QAS and Blue Cross Blue Shield

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KristaDeAnn

I have Blue Cross of California HMO and from what Cameron at QAS has told me.... Blue Cross has approved my home testing machine and supplies HOWEVER... they will not pay QAS they want to reimburse me and I will have to pay up front.

Now Cameron has told me that the unit will be $2414.00 INRatio and then BC/BS will reimburse me their "Contracted Amount". Thats the part Im worried about. I do not have the money to buy this machine..I could borrow it if I was in fact going to get ALL of it back..Im worried that BC/BS'S "contracted amount" may in fact be less than the cost of the unit to me from QAS and then I will be out the rest of the money. Cameron couldnt tell me if their contracted amount was the same as what the unit would cost me. In addition I imagine the supplies are going to be handled the same way.

Im very concerned that I am going to get the short end of the stick in this situation. As it stands right now, I can go to the doctors office for my testing...I do not have a co-pay..I basically just walk in and test. It is inconvenient for me but at least it doesnt cost me anything.

Has anyone with BC/BS been down this road??.... Did they reimburse the full amount.?? Cameron said they approved covering it 100%... It is just the contracted amount being different than what QAS is going to charge me that I worry about... Cameron is supposed to be getting me answers to these questions..but I wanted to ask another valver like me what their experience has been in this situation.. Thanks for any info anyone can provide.
 
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geebee

When I purchased my INRatio, my insurance (Anthem Blue Cross) approved it with me paying 20%. QAS had me pay 20% of the total monitor price (around $500 with test strips). Anthem only allowed $1500 for the monitor so my 20% was $300. I received a refund from QAS for the difference between the 20% I paid and the $300. So maybe you would get a refund for any difference between what you pay to QAS and what BC allows.

I would talk again with QAS and get something in writing about how they handle "allowed" amounts.

You might also talk to your insurance company and ask them what they will pay. Tell them your situation and maybe you will find a nice person who will help. Is there a chance QAS could send you a bill for the monitor that you can submit to the insurance company in advance?

The other thing you need to find out is how the monitor and supplies are handled when it comes to any deductible you might have. I never had a deductible until Sept. of this year and now my supplies fall under the deductible. So, instead of paying 20% of $120 for a box of strips, I am now paying the entire $120. You can bet I have increased the time between testing now.

Just a few thoughts.
 
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KristaDeAnn

Gee Bee
Thanks for the response. I have spent my entire day going around and around with both my insurance company AND QAS. No one at QAS can tell me what the "contracted amount" is for the monitor... ??? And yet my insurance said the "Providor" (QAS) would have to tell me what the contracted amount is??? I basically just want to know how much my inurance is going to pay yet even they cannot tell me that..they continue to say "the contracted amount".. (Duh!) So I am still in the dark.

My insurance approved the monitor and supplies at 100% (of the elusive "Contracted Amount" ) This will fall under Durable Medical Equipment of which I have a 5000.00 a year maximum. (Which should be plenty to cover everything including the cost of the monitor)

The first person I spoke to at QAS told me the monitor was going to be $2414.00 (I still have no idea how much the supplies are or how often you have to order them??) Then when I started asking about what their "contracted amount" is with Blue Cross I was put on hold and then a girl came on the line and told me that she handles all of Loma Lindas referrals..

So I had to start all over with her...she told me the monitor would be $1400.00??? So after it is all said and done I do not have any additional information that is useful to me than when I started this morning. My question is simply "If I pay for the monitor then submit the bill to insurance....how much am I going to get reimbursed"? Doesnt seem like it would be that difficult to answer.. and the only answer I get is 100% of the "contracted amount". (*Which insurance cannot tell me how much that is...and neither can QAS... ) ACK!!! Im about to pull my hair out.. The gal at my insurance said I need to speak to the contract manager for QAS and they should be able to tell me what that amount is...and QAS says they do not have that information... So now what?

When I was asking these questions of QAS all I got was a whole lot of "I don't knows"..that bothers me quite a bit... I dont know how to get to someone who does know.. I dont want to end up with a big unexpected out-of-pocket expense...thinking the entire time they are going to reimburse me for all of it.. So basically Im at a loss.. Thank you for your response..I appreciate the info..
 
K

Karlynn

Krista, you may want to try sending a PM or email to the member QAS - this is Lance's (from QAS) membership name. He might be able to hunt down the info you need.
 
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Kathy Canistro

Blue Cross of Massachusetts

Blue Cross of Massachusetts

Hi Krista,

I was told by someone at INRatio That Blue Cross of Massachusetts would not even consider it. I could also borrow the money to pay the instrument but I would be killed on the test strips I was tols $120 for 12 strips, I still have to test once a week because I can not seem to get to the 2.5 to 3.5 range that I should be in.

