Preauthorization for Durable Medical Equipment? - Mothering Forums

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#1 of 5 Old 06-21-2010, 11:09 AM - Thread Starter
 
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We are getting a Personal FM System for Connor (EduLink). The ENT and Audiologist wrote a medical justification and we submitted it to the insurance company for a preauthorization. The insurance company (BCBS) said that preauthorization is not required for durable medical equipment. The hospital called back and told the insurance company that this is a $3000 piece of equipment, and that we (the parents) need to know whether it will be covered. The manager looked up our contract and said:

"It appears that it will be covered, subject to copays, deductibles, and co-insurance [10%], but a medical necessity board will review it once the claim is received."

So basically, it "looks" like it "might" be covered, but we won't know for sure until we receive the equipment and they review it for medical necessity.

WTF???

The insurance company is saying that they won't tell me ahead of time if they'll cover it!! So I'm expected to just take my chances and get it, knowing that I might possibly be stuck with a $3000 bill??!!

Has anyone ever dealt with this? Is there a way that I can get a more sure preauthorization, without a formal preauthorization? (if that makes sense) I have other funding sources to help pay for this, so we won't be stuck with the whole bill, but those take time to process, and I'd like to start processing them now if I think that I will be responsible for the bill, you know? This is craziness..."we might cover it, bill us and we'll tell you"...

Mommy to BigBoy Ian (3-17-05) ; LittleBoy Connor (3-3-07) (DiGeorge/VCFS):; BabyBoy Gavin (10-3-09) x3 AngelBaby (1-7-06)
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#2 of 5 Old 06-21-2010, 11:12 AM
 
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Do you have a complex case manager? When we had BCBS of Kansas we had one. I would call them.

But I know what you mean. We have had this before.

Anne, Mama to Conner 2/27/04 blahblah.gif  Gabrielle 2/6/06 W/LMC-TCS, Neurogenic Bladder, AFO & KAFO wearer, Neurogenic Bowel energy.gif & Delaney 5/12/08 mischievous.gif &  Beethoven cat.gif& Gizmo cat.gif

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#3 of 5 Old 06-21-2010, 11:16 AM - Thread Starter
 
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He doesn't have a case manager through BCBS. He does have one with his secondary insurance, she is extremely helpful, but that insurance doesn't cover FM Systems for anyone (not even deaf kids). When I called the secondary insurance about it, his case manager sent me information on other funding sources, which was really great. But I hope to not have to use them, I'm hopeful that BCBS will cover it!

I'm about to call them now...hopefully I get someone on the phone who can help!

Mommy to BigBoy Ian (3-17-05) ; LittleBoy Connor (3-3-07) (DiGeorge/VCFS):; BabyBoy Gavin (10-3-09) x3 AngelBaby (1-7-06)
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#4 of 5 Old 06-21-2010, 03:28 PM - Thread Starter
 
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So this is just amusing

The billing code shows up as "hearing aids and accessories". But, Connor is not using his FM system as an accessory (many kids get FM systems with their hearing aids) He is getting an FM system because he isn't a good candidate for a hearing aid.

So it should be Durable Medical Equipment. But the code is hearing aids.

Hearing Aids are covered at 100% (no copay, no deductible, no coinsurance) up to $1400 per ear every 36 months. I'm getting conflicting information on whether we're responsible for any amount over the $1400 per ear, or whether that is the contracted amount.

DME is covered at 90%, plus copay, plus deductible. No cap.

Every person I've talked to says that they see no reason why it wouldn't be covered, regardless of whether it processes as hearing aid accessories or DME. But the Audiologist is cautioning me that they've had these denied many times before.

I don't know what to think now!

We were going to get him only one receiver this year, and the second receiver next year, but if insurance is going to pay for it, then we're going to get him two receivers right away. I wish I knew so I could order the dang things!! I'm going to call the insurance company one more time, talk to a different person, and see if I get a different answer. Then just bite the bullet and have the audiologist order it I guess.

Mommy to BigBoy Ian (3-17-05) ; LittleBoy Connor (3-3-07) (DiGeorge/VCFS):; BabyBoy Gavin (10-3-09) x3 AngelBaby (1-7-06)
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#5 of 5 Old 06-23-2010, 06:18 PM
 
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But it took a long time because Blink Twice the makers of the Tango sold it to Dynavox and BCBS was waiting for a letter stating how much it would cost (I never saw this letter but a Tango is about $7000). I didn't have to pay anything (co-pay, deductible, co-insurance) and I have BCBS as a PPO provider and they won't pay for much it seems. I kept telling everyone I had no money so if they wanted any they'd have to cancel the transaction and I was assured it was a "durable Medical equipment" and covered 100%. Too bad thety won't pay $15 a session for ST which we really need!?!

Best wishes to you and your family,
Sincerely Yours,
Debra
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