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In our Medicare section of Common Concerns, scroll down to:
PROBLEMS WITH PROTHESIS REIMBURSEMENT
Some tips and answers can be found at MoneySavingsPro to the following link:
Hidden Gem Life Solutions has some links to resources for aiding in funding cancer treatments. They also have insurance options for those travelling to other countries that could help you from the need to pay up front before treatment. They can be found at:
“WHAT IF….?” Insurance Answers
Dorothy Lennox, Luminaud, Inc.
[Part 1 of 3 from HeadLines, 2004]
What can I do if the supplier I want to get a product from will not bill my insurance company? Even though the insurance company sent them an authorization??
Background: Insurance company authorizations, unfortunately, usually have fine print that indicates they are not promises to pay. If the supplier provides the product and submits a claim, then the insurance company will consider paying IF all the factors are right. But it is very hard for a supplier, especially one who sells all around the country by mail order, to determine the coverage and current eligibility for all of its customers with insurance, especially considering that there are thousands of insurance companies, each with its own rules. Many of the suppliers serving laryngectomees have had great losses in unpaid bills and in phone, letter and fax time and in employee wages trying to collect from insurance companies. Some have regretfully decided that continuing to bill insurance companies would force them to either raise prices for everyone or go out of business.
So what can you do? Here are 3 possibilities:
1) You can pay for the product yourself and then try to get reimbursement from your insurance company. When you place your order, ask your supplier to include more than one copy of the “paid” invoice and also to include descriptive information on the product. Get a claim form from your insurance company, fill it out, and send it to the address the insurance company specifies, along with a copy of your invoice, a copy of information describing the product, and a physician's explanation of your need for the product. If the product is covered by the insurance company, then you should get some amount of reimbursement. If the product is something you will be ordering regularly, get several copies of the claim form and make copies of the descriptive material, along with the physician’s statement so you can easily send them along each time you send a claim.
2) You can find out if your supplier and insurance company will work with proforma (as a matter of form) invoices - this is an invoice with all the particulars filled in except the serial number (if there is one) and the shipping date. The supplier sends the invoice to the insurance company, and if the company pays the bill, THEN the supplier sends the merchandise. Often the insurance company will accept the invoice by FAX. Sometimes this works out very well and very quickly. Sometimes it drags on and you have to contact both sides to make sure they’re doing their part but when it does work it can be very helpful, especially in the purchase of a more expensive item that you cannot afford to pay for up front.
If the proforma invoice option is acceptable to both the insurance company and the supplier, you or the insurance company would need to provide the supplier with the insurance company name, address, phone number, fax number, name of a specific contact person - and also with all of your own information - name, address, phone number, insurance policy and ID#, Social Security number, date of birth - any such information the insurance company would require to be put on the paperwork. Because of the extra time, phone calls and paperwork involved, your supplier may be willing to use this method for the sale of several hundred dollars in merchandise but perhaps not for $15 worth of stoma covers. The more information you have ready and the easier you make it for the supplier, the more likely they will be to be willing to do proforma invoices for you. (Note: Insurance companies often have dozens or hundreds of representative with dozens of fax machines. Make sure you get rep names and phone and fax numbers that will get you and your supplier to the right people or department each time - not just the general insurance company number.)
3) You can find a local medical equipment provider who works with your insurance company and see if they can and will act as a middleman, buying the product(s) you need from the supplier and billing them to the insurance company for you. Your insurance company should be able to give you a list of the local medical providers that they deal with. (The provider list may already be in the information your insurance company gives you when it renews your policy, along with the list of doctors that work with your insurance company.) Then ask your supplier if s/he is willing to sell the equipment you want to a local provider.
Of course, the local provider may say they don’t carry the product you want and don’t know anything about the product you want - but if you are prepared and show them the product description and give them the contact information for the supplier - and give the supplier the name and telephone number of the local provider - then you may be able to get the two companies together and make the needed arrangements. Do everything you can to make it as easy as possible for them by having descriptions, contact information, insurance information and doctor’s prescription or orders ready. The less phoning/faxing or paperwork that has to be done on either side, the more willing they may be to handle the transaction for you.
