medicare allowance

[lhug]

Have had ostomy for 20 years, have always used edgepark. Medicare Part B is now my insurance. I have to change my pouch every other day for skin health. Medicare allows only every 3 days. It has been 9 months, and I have yet to have any part of my supply order go smoothly. Have talked to doctor about increased need,talked to medicare, and edgepark. And when it is allowable, still takes edgepark forever to confirm insurance and prescription. Can anyone recommend a different supply company or solution?

[Bob Webtech]

I won't comment here on particular suppliers. But regarding Medicare Part B, your statement "Medicare allows only every 3 days" may not be correct. As a nice reference on Medicare reimbursement, Hollister has prepared a video webinar for UOAA which can be viewed at https://youtu.be/LzamZ3qiRiE
Here's a screenshot from that video showing the Medicare Usual Maximum Quantities for many products (this occurs at about 10 min 20 sec into the video):

For many products (drainable pouches, urinary pouches, skin barrier wafers) the limit is 20 per month. For closed pouches it's 60 per month. If you're changing every other day, you'd be using about 15 per month, so you'd be within a 20 per month limit.

[steiconi]

Thanks, Bob, I've been wondering about some limits myself, and your chart answered my questions.

[lhug]

thank you for the info!!!!

[cdogtom]

my supplier said that i would have to pay in advance and bill medicare for reimbursement cost is 20 + $ ,i think she is wrong ....supplier is a pharmancy

[Bob Webtech]

If the supplier makes you pay up front, it probably means they don't take "assignment" for the item you're getting. When a supplier takes assignment, they agree not to charge any more than the Medicare approved amount. You generally pay nothing up front, the supplier gets paid directly by Medicare and then, the supplier bills you for only the Medicare deductible and coinsurance.

Suppliers fall into 3 categories:

1. Medicare "participating" provider. In this case, the supplier agrees to accept assignment for every Medicare covered item they sell.

2. Enrolled in Medicare but not a "participating" provider. In this case, the supplier can decide to accept or not accept assignment on a case-by-case basis. This can work out fine, as long as they accept assignment for the items you need. If they don't accept assignment for an item, they can make you pay up front and they can charge more than the Medicare approved amount, but they should still bill Medicare for you; they shouldn't make you file the Medicare paperwork yourself.

3. Not enrolled in Medicare. If the supplier isn't enrolled in Medicare, then Medicare won't pay for your supplies, even if you file Medicare paperwork yourself.

[Diane C]

Bob,

Super duper info -- and didn't know about the video. More thanks from me.

Diane C

[Mjc]

Hello
I have also used Edgepark for a long time - 25 years. While I was employed and had Blue cross I never had an issue. Now I am on Medicare and retired. I also have Tricare (for life) - which a combo of Medicare B and Tricare. Now edgepark has all sorts of problems with ins and submitting bills. I get bills in the mail and every time I call they assure me it is taken care of - and frankly I am not sure what I'm going to do. I make sure there is only a 100 dollar limit on my charge with them so I cannot be charged for one of the crazy amounts they say I owe. I'm not sure where the problem lies....However I have found them to be helpful on the phone. Still.... I would not mind finding a less stressful business to get my pouches from so I would not have to be on the phone constantly with Edgepark.
The chart is helpful. Thanks