Problem with Medicare Provider

Describe complaint: On October 7, 2010 I called…to place my mother’s monthly order for COLONOSPY BAGS. Since June 2010, my mother has been received quantity of 50. The colonospy bags are a two piece items. Before June 2010, my mother was receiving a quantity of 30 bags and has both a prescription for the 30 a month and for the 50 a moth as well as a letter of MEDICAL NECESSITY.


Son after I ordered the October bags for my mother, I received a call…telling me that they got a letter from Medicare that the could no longer supply my mother with 50 bags a moth, but only 20 bags a month. When I asked why, I was told that Medicare said so. When I asked for a copy of this letter, I was told NO.  Since the later found out that the date of the letter was for services on September, day that September’s bags were, I was lot that they received the letter on September 22, 2010, and when asked why my mother was not notified, they said that they did not have to. When I asked why there was a change when they had been supplying 50 bags before and 30 bags before then, why did they only agree to give my mother 20. Their reply was Medicare said that it was no longer a necessity. If I wanted to solve the problem I would have to call Medicare and have a three way and manager Teresa…there was no other options. I informed them that they have a number that they use to call for these issues, probably being NORIDIAN, but would not do so. 


When I got off the phone with Teresa, I called Medicare for the second time yesterday and spoke with a supervisor about the problem with having a three way call, and why would Medicare  approving the additional month supply of bags. Remember my mother is 90 years old, has had the need for the bags for over 8 years, and has two prescriptions and a letter of medical necessity. Because Medicare computers were down last night and his morning, October 8, the supervisor was limited to what he could see regarding my mother. He informed me that [DME supply company] was no longer an ASSIGNMENT Medicare provider, and that I was not responsible for any possible charges that might exist. He also suggested and provided me with other venders in my area that could supply my mother with her bags and that if…was not willing to fill her required 50 bags for October, this was a clear sign that I should no longer use this vendor. I was also told that any three way call between myself, vender and Medicare would not solve their problem. At this time I still had no idea why the vendor would not provide the 50 bags to my mother for October as a medical necessity?


This morning I called again to Medicare and billing, and again their computers were down, to call back. I placed a second call to Medicare about 2 hours later and their computers were back up. I explained the situation, and was told that the reason Medicare was not willing to pay. What was >$400.00 ws that…had billed on September 7, 2010 20 bags and 30 bags. Thus Medicare did not except the 30 bags. I was told that my mother was not responsible for their mistake, and when they looked back at previous bills submitted  by…they had submitted them as 50 bags, and that Medicare had paid them with NO problem. As noted, when they were supplying my mother with 30 bags, they had no problem with  their billing and Medicare’s payment.


After taking to Medicare, I called Teresa…and TRIED to explain to her that Medicare would not do anything with a three way  call, and that the reason that Medicare did not approve the 30 additional  bags, was that they had billed Medicare  as 20 and 30 bags, that the 30  bags was denied. I was told that if I had a problem, I should file an Appeal. I told her that I had nothing to APPEAL in that Medicare had not sent my mother any notice of denial and would not get one, and again asked for a copy of what they received, I was told again NO. I was told that she was going to file an APPEAL, and I continued to ask WHY did she just did not call their number they have to Medicare, she said she would not do so. In fact she said she would not take my word for what I was telling her, and when I asked if she would look at the previous monthly bill to Medicare she said again NO. She continued to say that they had billed the same way in previous  months and refused to work with me in solving their billing change. I did inform her that I would be looking for a new vendor since they were not trying to resolve the problem.I asked to talk to the owner and their name, she also said she would not give it to me, but would pass my phone number to them. I have not received a call back since 9:30 AM today.


I again called Medicare and found that each person you talk to says something different when asked the sme questions. When they looked again…they told me that the reason they denied the claim, was because there was no medical necessity, when asked to look at and answer why Medicare has been paying for additional bags, they  may continue to say that things have changed, or that you need a new prescription, that you need a letter of necessity ever month, while other Medicare people agree that in the case of Colonoscopy bags, there is no need to get a letter of necessity once one has been given to my mother since her need for the bags will never change till she dies. That the prescription dated June 2010 was OK, yet each time you get into the problem with the Septemner 7, 2010 denial, the issue with a Letter of Necessity comes up and no one a Medicare seems to be able to explain why my mother should now only get 20 bags a month from 50, as nothing has changed and Medicare’s requirements have been meet by her doctor?


To resolve the problem with  the shortage of 30 bags, I asked to file a grievance with Medicare, and was transferred to a supervisor, who for over 30 minutes refused to aslow me to file one. All she keep doing was repeating that  my mother can be responsible for the additional bags for the September 7 order and that my mother needed a Letter of ecessity and a new doctors prescription, and no matter how many times I asked why Medcare paid the month before and thte moth before with no problem, she would only quote what the letter that my mother did not get said, “it was no longer necessary’ for her to get the additional bags. And more than one times told me she would hang-up on me if I continued to talk when she keep repeating the same excuse that she read from the letter to [DME supplier], after over 30 minutes of keeping asking to file a grievance, she took down my name again and phone number, but did not read what the grievance said. I was told it could take up to 45 days and they would call me, if I’m not home, a letter would be sent. Since I work, the chance that I would be home is rather small, and I was not told that there was anyway to ask that the call be late in the afternoon when I am home. Acopy of the denial was to be sent out to my with the next 2 weeks.


I have found that those individuals that are answering calls on Medicare issues do not want to hear what the caller is asking or providing, they only want to quote what they see on their screen, in my mother’s case the denial that no one but the vendor had, and was not willing to explain when I was able to provide a back round as to what has been provided to the vender, and that Medicare just had to look at previous months, that the mistake was the vendor in is billing, and not documentation by my mother from her doctors allowing the 50 bags a moth. The time I spent on the phone and the time Medicare spent giving different answers to the same problem could have been solved if Medicare was willing to notify the vendor what the change/error was made on September 7, 2010, instead the only answer that Medicare keep saying is you can FIND A NEW VENDOR or FILE A APPEAL.


Lucky I’m not 90, there is no way that my mother would ever be able to question the denial that she never got from Medicare, and I have no idea how she is going to make it on 20 bags  for 30 days. I would like to ask the reader of this email how Medicare believes that someone that has a bowl movement daily or more can be limited to 20 bags a moth?  If you ever had a chance to be around someone with a bag that is becoming full, you might become sick, the bag stinks when getting filled and not replaced, yet with the denial, my mother has been placed in that position, being limited to 20 pages for October 2010! Almost all medical prescriptions are for 30 days, those that are for a life time as in insulin don’t change as to my knowledge, but here my mother is with a limited 20 bags a moth on 30 days, something is wrong?

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