Insurance Answers [Part 2 of 3]
WHAT CAN I DO IF I got a product from a supplier and paid in full, but the supplier will not fill out a claim and send it to my insurance company to get reimbursement for me???
Background: This may seem like coldhearted behavior by a supplier, but please be aware that many of the suppliers in the laryngectomee field are small companies, selling nationwide, and that the profit margins in this special market are usually much lower than the general profit for medical markets. Since there are literally thousands of insurance companies around the country, many with their own unique forms, requirements and procedure, it is not surprising that suppliers often feel that it would be impossible, both financially and timewise, for them to obtain/figure out/fill out these forms. So what can you do?
You can make sure that you are prepared to fill out and submit your own claim forms to your insurance company with as little hassle and expense to yourself as possible. Get a supply of claim forms from your insurance company - enough to allow for throwing away mistakes and enough to have several for future needs. Study the forms and instructions so that you understand what information they require. Plan ahead. If you need a doctor’s statement, ask for it at a regular visit or check-up so you don’t have to make a special trip back.. If you are expecting to get repeat orders of a product, ask the doctor to write something indicating that you will need refills and stating how many and how often. Then get copies made so that you can send in a copy with each claim. When you order from your supplier, request enough copies of your paid invoice to use for insurance, taxes, your own records and anything else you might need copies for. (Depending on the supplier’s computer invoicing program, it is often fairly easy for a supplier to send you more copies of the invoice at the time your order is processed, but much more difficult and time consuming for them to have to generate copies at a future date, so you might have to wait longer or might be charged for the extra service. Therefore, it’s much better to ask for what you need at the time you order.) If the supplier cannot or will not give you as many copies as you want, then get copies of the originally invoice made locally. (Note: Aside from insurance - if you order supplies regularly from the same supplier and want records of all your purchase for a year for taxes, proof of expenses for subsidized housing requirements, etc. be sure to KEEP the copies of your invoices as they come in and file them carefully. If you ask your supplier for “copies of all the invoices I’ve had for the last year” because you had a fire or disaster of some sort, most companies will be happy to help you, but if you routinely throw them away or lose them and then repeated ask for copies at a later date, you cannot expect your supplier to very cheerful and prompt about the extra work or to do it at no charge.)
Also, when you order, ask your supplier for descriptive information on the product you’re submitting a claim for and include the description along with your invoice and the doctor’s statement. Again, if it is to be a repeated order, get several copies made so that you will have one to send with each claim.
WHAT CAN I DO IF my insurance company says that I must purchase from a “Preferred Provider” instead of from the company that sells a product I need? How do I find a Preferred Provider? What if they don’t carry the product.
Background: Some insurance companies have legal and financial agreements with specific providers. If you go to a provider who is not in the insurance company’s network or on their Preferred Provider list, then you may not get full insurance coverage - or may not get any coverage at all. So what can you do?
There is often a way around the Preferred Provider problem. Your insurance company will have a list of the companies they work with as providers. Check with some of those nearest to you, show them information on the product you want and provide them with contact information on the manufacturer and a couple of major suppliers. The provider may be able to buy the product and then bill your insurance company. Some manufacturers or suppliers may offer a small discount to the local Preferred Provider to help things along - and the Preferred Provider is often allowed by the insurance company to add a mark-up of a reasonable percentage - so it sometimes works out quite well all around. (The insurance company often ends up paying more this way, but they are apparently often willing to do that to have the whole process taken care of through the proper channels and procedures.)
(Note: Sometimes insurance companies or health plans have agreements with Preferred Providers that require the Preferred Provide to furnish any covered product for which the insured person had a prescription or doctor's order. Even if it means a loss for the provider, the provider must handle the sale in order to maintain its "preferred" status. An occasional loss of that sort may be worth it to the provider in order to keep its preferred status for the many routine items like diabetic supplies, incontinence supplies, etc. that are quite profitable.)
