Katsmeow
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
- Joined
- Jul 11, 2009
- Messages
- 5,308
Very frustrated here. My daughter (who is on my insurance) was going to get Nexplanon which is a long acting form of birth control. This is implant that goes in the arm and lasts for up to 3 years.
The implant is expensive because it is releasing chemicals for 3 years (think about $1000). So, the gynecologist submitted the purchase of the Nexplanon as a pharmacy claim since they don't keep these in the office (since they are so expensive).
Pharmacy denies it. I'm surprised because I know ACA compliant policies must cover it. After lots of time on the phone with the insurer (United Healthcare) I find out that it is 100% covered as medical, not as pharmacy. Yay!
I call back the provider. The thing is they still won't do it. Here is the thing:
If they buy from pharmacy it is sent directly to them and they aren't out of pocket. If it is a medical call, it is treated like other medical claims. They have to buy the implant, insert it and then bill the insurer who will reimburse. They won't buy the implant since they have burned on that before and they don't get their money back if it never gets inserted.
So, yes, it is 100% covered but I haven't been able to find a way to actually get it. I called other doctor's office and they said they same thing. They won't do what is called "buy and bill." They said they didn't know of any doctors who would. Maybe I could find one but they seemed doubtful. I asked if I could give them money in advance to buy it and then have it get submitted to insurance. The answer was no. I could buy it in advance, but it would be pure self pay (except for the minor cost of the insertion).
I was told that Planned Parenthood actually keeps it in stock so she can go there. Great. The problem there is that Planned Parenthood is out of network so we will have a rather sizable 40% co pay.
I am just annoyed by this as it is a product covered by the medical plan and required to be covered under ACA. But, I can't seem to find a way to actually get it reimbursed since the providers I've talked to won't order it. I can have her do Planned Parenthood but there will be 40% co pay.
Anyway dealt with this? (Oh, and the same problem exists with IUDs but at a less expensive level).
The implant is expensive because it is releasing chemicals for 3 years (think about $1000). So, the gynecologist submitted the purchase of the Nexplanon as a pharmacy claim since they don't keep these in the office (since they are so expensive).
Pharmacy denies it. I'm surprised because I know ACA compliant policies must cover it. After lots of time on the phone with the insurer (United Healthcare) I find out that it is 100% covered as medical, not as pharmacy. Yay!
I call back the provider. The thing is they still won't do it. Here is the thing:
If they buy from pharmacy it is sent directly to them and they aren't out of pocket. If it is a medical call, it is treated like other medical claims. They have to buy the implant, insert it and then bill the insurer who will reimburse. They won't buy the implant since they have burned on that before and they don't get their money back if it never gets inserted.
So, yes, it is 100% covered but I haven't been able to find a way to actually get it. I called other doctor's office and they said they same thing. They won't do what is called "buy and bill." They said they didn't know of any doctors who would. Maybe I could find one but they seemed doubtful. I asked if I could give them money in advance to buy it and then have it get submitted to insurance. The answer was no. I could buy it in advance, but it would be pure self pay (except for the minor cost of the insertion).
I was told that Planned Parenthood actually keeps it in stock so she can go there. Great. The problem there is that Planned Parenthood is out of network so we will have a rather sizable 40% co pay.
I am just annoyed by this as it is a product covered by the medical plan and required to be covered under ACA. But, I can't seem to find a way to actually get it reimbursed since the providers I've talked to won't order it. I can have her do Planned Parenthood but there will be 40% co pay.
Anyway dealt with this? (Oh, and the same problem exists with IUDs but at a less expensive level).