Isn’t it frustrating that we pay thousands of dollars per year for the “privilege” of having health insurance only to find out they are not going to cover a procedure or piece of equipment we need? Sound familiar? I wish it wasn’t, but unfortunately, I hear this all too often. I get calls on a daily basis asking whether or not insurance will pay for certain kinds of medical equipment such as Continuous Passive Motion (CPM) machines, Pneumatic Compression Devices (PCD) or Cold Therapy machines. Unfortunately, the answer is not cut and dried. It varies on a number of factors:
1)Type of Surgery
2)Type of machine desired
3)Type of insurance
4)Benefits allowed by your insurance
5)Other treatments tried/available to your doctor
I wish it was a simple yes or no (mainly yes), but it usually involves far more work.
We, here at The Medcom Group, have a number of insurance specialists on staff. A large part of their job is to determine whether or not you have coverage for certain items, either rental or purchase, by speaking to your insurance company on your behalf. They work to obtain authorization from your insurance company to provide you the equipment your doctor has prescribed for you. However, obtaining authorization does NOT guarantee that the insurance company will actually pay for the machine. And that is where problems can pop up.
Let’s call a spade a spade. Insurance companies are a for profit business. Profit should not be a dirty word. However, it does mean that they do look for ways to control costs and one of those ways is by denying claims. The amount of hoops both you and I have to jump through to obtain coverage is only going to increase. Some days it seems like they are going out of their way to deny a claim. But, that is where we come in to assist you. We have over 25 years of experience in dealing with insurance companies. If you want us to try with them, we can and we will. We do offer one other great option for you. We have special prepay pricing available. The prepay price is going to be significantly less than the insurance billing price. Here is why. If we bill an insurance company, we have to have staff to obtain the preauthorization, data entry staff to handle the paperwork, a billing department to make sure all those hoops I mentioned earlier are jumped through and then collections staff to follow up and make sure the bill is actually paid. It is a lot of work and takes a lot of people to accomplish. For example, our prepay price for a two week Knee CPM rental is $375 while the same two weeks for an insurance billing may be $1000. The $625 difference is there so we have the people in place to make sure the bill is paid. The other reason the prepay price is advantageous is if they do deny the claim, you are responsible for the balance. You can prepay and we will supply the documentation for you to file the claim. If they insurance company pays the claim it is sent directly to you.
Now, I like to think that I am knowledgeable about my field and profession. Part of this is me knowing what our competitors are doing or advertising. I have seen claims on other company’s websites that imply ALL CPM’s are covered by insurance, regardless of the circumstances. I hate to be the bearer of bad news but that is not the case. Not only is it not true, it is a blatant disregard of the truth. For instance, let’s look at Medicare coverage for CPM’s. Medicare will cover a CPM for 21 continuous days, if ALL of the following conditions are met:
1)The patient had a Total Knee Replacement (TKR)
2)The patient started using the CPM within 48 hours of the surgery
3)There is no lapse in coverage. In other words, if the CPM was put on in the hospital and the patient discharges home, there cannot be a break between the hospital use and the home use.
What this means to you is Medicare will not pay (even if your doctor prescribes usage of a CPM) if you have surgery on your shoulder, elbow, ankle, etc…
More and more insurance companies are beginning to follow Medicare guidelines. However, many do not. A lot of insurance companies WILL pay for CPM’s, SCD’s, Cold Therapy machines and other available equipment, but not with the certainty that some DME companies lead you to believe. We want to be an asset to your recovery but not at the expense of our integrity. We will not rope you into accepting equipment if we know your insurance company is not likely to pay. We will be up front with you and give you the prepay option. If you want to submit a claim to your insurance company, we will provide you with the documentation to do so. If you do file the claim, any amount they reimburse is sent directly to you. You can also use our years of experience to increase the likelihood of you getting reimbursement from your insurance company.
Here at The Medcom Group, we prefer to be honest and upfront with you. Dealing with insurance companies can be a hassle. Let us use our decades of experience with our products and with your insurance company to steer you in the direction that is best for YOU. Please call us at 877-301-4276, to answer any additional questions you have about your medical equipment needs. Or you can email us at firstname.lastname@example.org
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