Insurance Answers [Part 3 of 3]
WHAT CAN I DO IF my insurance company says the product I want is not covered and turns down my claim?
The best thing to do is to try to anticipate and prevent the rejection in the first place by providing very obvious and detailed information with your claim showing that the products are logically covered just as any prosthetic device would be.
Insurance policies may be vague about more unusual items like artificial larynges and not mention them by name, but your policy should tell you if it covers prosthetic devices such as artificial limbs. Electronic artificial larynges and TEP prostheses are true prosthetic devices - replacements for a part of the body that has been lost or that is no longer functioning. If your insurance would cover an artificial leg for you so that you would not have to go around in a wheelchair for the rest of your life if you lost your own leg, then it should not deny coverage for an artificial larynx or TEP voice prostheses for you so you can speak again and are not left with writing or gesturing to communicate for the rest of your life.
Tracheostoma covers, from the little foam patches to the HMEs (Heat/Moisture Exchangers), are really artificial noses.
Voice amplifiers enhance the function of the voice production mechanism. They may be harder to get coverage for, but Medicare is covering them now and insurance companies often follow their lead - though Medicare, apparently not understanding voice amplifiers fully, indicated that they are only for people with their larynges in tact, so coverage for them is much more iffy for laryngectomees - but worth a try!
A good number of insurance company denials for laryngectomee products are no doubt because the claim does not include sufficient information about the product and the need. Examiners see dozens of claims a day for diabetes, heart problems, etc. But any given examiner may see a claim for laryngectomee products only very occasionally, so the need and the product have to be explained very well. You want the examiner to read it and think, "Yes, that's obviously a prosthetic or medically necessary device and it makes sense that our insurance company would cover that." Otherwise, he/she may turn it down to save the time and hassle of looking into it further. Examiners probably get some sort of efficiency rating on how many claims are handled a day and if they have to spend a lot of time looking up information to figure out the products, they may not bother - may just deny it and figure it is another claim that has been processed that they won’t have to think about anymore.
So the important thing in getting coverage is making sure that the insurance company examiners understand that the products you are order are prosthetic devices and/ or fill a valid medical function. When you or the doctor or someone helping you is writing or speaking about it, artificial larynx should not be referred to as a “speaker” or a “talk box” or an “amplifier.” Always refer to is as a “prosthesis” or “prosthetic device” or an “electronic artificial larynx.” he same applies to TEP prostheses. It is common and quicker to just write or say TEP, but it should always be “TEP Prosthesis”. Stoma coverings should be referred to as stoma filters or and explained as devices that act as artificial noses in warming, moisturizing and filtering incoming air. On stoma covers/filters/HMEs, hopefully the doctor can give a standing order for the product(s) to be supplied every so often and then you can just send in a copy of that doctor’s order each time you send a claim. Voice amplifiers should always be called “voice amplifiers” and not just amplifiers - and the medical need to assist the voice production mechanism should always be emphasized rather than the social or emotional wish to be able to carry on a conversation easily.
Doctors are busy and don't like to write much, but if you, the doctor, the speech pathologist, the respiratory therapist - someone - can supply some reasonable DETAIL about the product and the need, you have a lot better chance of coverage, both initially and then if you do have to appeal. Again, descriptive sheets from suppliers can be a big help.
OK - So what can you do if you the insurance company turns you down?
APPEAL!!! Any denials on products for laryngectomees should definitely be appealed unless the insurance company can show you in writing that such things are specifically excluded from coverage. The insurance company's own paperwork should tell how to appeal. Look everything over. Figure out what can be improved. Get a better write up from your doctor and/or additional information from your speech pathologist or respiratory therapist. Get more extensive descriptive material from your supplier. Put it all together and APPEAL - make the insurance company ‘s people take the time to really think about it. Someone’s study showed that if you go to the 2nd or 3rd round of appeal you’re much more likely to be successful, so don’t give up after just one try. Help teach the people who make the decisions about the products you need. The more the examiners from insurance companies, Medicare, Medicaid learn about laryngectomee products, the easier it will be for all laryngectomees to get coverage more routinely without as much hassle.
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