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Your Health, Your Choice - What to Do When You Can't Get the Medical Equipment You Want
A Doctor’s Prescription Doesn’t Guarantee Insurance Coverage
Many specialty medical products require a prescription in order to purchase. However, as many people ultimately discover, having a valid prescription from a doctor sometimes isn’t enough to get equipment covered by an insurer.
Medical Equipment, Private Insurance, and Medicare
Insurance companies generally categorize medical supplies as Durable Medical Equipment, or DME. If you have private insurance, it’s important to read the Explanation of Benefits (EOB) to find out the coverage limits for DME, because they’ll vary by provider. In terms of Original Medicare coverage for DME, you’re responsible for paying 20 percent of an amount that’s been approved by Medicare.
Medicare also has a Competitive Bidding Program that affects people living in certain areas of the country. While it doesn’t play a role in determining which doctors a patient can see, it impacts the rates paid for DME. The program allows suppliers to submit bids for the right to become Medicare’s contract suppliers. The rates for products are lower than prices Medicare paid previously, and are supposed to reflect pricing schemes that are more up-to-date.
Requirements to Purchase DME from Approved Providers
In addition to the stipulations above, many insurers mandate a person must only purchase equipment from authorized suppliers. Failing to do that usually means coverage will be denied.
Authorized Providers and Profit Margins
Unfortunately, one of the major downsides of being required to only get supplies from particular places is that selection may be very limited. Often, the brands and products offered by approved providers are determined by profit margins. Suppliers frequently carry options that are cheaper to source and less effective than other choices, while billing insurance companies at rates that boost profitability. Clearly, this approach is not advantageous to a patient’s health or freedom of choice. Also, regulations require suppliers to never sell products at lower rates than what’s billed directly to Medicare, even when patients are insured.
The Out-of-Pocket Alternative
When patients want devices or treatments that aren’t covered under insurance, they often decide to prioritize their health by paying out-of-pocket. According to data from the National Health Expenditures Accounts, out-of-pocket spending throughout the United States in 2012 totaled $328.2 billion. Two years prior, the Agency for Healthcare Research and Quality performed a Medical Expenditure Panel Survey and released it last year. That research found 14.2 percent of individuals and families opted to pay out-of-pocket for medical equipment.
Although some analysts suspect those figures may eventually decline slightly due to President Obama’s Affordable Care Act, those statistics show how a substantial number of people are being proactive about access to medical devices by covering the costs themselves when necessary.
Going Online for Out-of-Pocket Purchases
You’ve just gotten an overview of some obstacles people must frequently overcome when seeking compensation for DME from Medicare or an insurance company. Not surprisingly, even individuals who have healthcare coverage sometimes opt to pay for equipment out-of-pocket immediately, because it may be more efficient to do that than file an insurance claim.
Authorized Internet-based companies that supply medical products directly to patients are not bound by Medicare regulations that forbid making a product available to a consumer at a price lower than the billed Medicare rate.
Often, that means products are available at more reasonable costs. For example, Nebology.com is an authorized online retailer of the PARI line of nebulizer supplies. It frequently gets direct referrals from DME providers that can’t offer customers the desired products or prices.
Out-of-Pocket Purchases Could Help You Feel Empowered
Enjoying access to the best equipment available lets you take a proactive role in your health, and could make it easier to follow the specifications outlined in a physician’s treatment plan. Sometimes, that means using products that aren’t covered by an insurer. However, people who don’t have insurance at all also rely on merchants that cater to patients who want to pay out-of-pocket for optimal supplies.
Patient choice is a powerful thing. Rather than being under the impression you must purchase from providers who may not stock what you really want or need, explore alternative shopping solutions instead. That demonstrates by example you’re not willing to have treatment options dictated to you. Profit margins may be the focus of many suppliers, but it’s your right to use products that could help you stay healthier and live better because they’re the most effective solutions on the market.
For more information:
Kristen Perkins - Nebology.com