Letter of the Week: Mother Caught Between Medtronic and BlueCross BlueShield Refuses to Give Up

Dear Diabetes Health,

After reading the story in the April/May Diabetes Health about the mother and daughter who won approval from Blue Cross/Blue Shield to pay for the continuous monitor, I wanted to share our story.

Our daughter was diagnosed with type 1 in April 2002.  Jae had problems regulating her blood sugars for many years, had seizures, and missed a good share of her senior year of high school due to health issues.  She also has polycystic ovarian syndrome and endometriosis.  In November 2006, we purchased Medtronic’s continuous blood glucose monitoring system for her, as she had been an insulin pump user since November 2002.  At the time of purchasing the CBGM System, we were informed by Medtronic that it would be our responsibility to work with BCBS to pay for the sensors.  Medtronic claimed that they did not yet have a billing number to submit to BCBS for the sensors.

In January 2007, I started the appeal process with BCBS of Minnesota to cover the ongoing sensors needed for the CBGM system.  Jae was wearing them daily and thought they were great. She thanked us many times for getting them for her and told us we didn’t need to buy her any Christmas presents in 2006 because not having to test so many times a day was a Christmas present all in itself!  Jae was going through about 10 sensors a month.  Thankfully, my husband and I have been fortunate enough to be able to pay for the sensors without insurance assistance.

I ended up having to file an appeal/request with BCBS three times until finally, in February 2008 (14 months after our initial request), thanks to a very determined and caring customer service liaison at BCBS, the sensors were approved for coverage under Jae’s insurance.  BCBS denied our first request, stating that Jae didn’t meet their criteria for being ill enough to need the CBGM system.  Our second appeal was also denied; this time BCBS claimed that the CBGM system was not FDA-approved.  After sending a copy of the approval letter from the FDA to Medtronic along with our third appeal, five years of A1C results and other historical information, insurance coverage was granted for the sensors.  (This approval was later denied and then overturned after I questioned how BCBS could deny an approval that had just been granted.  Mind you, there were many liaison customer service representatives involved in our case over the 14 months that it took to get this approved.)  From April 2007 through August 2007, I made and documented 10 calls to BCBS, during which I was only able to leave a voice message inquiring about the case and didn’t receive any return phone calls regarding our appeal process.

But the difficulties continued with this request.  BCBS refused to reimburse us for our out-of-pocket expenses, stating that they would pay Medtronic.  I filed paperwork for Medtronic to be reimbursed.  BCBS ended up sending Jae a check for some of the out-of–pocket expenses but then later requested that money back.  Since February 2008, I have called Medtronic 15 times (I have this well documented) requesting our refund.  Though we have received approximately one-third of what is owed to us, Medtronic is refusing to give us the remainder of the credit on our account, stating that BCBS has not paid the claim correctly.  They say that until BCBS pays the claims correctly, they will not refund us any more money.  Medtronic is stating that they will only refund us what BCBS has paid to them.  BCBS has told me that since Medtronic is a provider with BCBS, Medtronic needs to accept what BCBS considers the allowed amount and only charge us for our 20 percent co-pay.  The amount in question is substantial, approximately $1,500.00, that is still owed to us as a refund and is sitting as a credit in our account at Medtronic.  We have always paid our Medtronic bill on time and have no outstanding bill with them.

Throughout my many calls to Medtronic requesting a refund, I have been promised that a supervisor would call me back.  I have heard back on two occasions, out of my 15 calls to Medtronic, from a supervisor.  I have faxed Medtronic requested EOB’s, filed whatever paperwork anyone from either BCBS or Medtronic has requested, made copies and faxed bills, invoices, etc., to BCBS and Medtronic, whatever they have wanted to get this issue resolved.  Unfortunately, the liaison with BCBS who finally obtained our approval retired in March 2008. I joked with her about wanting her home phone number!

I have worked with or received letters from eight different liaisons through the consumer service center at BCBS, talked to 13 different billing representatives with Medtronic, made copies and kept all paperwork involving this process.  My file is now quite thick.

My point in this letter is DON’T GIVE UP!!!!  I wasn’t going to stop appealing our request with BCBS for payment of the sensors for our daughter, and I won’t stop calling Medtronic for a refund until this gets corrected.  Our daughter is going to have to live with diabetes for the rest of her life, and if I can do anything to make her life and health issues easier to manage, as a mother I will continue to do that!

I have no arguments or complaints about how BCBS has covered healthcare needs for our family except for this issue.  We have had BCBS health insurance for the past 29 years, and they have always been very good about covering our daughter’s healthcare/diabetic needs.  I have no arguments or complaints about Medtronic’s products and their customer service.  Medtronic has always been very helpful and quick to respond with supply requests, pump problems or concerns!  For whatever reason, this issue involving the CBGM system seems to be problematic for many!

Also, as a subscriber of your magazine for the past five years, I want to let you know how much we enjoy your articles, your updates on new and ongoing research, product information, etc.  We have learned of many new products that Jae has been able to take advantage of because of the articles in your magazine!  Keep it up!

Thank you for reading this letter. Writing it has been cathartic for me, as no one really understands the frustration unless you have had to go through this yourself!

Sincerely, from a Mother’s Heart,

Patti Venekamp
Long Prairie, MN

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