Insurance EOB Repriced CGMS Sensors?

[sticker]

Has anyone ever seen a repriced EOB for their MiniMed sensors and/or transmitter? I'm wondering if MiniMed is repricing any of these items?

Based on an email I received from my lawyer, I'm expecting an EOB from my insurance company any day now. Here is an excerpt from that email.

"I wanted to follow up with you regarding the claim for the continuous glucose monitoring system. We checked for repricing for that item, but there was not any available. The claim is currently being processed. The claim was submitted for $1399, all of which is considered to be a covered expense. The actual benefit is subject to plan terms such as deductible or coinsurance. For this claim, the amount payable will be the entire $1399."

My $1399 claim broke down to $999 for the starter kit and $400 to upgrade my 715 to a 722 pump. It appears I'm getting a refund for the whole thing. If so, after lawyer fees I'm only in the hole by $1500 bucks.

So after many denials, finally paying for the CGMS system myself and ultimately suing my insurance company, they've decided to pay for the MiniLink. The above indicates that MiniMed does not reprice. Has anyone seen their own EOB with repriced sensors and/or transmitters? If so, what were they repriced to?

[kgm0612]

What insurance do you have? I have United Healthcare and my plan is not covering any of it.

Karen

[sticker]

I have Golden Rule Insurance, a UnitedHealthcare Company. It's a very old policy. If/when I get the elusive EOB, I'll see about posting it.

[sticker]

For what it's worth, I was asking the MM store rep if they have any knowledge of repriced amounts for the CGMS items and they said "no. There isn't a code for these items, so there is no repricing." That differs with what I was able to glean from the Pathway rep. She said for those few who are covered, they negotiate prices. What gives?

[JediSkipdogg]

For what it's worth, I was asking the MM store rep if they have any knowledge of repriced amounts for the CGMS items and they said "no. There isn't a code for these items, so there is no repricing." That differs with what I was able to glean from the Pathway rep. She said for those few who are covered, they negotiate prices. What gives?

EVERY insurance negotiates prices with a company to cover their products. One great example is my doctor's office. They charge $25 for an A1C, yet my insurance only pays $8. The doctor's office eats the cost or most often just raises the price. So the test could truely cost them $20, but since they negotiate rates, some cost $25, some cost $8.

When they do this the billing code stays the same. The huge difference that makes it hard for the average person to get this is they aren't buying the massive quantity that insurance would buy. For example, Blue Cross of Ohio can tell MM no more than $25 for each sensor, and they either take it or leave it. If they leave it, then they lose all the patients in Ohio that have BCBS.

Generally speaking, medical providers are suppose to be able to charge whatever the lowest they charge insurance is. HOWEVER...to get that you need to pay the bill in full in cash.

[sticker]

EVERY insurance negotiates prices with a company to cover their products. One great example is my doctor's office. They charge $25 for an A1C, yet my insurance only pays $8. The doctor's office eats the cost or most often just raises the price. So the test could truely cost them $20, but since they negotiate rates, some cost $25, some cost $8.

When they do this the billing code stays the same. The huge difference that makes it hard for the average person to get this is they aren't buying the massive quantity that insurance would buy. For example, Blue Cross of Ohio can tell MM no more than $25 for each sensor, and they either take it or leave it. If they leave it, then they lose all the patients in Ohio that have BCBS.

Generally speaking, medical providers are suppose to be able to charge whatever the lowest they charge insurance is. HOWEVER...to get that you need to pay the bill in full in cash.

Is BCBS of Ohio paying $25 per sensor?

[JediSkipdogg]

Is BCBS of Ohio paying $25 per sensor?

They aren't even covering them. I just picked the first insurance company that comes to mind. If I get a CGMS soon (very unlikely now) I'll see what my insurance bill says when I get that as well.

[sticker]

EVERY insurance negotiates prices with a company to cover their products. One great example is my doctor's office. They charge $25 for an A1C, yet my insurance only pays $8. The doctor's office eats the cost or most often just raises the price. So the test could truely cost them $20, but since they negotiate rates, some cost $25, some cost $8.

When they do this the billing code stays the same. The huge difference that makes it hard for the average person to get this is they aren't buying the massive quantity that insurance would buy. For example, Blue Cross of Ohio can tell MM no more than $25 for each sensor, and they either take it or leave it. If they leave it, then they lose all the patients in Ohio that have BCBS.

Generally speaking, medical providers are suppose to be able to charge whatever the lowest they charge insurance is. HOWEVER...to get that you need to pay the bill in full in cash.

You are pretty much right. The provider can be, or not be, in whatever network they decide to be in, and the consumer of services can choose to remain in-network (where possible) or go out-of-network. Now, let's say you visit a doctor, or obtain services from a provider who is an in-network provider and they bill you $1000 for a given service. You later receive an EOB that allows $350 for that service, you are only responsible for the $350, as the provider has agreed to the discount schedule for that service.

Should you be uninsured and self-pay, you would receive NO discount, beyond some meager 10% discount for paying cash on the barrel head. It would be nice if providers would extend the repriced amounts to uninsured patients, but generally, they don't, nor would they ever have any clue to the discounts possible on the 'negotiated amount' of the EOB.

From what I can tell, as of this date, MiniMed is getting full sticker-price from everyone for their CGMS system. It's new, it's hot and everyone wants one. I wanted one, too and decided to pay out of pocket to have it, until I could get all this sorted out with the insurance co. As I mentioned earlier, I had to sue to get a determination of benefits for it. Since my personal health insurance policy is a plan that's probably older than you are, it was written before there were networks and has simple language. They had to finally admit that the CGMS is a covered benefit and lamented that MiniMed would not discount this product. I am anxiously awaiting my forthcoming EOB and am very curious to see if MiniMed will agree to a repriced amount. I am also VERY curious to see if anyone, anywhere has an EOB for the MiniMed CGMS system components with anything less than full retail. Anyone???

[sticker]

I just received the EOB and a full reimbursement check for $1,399.00, which includes $999 for the starter kit and $400 to upgrade the 715 to the 722, from Golden Rule Insurance, a UnitedHealthCare company. Now if they will just continue to cover the ongoing sensors and transmitters....

If anyone wants to see the EOB, help me figure out how to post it, or PM me for a copy.

[Dewey]

I just received the EOB and a full reimbursement check for $1,399.00, which includes $999 for the starter kit and $400 to upgrade the 715 to the 722, from Golden Rule Insurance, a UnitedHealthCare company. Now if they will just continue to cover the ongoing sensors and transmitters....

If anyone wants to see the EOB, help me figure out how to post it, or PM me for a copy.
Good deal that they covered it for you. I too, hope they'll continue to cover your sensors.
On posting the EOB, what you can do is (if it has already been scanned in) save it as a .JPEG to a place like photobucket, etc., and then use the image tags to post the pic. If you need help, feel free to PM or e-mail it to me & I'll be glad to assist!

[sticker]

http://i167.photobucket.com/albums/u146/flybeech/eob.jpg

[someone]

Good for you! Looks like a lot of people with UHC are getting covered. So far I have not had any luck with BCBS/Il.

[sticker]

Good for you! Looks like a lot of people with UHC are getting covered. So far I have not had any luck with BCBS/Il.

It hasn't been easy and I'm not 100% sure of being out of the woods, just yet. Before dismissing anything, I'm waiting to see how subsequent reorders for sensors go.

Now that you've actually gotten your starter kit, have you sent BCBS the bill? Has your submitted bill actually been determined not to be a covered item? Have you been officially denied benefits for your CGMS?