AAAARRRRRGGGHHHH Insurance...

[Glucoweb]

Walks in room places down soap box..... steps on top

OK, just got the call back from Smiths Medical regarding them filing with my insurance company. My insurance denied the claim. They will not cover their portion of a new pump, unless my current pump (though not longer under warranty) malfunctions. This really just irritates the snot (for lack of a cleaner word) out of me. My current insurance company has never paid for an insulin pump for me. My current pump was received through the insurance carrier at my last job.. irregardless they will not pay for a new pump. The Smiths rep was super nice and professional and explained to me how things would work, if my current pump malfunctions:

Pump breaks, technical malfunction, powers down, severe crack, etc...
I place a call to clinical and inform them.
They then place a call to their reimbursement rep (the one I have been speaking to on the phone regarding this matter)
She sends me a warranty loaner pump (not to be confused with the loaner pump I can still request when going on travel) free of charge and I send back the broken pump. She then files a claim with my insurance and seeks authorization. She says there has never been a case in the past where the claim is denied at this point. Smiths still has to investigate the returned pump and document its failure for my insurance company, but by this time I should already have my new pump (providing I have met my deductible and paid my share of the 20% or have a payment plan setup with Smiths Medical).
This just kind of wears me slick. Maybe I am just spoiled because my previous insurance company did not have an issue with approving the claim when my first pump was out of warranty. This just grates on my nerves so bad, I wish I was in range to hit some golf balls toward my insurance companies building. or I could just go:

AAAARRRRRRRRRRRRRRGGGGGGGGHHHHHHH!!!
:banghead: :argh: :mad: :hmpf:

ok, that actually helped some :)

Steps off of box, picks it up and calmly returns to my seat.

[morrisma]

Sounds like Smiths will go a ways to really help you here. Good for them. Really a shame about for profit medical establishment's $$$ goal set. Any appeal process possibly? Any MRI near you where you can forget you have the pump on?
Mike

[Funnygrl]

At least they told you this BEFORE you got the new pump ;) When it happened to me I got a bill after I had been using it for 6 months. Just appeal it. Do it enough times and they'll give in. Write them a letter explaining that a new pump could take a long time to arrive, and waiting until a malfunction puts your health at serious risk during those days, and may result in ER visits and the like as you can't plan for a pump malfunction and doses will take a long time to figure out on MDI. They'll eventually approve it.

[notme]

Hmmmm..........


Sounds to me like your pump might definitely malfunction in the near future or get a nasty crack...... :whistling

[camjen1]

Hmmmm..........


Sounds to me like your pump might definitely malfunction in the near future or get a nasty crack...... :whistling

LOL!!

I see the pump taking a fall down the stairs in the near future. :T

[pegasus]

You have my absolute and complete sympathy. I would send letters to the local offices of your congressmember and senator and local city/town/county etc. officialss, talking about the national diabetes epidemic and how important it is to have coverage for this sort of thing because it will be cheaper down the line when you avoid complications with tighter control.

It wouldn't hurt to put something in about why we need health care reform that includes reforming the insurance system, since that's been a big prez campaign issue.

Ask them to intervene. Local offices are there explicitly for constituent service, and they can often get results on all kinds of things you might not imagine. Make a clear medical case for why a new pump would be good for your health.

Also write to the state insurance department (all states have to have them since insurance is regulated within each state) and the state health department; they may have an internal consumer advocate or inspector general. Find out who heads the state legislative committee(s) on health and cc them. (I don't know your state's legislative setup, so I don't know if there's one or two bodies, like the federal house and senate0).

Then cc the rep and the insurnace company, listing everyone you've written to.

I know this is a lot of paperwork, but this sort of approach has helped to change minds occasionally. It also can be cathartic ;) though I'd try to keep out (or edit out) the expletives you might be tempted to put in,

Good luck.

PS If you can get a letter from your doc, I'd enclose that.

[JediSkipdogg]

Animas is the same way in regards to a pump out of warranty. I'll be using this method but not to save my insurance company money but to save me the 20% out of pocket. I'll keep my current pump till it breaks and call them and have them overnight me one like it's under warranty. Then I'll make the request to the insurance company for the new pump.

