My husband has been on oxygen therapy for over five years. Our insurance is an Advantage Care. The supplier no longer wants, it seems, to delivery portable oxygen tanks and will no longer provide a portable oxygen concentrator POC. I have read the Medicare website about the five year rule and have called Medicare but they will not talk to me because we are in an Advantage Care plan.
What options do I have? I have sent a grievance letter to our plans member services and requested a new supplier for both tanks and POC that we will pay for. The issue with that is that this company only has one supplier contract. My husband's doctor will not write a prescription for outside supplier/vendor. This is a real mess!!
Without either or both of these supply items and services my husband is not able to go out of the house and is a shut-in. He has an oxygen concentrator in our home.
Solution. Call the hospital social worker. Tell them you need a list of oxygen providers for an oxygen concentrator. Oxygen cylinders are provided for use if you lose power or your concentrator does not work.
When you get the list contact your insurance company. Your Medicare Advantage Plan. Ask which providers they will work with…they probably have preferred providers with a contract for a negotiated lower price to save money. Large volume of patients provides efficiencies and reduces cost.
Next call several oxygen providers. Ask if they work with your insurance company. If you like them and they work with your insurance company ask them to call your doctor for an order. Before they bring equipment to your home, ask the price. Both to start and then monthly. They will call your insurance company for authorization to provide your service. Make sure your insurance will cover their services. Make sure you know how much it will cost you. Make sure they will accept your insurance company’s allowable and hou only pay your deductible and copay.
If your doctor refuses file a complaint thru your insurance or who they tell you to contact. You can call Medicare and ask how to file an expedited complaint. Keep appealing the decision until Medicare themselves are doing the review. Best chance is keep pushing it up the ladder of appeals. Then report the doctor to the practice manager, hospital and AMA.
References
Federal Regulations
Patients' Bill of Rights (PBR)
AMA Patient Bill of Rights and Responsibility.
Patient Rights under HIPAA
Current status is that after my grievance letter hit member relations. Things started to move in the right direction. It was my husbands pulmonary doctor who said he could not fill out forms or write a prescription. WELL, that changed but put his nurse in charge of getting it done. My rep for the new oxygen concentrator finally got what he need by primary doctor who was out of the county. He came back June 10 and in one day got it done. I have spent two weeks talking with administration who would not answer my question--WHY DID MY HUSBANDS BENEFITS CHANGE? Also 6 portable oxygen tanks were delivered.
To those who think lawyers are the answer. Well I have a fancy lawyer who will not go after the FEDS just medicaid. So I did this on my own just working the "system" of Advantage Care.
My husbands condition is severe and I can't take the risk changing insurance.
It is hard for me as a caregiver to keep up with all the daily Agingcare emails but I do read many. My heart and love goes out to all of you who are caregivers. IT'S HARD WORK. SELFLESS work. I felt like I had gone through a "ringer" (some of you are old enough to know what that is) after two weeks of this. So I'm resting as much as possible.
THANK YOU...ALL!
if your doctor feels you need a certain treatment or medication and your insurance company doesn’t pay you should file an on line complaint with your state insurance commissioner. Your advantage plan will see this in real time or within a few days. Be sure to include your telephone number.The insurance companies take these complaints seriously and I predict they you will hear from them within a few days most likely with a favorable response. Over the years I had to resort to double this and was always satisfied with the outcome.
i do not get why your doctor just can’t write a generic prescription and you find the company you want to fulfill it. I hope things turn around for both of you.
1. Switch to a different Advantage plan that uses a different oxygen supplier.
2. Switch to Original Medicare (Part A and Part B). If you choose this option, you will also need to select a standalone prescription drug plan (Part D) to cover his medications. However, please note that because of his preexisting condition, he might not be able to get a Medigap (Medicare Supplement insurance policy, which helps cover some of the costs that Original Medicare doesn’t. This means you may have to pay 20 percent of the cost of his medical care out of pocket.
Additionally, I recommend calling Medicare directly at (800) 633-4227. They can help you find a new doctor, locate a new oxygen supplier and assist in choosing a prescription drug plan if you decide to switch to Original Medicare.
I hope this information helps and you can get the necessary support and equipment for your husband soon.
This oxygen problem is a product of a legislation bill several years ago. DME suppliers have been going out of business because CMS reimbursement is upside down. There is SOARS act just introduced in Congress and supported by medical organizations such a ATS, AARC,and others. Many people are suffering, especially in rural locations. He routinely should be getting re supplied with nasal cannula. Your situation is getting out of hand and is not unique
"If you have Medicare and use oxygen, you can rent oxygen equipment from a supplier for as long as you have a medical need, but payments for the equipment stop after 36 months of continuous use."
I also found this. Seems if you rent you own after 36 months.
"Section 5101 of the Deficit Reduction Act (DRA) requiring suppliers to transfer title of oxygen equipment to the beneficiary after 36 continuous months and capped rental items after 13 continuous months of rental payments."
So seems you can pay a supplier out of pocket. So I don't understand why the doctor can't write a script to another supplier.
This is where I would start, and I would go directly to the Medical Licensing Board for him, if I had to.
Can you tell me a bit about what the doctor says about his REASONING in not ordering O2?
Does he not believe your husband "needs it"? I would ask him to put in writing his refusal to order the O2.