me to get frustrated and "Give Up and Give In". OK, now that my taxes are done, I will write that appeal (next week), just for you Nancy

'AL'

 

[Birky]

cuvettes

cuvettes

I have BCBS of Iowa and Lance was working on getting me a machine. Had all the papers from the Cardiologist.BCBS would not give him a answer if it would be reimbursed or not. They said that I would have to purchase the machine and then they would decide if it was covered. So right now I am on hold. It is a lot of money for us to come up with now since we are still paying off hospital bills from last year. I work with insurance and right now this is a very frustrating area.

 

[Ross]

They said that I would have to purchase the machine and then they would decide if it was covered.

That pretty much summed it up. They aren't going to cover it and they want you to use your money so they can laugh at you. I would not fall for that crap.

Ask them if they'd give you insurance and let you decide if you want to pay for it!