Personally, and keep this in mind as it's my own opinion....What the insurance company is doing I think is alright. Otherwise everytime someone switched insurance companies they could get a new pump. And why should they replace a pump that works fine just for the warranty aspect? I personally think pump companies should sell extended warranties. They'd most likely make a killing off of that from insurance companies and people that just want to hold on to their pumps and not have a huge out of pocket.

[SGT Shoutmore]

Hmmmm..........


Sounds to me like your pump might definitely malfunction in the near future or get a nasty crack...... :whistling

I am rolling! You owe me a new keyboard! Ya know, tea with lemon shot out of my nose.. Ouch!

:adore:

[SGT Shoutmore]

LOL!!

I see the pump taking a fall down the stairs in the near future. :T


Jeeze! You're just as bad! :rofl:

That is evil, I love it.

[notme]

Technology is moving so quickly, I can't see hanging on to a pump for longer than four or five years. If I had to wait until my pump broke, I would still be using a 508. My 508 was a workhorse and it still works to date. However, my 715 has helped improve my numbers because of the bolus wizard, is smaller and doesn't require that I wear an ugly leather case to protect it from static. Medtronic will only carry the supplies for the 508 for a few more years and then they will be harder and harder to purchase.

I think five years is a perfect number for pump warranty and wear.

[Glucoweb]

Personally, and keep this in mind as it's my own opinion....What the insurance company is doing I think is alright. Otherwise everytime someone switched insurance companies they could get a new pump. And why should they replace a pump that works fine just for the warranty aspect? I personally think pump companies should sell extended warranties. They'd most likely make a killing off of that from insurance companies and people that just want to hold on to their pumps and not have a huge out of pocket.

I would be less annoyed if they had such an extended warranty, if that insurance company bought me the pump. But lets consider the pump runs 24/7, and suffers a lot of casual abuse (ie: jarring, shaking, occasional bumping, vibrate) any and all of which contributes to wear and tear on the pump (casing, mechanics, & electronics). Not to mention the function of the pump itself, loading reservoirs, regular use, etc... Such a program should also include a maintenance clause, allowing me to send the pump in for a thorough inspection.
While I am not as annoyed as yesterday, and I agree that Smiths is being very flexible and eager to assist; I feel that the insurance company should be willing to buy the pump, since I have never filed a claim for one with them before. I will probably be switching plans in the future. Even if I have to pay a little more, I would rather do that and have better, more reliable customer service able to get me the medical equipment I need to assist in my control of Diabetes.

[JungleJim]

I am going throught the same thing. This week my ins denied me a new pump although mine is out of warranty and has a crack in the case. The denial says "no documentation of pump failure". Basically their stance is, as long as it is working, cracks or anything else do not matter. When it quits, they will consider it again.

What really gets me is the statement in the middel of the letter that lets me know (in large bold letters) that they are not governed by the state board of insurance since it is a governmental insurance pool. They made it very clear that there is no one but them to complain to.

[Glucoweb]

What brand of pump do you have? In my post above about Smiths they would provide a warranty pump and perform the inspection of the pump and provide documentation to my insurance company which is also a State insurance plan. At a minimum it is then up to the pump company to declare the pump unfit for use and battle with the insurance company.

[JungleJim]

I've got a Cozmo too, and they have fought the good fight with the insurance, and have also told me they would send me a loaner if mine quits while waiting on ins approval.

They and my endo have documented the crack and warranty being expired, but the isssue is my ins is not going to pay for a new pump unless this one dies. It's that simple.

When an ins company tells you they are trying to control costs, they are.................... THEIR costs.

[Glucoweb]

WOW, even if the pump manufacturer documented the crack... Interesting, but now that I think about it, I wonder how anxious a manufacturer would be to document a failure. This would also require them to file with the MAUDE Database with the FDA (FDA > CDRH > MAUDE Database Search (http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.CFM)).
I mean no manufacturer really likes to release information showing defects or problems with their product. I just contacted my insurance and requested a copy of the policy regarding Diabetic DME. Also asked for claim status' approved or rejected relating to such.
Not saying I would or anything, but with a severe crack a dip in water might be tested. (oops I mean I might leave it on while I shower or something). The thing is I have had a pump fail before from getting wet, but when it dried out all was just fine. I have an appointment with my Endo next week. I will get his opinion on this matter and if he suggests pushing it then I will.

