We re-ordered our Dexcom supplies three times through Byram, because Dex quit working directly with patients. But the most recent bill came in at $640 instead of the expected $160. Turns out Byram added a “modifier 200” to Kaiser’s patients bill. The modifier usually mean a different product on the manufacturer’s end. So Kaiser had us call back Byram and ask about it. Byram then said they didn’t know what the modifier was, applied insurance funds because the modifier was preventing that, and now the bill is down to $65 instead of $160. wtf? Crazy stuff going on…
Also the Byram staff couldn’t explain the modifier. If you are having issues, call Kaiser because they are the ones that can see the whole process even though they can’t change the Byram inputs. The Byram staff is blind to the Kaiser information.
So now we need to wait 72 hours to see what the real amount we owe is. I truly hate these intermediary companies. If you aren’t paying attention they will skin your credit card alive.
IRC (it was a while ago) I simply stopped auto-refill with EdgePark so that I could walk each order through. Otherwise something went wrong. As with your experience my insurance company was the only place to go; they (insurance and supplier) always maintained it was the other guys fault but it seemed to always end up with EdgePark not keeping up to date with insurance changes.
I don’t auto-refill with pharmacies either - that causing overstocking because they refill too early. I haven’t had any unexpected charges with them (either of the Wals); they check with me when the charge is $300+, otherwise it just works automatically without my involvement.
What that means is that pretty much every high tech prescription gets verified before the charge at the start of the year; Walgreens telephoned at the start of this week to verify a charge of $529.41 for a month supply of Dash pods, which is fine - it was $511.90 a year ago [3.4% inflation though such calculations are effectively meaningless because of the system].
There aren’t any prices on that page. The actual Medicare cost should be the same - $530/month - because the CMS is required to pay the same cost as private health insurance. This is the shebang; by inflating the private costs artificially while offering an indirect rebate (via the PBMs or the medical device suppliers) the government is obliged to pay the inflated price with no rebate. This is where the big money is - the private insurance price is an illusion, the insurance companies do not pay that, but the government does.
I was referring to this, but now see it is insulin cost not podd.
New for 2021- Medicare Part D Senior Savings Model!
The Centers for Medicare & Medicaid Services (CMS) has recently announced that they are launching a “Part D Senior Savings Model” that is going live January 1st, 2021. The goal with this program is to reduce Medicare Part D out-of-pocket costs through stable, predictable monthly insulin co-pays throughout coverage phases in the standard benefit design. Many Part D plans (including the plans that have preferred access for Omnipod DASH®) are limiting Insulin costs to $35 a month.
I have never understood an insurance bill from those providers. Every bill looks like this:
This is the amount we charge.
This is the amount the people who make the product you are getting say we are allowed to charge.
So this is the modified amount we will actually charge you.
But this is the percentage of the modified amount you have to pay, based on if you have hit your deductible.
So this is the amount you will actually pay.
I had to read that paragraph 3 or 4 times then think about it. I don’t think “$35/month” covers necessary supplies. For covered medical devices any necessary supplies are also covered - test strips if the meter is covered, canulas for pumps etc. IRC they are also covered as devices. I’m pretty sure this does not apply for prescriptions yet insulin is useless without pens or syringes or an insulin pump. In any case that’s just coverage, not cost.
One of the really annoying things about this “insulin costs so much” stuff is that the fix is to reduce or limit the cost of insulin, so what does that fix? Now we have to point out that blood test strips cost so much? Everything costs so much.
It’s the same as an EOB. There’s unnecessary detail there - the only price that matters is the negotiated price, which is not even on the EOBs I get. Here’s an example from moda:
Total amount billed [p]
Provider discount and amount not covered [x = pd+nc]
Medical plan paid [i]
Member responsibility [m]
So there is no distinction there of the “provider discount” (which we don’t pay) and the “amount not covered” which we do pay:
m = p - pd - i
x = pd + nc
Rearranging the equations:
pd = p - m - i
nc = x - pd = x - p + m + i
I think I got that right… The moda EOB breaks the “Member responsibility” down on the next page, “Medical claim details”. The only thing we need to know on the first page is “member responsibility”, everything else is sound and fury.
As for the deductible and OOPMax, nothing has changed there since I’ve been in the US (since mid 1993) - health insurance was always ridiculously overcomplex and is now only ever so slightly simpler (only one deductible, not multiple for different things). I only care about the OOPMax because the deductible is the same number, that’s the way it should be.
I’m with @Terry4. There’s an old English saying, “What you lose on the swings you gain on the roundabouts.” There’s no American translation for this. We can’t beat the part D guys; they only make money by beating us, that is their job. Sorry, I’m being too british; you’re - on the way in and you’re - on the way out.
I realize your post is a year old, but we are having the exact issue with Byram changing the billing code, or maybe it is the modifier you referred to. This change means that our bill of $125, is now $639, because it applies to our deductible with this change in code name. I am going back and forth between Kaiser and Byram. I have two type 1 children so the issue is the same for both of them. Anyway, I am wondering what ended happening in your situation? Thank you
Who is your insurance carrier? If Kaiser, definitely give them a call and mention the modifier issue. They eventually resolved the issue and it never happened again, but it was frustrating. If you aren’t on Kaiser call your insurance and try to get it sorted. Let us know how it worked out, and Welcome to FUD!
Thanks so much for getting back to me. Our insurance is with Kaiser. I went back and forth between Kaiser and Byram, each one blaming the other for the change in billing codes. Anyway, I finally found someone who serves as a liaison in Kaiser for type 1 diabetics and she said that the codes were a mistake and she is working on fixing them now. So thank goodness for that. You were the only one that I could find who had a similar issue. I’m glad you got your issue resolved as well. I really appreciate your response.
I am so glad that our site had the information that helped you. That is why we don’t take any outside funding and speak the truth as best as we can. Diabetics and their families need to have as much unfiltered information as possible because insurance doesn’t work well for these chronic conditions. I hope that you are able to stay with us and add some information that helps others as well if you have the time.