Medical insurance can be a tricky process to navigate, especially if you or a loved one is going through a tough time and needs medical supplies. Our staff is trained and knowledgeable on the DME insurance process and through the years, we’ve heard a lot of the same questions pop up. We’ve answered the 3 of the most asked insurance questions to give some insight and more in depth information in this week’s post.
Q: What insurance do you accept?
A: We are able to accept Medicare, and through the state of California/Medical – Western Health Advantage (via NorthBay Healthcare) and Partnership HealthPlan of California.
For Medicare, we offer non-assigned billing. This means we’d collect full payment upfront, then we submit the claim for the customer, and the customer is reimbursed directly by Medicare and if they have secondary insurance, from them as well. The only exception to this is for mastectomy products, we do assigned billing (no payment upfront required.)
Partnership Healthplan will pay for items that are approved by the customers plan, and we do not collect payment up front. We will submit the claim and will be reimbursed directly.
Western Health Advantage will pay for items that have an authorization, meaning an insurance approval, and no payment up front is needed. However depending on the customer’s health insurance or item needed, there may be a copay collected at the time of purchase.
Q: Does my insurance cover this item?
A: Medicare reimburses for most large durable medical equipment (walkers, wheelchairs, canes) items. Some items are a one time purchase (like commodes and walkers) and others are month to month rentals for up to 13 months (like hospital beds, Hoyer lifts and wheelchairs) then the equipment is considered purchased. In addition to large DME items, JMS can bill Medicare for catheters, ostomy, and mastectomy products. JMS does not bill medicare for soft goods like wrist braces or slings. Additionally, Medicare does not pay for bathroom equipment. In order to bill Medicare, JMS needs insurance information, a valid doctors prescription, and chart notes explaining why the item is needed. We also require a credit card on file to collect the non-assigned billing payment.
Partnership pays for most large durable medical equipment items (walkers, wheelchairs, canes). Some items are a one time purchase and others are month to month rentals for up to 12 months then the equipment is considered purchased for them by insurance. PHP will pay for soft goods and some bathroom equipment like shower chairs or transfer benches. JMS can also bill PHP for catheters, ostomy, and mastectomy products. Most items require prior authorization from PHP. In order to bill PHP JMS needs insurance information, a valid doctors prescription, and chart notes explaining why the item is needed. In most cases we will then send all information to PHP to get the equipment authorized. Once authorized, JMS will be able to provide the customer with what is needed.
Western Health pays for most large DME items (Walkers, Wheelchairs, canes, etc) items. Some items are a one time purchase and others are month to month rentals for up to 12 months then the equipment is considered purchased for them by insurance. Western Health will pay for soft goods and some bathroom equipment like shower chairs or transfer benches. JMS can also bill WHA for Catheters, Ostomy, and Mastectomy products. In order to bill WHA JMS needs insurance information, Doctors RX, and chart notes explaining why the item is needed. In most cases we will then send all information to WHA to get the equipment authorized. Once authorized JMS can provide the customer with what they need. Depending if the patient has a copay we will also need a credit card on file to collect the copay monthly or for the approved time.
Q: My doctor wrote me a prescription, why do I have to pay?
A: Insurance policies have limitations to what they accept, as we are the middle man between insurance and customer – prescriptions allow us to ensure we are supplying the correct item for the diagnosis. However just because something is deemed a required item from a doctor, insurance companies have limits on what they will reimburse due to their own business policy, or due to the customers insurance plan.
Some items are not deemed covered by insurance. Depending on the insurance, JMS may also collect a reduced rental fee up front and the customer can get back the amount that insurance reimburses. This is called non-assigned billing. Our staff is trained to understand the latest insurance policies, are able to research, make phone calls and ask the right questions to ensure our customers get what is needed and covered by their insurance.