[Glucoweb]

UPDATE: I sent an email to my insurance company through their on-line help site asking for a written copy of their Diabetic Durable Medical Equipment, specifically Insulin Pumps. And if anyone has made a claim against my policy for insulin pumps. I got back an email stating their policy on Durable Medical Equipment is on page 45 of the 2008 benefits handbook. I had already looked there and the single statement on that page regarding durable diabetic equipment does not mention anything regarding pumps. (I was looking to get documentation concering what the Smiths rep told me about them not paying for a new pump, even though mine was out of warranty, but still working.) I ended up calling them, to let them know the response email was joke and did not address any concern in my email and to get the answers I was after.
After some lengthy discussion, it turns out I am eligible for a pump. The insurance company was not aware that my current pump was not purchased by them and the Smith's rep did not bring that up. There are a few things wrong here:
1) They are my insurance company... they have my records... they know which claims have been made... all they had to do was check the history.
2) I discussed this matter when dealing with the Smith's rep and she was completely aware of this and neglected to bring it up
Now I just have to decide if I want the pump now, or wait until more of my deductible is met.

[pegasus]

What really gets me is the statement in the middel of the letter that lets me know (in large bold letters) that they are not governed by the state board of insurance since it is a governmental insurance pool. They made it very clear that there is no one but them to complain to.

I am *really* curious about what they mean by "governmental insurance pool." Without giving more info than you're comfortable with, do you mind giving an idea of what insurance you have, or who you have it with? I've been doing health care advocacy on and off for years, and that's a new phrase I'm going to look into. In any event, that's clearly an intimidation tactic (which you clearly know :D), because it just means that it's a *federal* plan of some sort, or a state employee plan, so you get other recourse. (If federal it makes contacting your Sen/Rep more relevant.) I may have some suggestions if you don't mind being more specific.

And of course, there's always letters to the editor. Or an oped ... :D :D :D

[JungleJim]

I am *really* curious about what they mean by "governmental insurance pool." Without giving more info than you're comfortable with, do you mind giving an idea of what insurance you have, or who you have it with? I've been doing health care advocacy on and off for years, and that's a new phrase I'm going to look into. In any event, that's clearly an intimidation tactic (which you clearly know :D), because it just means that it's a *federal* plan of some sort, or a state employee plan, so you get other recourse. (If federal it makes contacting your Sen/Rep more relevant.) I may have some suggestions if you don't mind being more specific.

And of course, there's always letters to the editor. Or an oped ... :D :D :D

Sorry for the delayed response.......... well, not really, I was on a mini-vacation for a couple of days!

I work for a city in Texas. In the past we were "self insured", but had a company hired that administered the benefits. For the last two years, we have been in a "pool" of many cities in Texas to hopefully spread out the cost. While it is still self insured through TML, we use the United Healthcare Network.

[Scrabblechick]

You can also call your local newspaper or TV station and see if anyone is interested in doing a story, what with all the issues about healthcare these days. Ask if they have a health issues reporter. If no one can get a story about you right now, write that letter to the editor! Keep it to about 300 words and make sure you include all your contact information.

I work for the media myself, and a story about someone can do amazing amounts of good. The only thing insurance companies hate worse than paying legitimate benefits is an unflattering story in the paper or on TV. Trust me. :D

[pegasus]

Sorry for the delayed response.......... well, not really, I was on a mini-vacation for a couple of days!

Good for you!

I work for a city in Texas. In the past we were "self insured", but had a company hired that administered the benefits. For the last two years, we have been in a "pool" of many cities in Texas to hopefully spread out the cost. While it is still self insured through TML, we use the United Healthcare Network.

Interesting. What I think that means is that you're covered under federal "ERISA" law (I can't remember what the acronym stands for, but I think it's something like "Employee Retirement Insurance Something Assistance). If I'm right, it does take the regulation out of the state realm and into the federal (I will check), so I would definitely contact your congressperson and senators. Are you in a union?