I wonder how the insurance company can decide the actual hospital lab is more cost effective?

Please keep me updated if you are successful.

Thanks Kathy
 
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geebee

Krista,

Since the contracted amount I was dealing with was $1500, I would think the $1400 figure you were given was the contracted amount. Based on the information you have, I would suspect that you would be reimbursed the $1400. Why no one actually wants to come out and say so is beyond me but that is one of the insurance circles we have to navigate.

A box of test strips for the INRatio monitor is $120 and it sounds like you will be reimbursed for that amount as well (or something very close). If you test weekly, one box will last 3 months (unless you have error issues which do happen). In addition, you need lancets which run around $10-$15 for a box of 50. I highly recommend you order capillary tubes which make using the INRatio monitor so much easier. You collect the blood in the tube and squeeze it into the test well.

Good luck with your insurance maze.
 
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Mary

Krista,
I called my daughter who works for BC/BS of Missouri and was at one time in provider services; now she's a manager for them.
I read her both your posts, and she said typically BC/BS isn't allowed by their contract with the provider (in this case, QAS) to tell you how much the contracted amount is. The reason is, the provider-QAS- will charge different customers different prices. If you walk in with no insurance, only cash, they might say the monitor is 1300 dollars. If you walk in with Medicare, they will say it's $1600 because Medicare will pay the entire amount. So everyone is apt to pay different prices, and they don't want you to know that.

I asked her if QAS shouldn't be upfront with you, and she said, "Yes." I then asked what she would advise you to do. She said you should tell them that they can either give you the cost-contracted amount-or you're going to take your business elsewhere. She believes they will then quote you a price.

I hope this helps.
Mary

ps In this case, it's not the insurance playing games, it's the company.
 
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KristaDeAnn

Thank you so much everyone that replied... You have given me some very useful information here to work with. I now understand the reason they are reluctant to give out what the contraced amount is and why my insurance would not give me that information..

I am very hopeful about getting this machine..I did not expect it to be approved at all. In fact I only got my doctor to sign the prescription because I told him I was just trying to find out whether or not it would be approved if I eventually wanted to do home testing.. He is very unsure of allowing me to do this.. (I am his only heart patient..and he looks like he is 12 years old..).
So Im somewhat shocked at the out come of this.. But now since it has been approved I only have until Feb 11 to use the approval to get one..so Im going to try to push it threw. GeeBee..I asked about those tubes and the girl I was speaking with said "You dont need those with the INR ratio. I agree with you they do make it easier..as my cardiologist did not use them however my regular doctor does use them and it is much easier to transfer the blood with one of those than to try to make it drip in the right place.

It is interesting that EVERYONE I talked to at both my Cardiologist office and my regulard doctors office told me to not even bother trying to get my own machine. That my insurance would not cover it and I would not be able to afford the test strips even if they did approve the machine. Not one single person was supportive of me trying to do this.. ?? I find that rather strange..

I will let you know how this turns out I am going to call QAS again today and again request the information I need to push this through. They have got to understand that any normal person would want to know how much they are going to get reimbursed for this after paying up front for something so expensive..

One other thing...do these machines get out dated..where you have to eventually purchase a new one or get to the point where you can no longer get supplies due to them becoming obsolete...?? Do you have to go through this entire process again if that does happen??? Thank you again for your information and support...AND Merry Christmas.. Krista
 

catwoman

VR.org Supporter
Supporting Member
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Messages
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Location
near Fort Worth TX
Krista:

Sounds like your doctors are still in the Dark Ages. Guess they haven't read the studies showing that home-testers stay in range better than other warfarin patients.

FYI: When I was looking at home test units, I was quoted one price if I purchased it w/out going through insurance and another price if I went through insurance, i.e., the provider billed my insurance company.
 
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KristaDeAnn

My machine has been shipped!! Yippee

My machine has been shipped!! Yippee

For anyone interested I was notified today that my INRatio machine was shipped out today overnight!! :D I had to pay for it up front however my insuarance with reimburse me once I submit the invoice to them. I will have to pay for my supplies the same way but that is a small price to pay for the freedom I will have and the ability to test weekly instead of monthly as I am doing now. I have Blue Cross of California HMO.

Thought maybe this post would encourage anyone with the same insurance to charge ahead and try to get their own home testing machine.

Thanks to everyone that posted encouragement and thoughts on this matter..all of your information was very helpful...
 
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KristaDeAnn

Delivered this Morning

Delivered this Morning

Yippeee...:D Seems like Christmas again. :D Now I have to complete the training.:p ..sit down with my GP and have "a long talk" per his request :rolleyes: , and agree to test in his office the first few months so he can see I know what Im doing.;) .and so we can determine the variance between their machine and mine. No problem...

Happy Day.. :D
 
K

Karlynn

KristaDeAnn said:
Yippeee...:D Seems like Christmas again. :D Now I have to complete the training.:p ..sit down with my GP and have "a long talk" per his request :rolleyes: , and agree to test in his office the first few months so he can see I know what Im doing.;) .and so we can determine the variance between their machine and mine. No problem...

Happy Day.. :D

Krista, sounds like he's making you jump through some hoops, but at this point, do what you gotta do. Don't forget the discussion of late here that the INRatio seems to test at .6 higher than other machines. If that happens assure the doctor that you are intelligent enough to do a little math. :)
 
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PamO

I've read this thread and am going to be going through the same thing with my husband, as he's just getting into self-testing. But...one thing that no one mentioned is how BC/BS categorized the home test unit. Is it durable medical equipment or medical supplies?

I know that in the plan documents I administer, no one specific item is listed, but rather they are categorized into different sections. From what my broker and I can figure out, the home testing unit falls under durable medical equipment and the benefit for that is 100% up to $2,000 per year. (Same thing with physical therapy - go figure). As for the supplies, from what we can figure out, they are written as a script and sent directly from our prescription provider under the "umbrella" of our insurance provider (oh, how I love being a benefits administrator). Of course, knowing how insurance companies work, I'm not believing this until I get direct answers from them!

I would look at how your insurance company categorizes the home test unit and then look at the amount allowed under that category. That should tell you what they will pay. They may say 70% of contracted amount, etc., but it'll get you in the range (or close to it).

And, fyi...the insurance company telling you that the provider needs to give you the contracted amount...is bull. The insurance company is the one that designates the contracted amount, NOT the supplier! The supplier would send them a bill and then the insurance company pays the contracted amount. Sheesh! Talk about passing the buck!
 
M

Mary

PamO said:
I've read this thread and am going to be going through the same thing with my husband, as he's just getting into self-testing. But...one thing that no one mentioned is how BC/BS categorized the home test unit. Is it durable medical equipment or medical supplies?

I know that in the plan documents I administer, no one specific item is listed, but rather they are categorized into different sections. From what my broker and I can figure out, the home testing unit falls under durable medical equipment and the benefit for that is 100% up to $2,000 per year. (Same thing with physical therapy - go figure). As for the supplies, from what we can figure out, they are written as a script and sent directly from our prescription provider under the "umbrella" of our insurance provider (oh, how I love being a benefits administrator). Of course, knowing how insurance companies work, I'm not believing this until I get direct answers from them!

I would look at how your insurance company categorizes the home test unit and then look at the amount allowed under that category. That should tell you what they will pay. They may say 70% of contracted amount, etc., but it'll get you in the range (or close to it).

And, fyi...the insurance company telling you that the provider needs to give you the contracted amount...is bull. The insurance company is the one that designates the contracted amount, NOT the supplier! The supplier would send them a bill and then the insurance company pays the contracted amount. Sheesh! Talk about passing the buck!

I don't agree with your last paragraph, Pam. The insurance company is not allowed to disclose the amount to the client; the lack of disclosure is part of the contract that they sign with the supplier. The supplier works like many hospitals do; charging one price for patients with insurance and another price for patients who are private pay.
 
G

geebee

Pam,

I have Anthem Blue Shield and they designate the supplies under DME. I don't know if Anthem is different from BC/BS in other areas but my supplies are now subject to my $500 deductible. That pretty much means they are out of pocket for me (at least until late in the year).
 
K

Karlynn

I don't know if this applies to medical equipment or not, but our insurance company (BC/BS) always puts down the "agreed upon" amount that they have with the provider. For instance, it will say:

Complete CBC Charge: $150, Contracted Amount: $112, Amount paid to provider: $112, Amount owed by patient: $0 (If I've reached my deductibe. And the numbers here are strictly ficticious.)
 
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Dave S

I have BCBS of Florida and was told they would not cover the cost. then they told me to resubmit the paperwork with more detailed information.

I went through QAS they filled all the paper work with my doctor.
I am woundering if anyone could tell me what was written on the paperwork to get the machine.

Thanks
Dave
 
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geebee

Usually the doctor has to "write a prescription" indicating that you have a need for weekly testing. Most insurance companies will not approve the purchase of a machine for monthly testing. It also helps if the doctor writes something about accessing a lab to be a problem, that you travel a lot or that you are a "hard stick" when it comes to venous draws. All those are issues that help to get a home tester approved.

I don't know if QAS asked for those on the prescription or not but those are some of the requirements that are needed.
 
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