When a patient is living with diabetes, making a transition from fingerstick testing to a continuous glucose monitor (CGM) is life-changing. It’s an opportunity to leave behind pain, and go about the day without the many interruptions from the traditional way of measuring blood sugar. Along with that, they get better data with which they can make better decisions about eating, exercising and managing stress. Unfortunately, patients end up waiting for days, weeks, months or longer for their prescription to get filled.
Why do patients end up waiting for CGM devices?
When you prescribe a CGM, it seems like getting it filled would follow the same steps you have grown accustomed to throughout your career — send it to the patient’s pharmacy. But it is important to understand that for Medicare patients a CGM device is covered under their part B benefit as opposed to the usual Part D pharmacy benefit. If you don’t have the processes in place for verifying benefits, your patient would end up going to the pharmacy only to be disappointed because it is not covered. This will ultimately create a gap between the date of their visit and your patient’s ability to follow your recommended therapies.
What’s causing the delay?
The root of the problem has to do with the complexity of Medicare coverage guidelines. CGMs are classified as Durable Medical Equipment (DME) and fall under Medicare Part B coverage rather than the traditional Medicare Part D pharmacy coverage. Actually, as CGMs have become more mainstream, most clinics are caught by surprise by this and don’t realize this is the case until the patient gets denied by the pharmacy. Medicare decided to classify these devices as DME because they are not disposable like traditional testing strips and lancets and should have a life expectancy of at least three years.
This little detail creates a cascade of problems. A clinic might mistakenly send the script right to the pharmacy without realizing it’s not covered. To be honest, even some suppliers of CGM devices also overlook this step.
What happens if you don’t follow Medicare Part B requirements?
Eventually, the patient finally hears back about the CGM device they’d love to start using. Even if their doctor and their research say otherwise, they’re told it is not covered by their insurance. That’s frustrating, but worse, it creates an obstacle. By not understanding the Medicare coverage criteria for these devices they can miss out on their Medicare benefits and therefore miss the ease and convenience that comes with switching from painful finger sticking to painless scanning.
What’s the solution to delayed CGM devices?
Now that you know why CGM scripts can easily get denied, we are here to help and make sure your patients get access to the care they deserve.
Quest Health Solutions has created a more efficient system, so we can get a CGM delivered to your patient’s door in 72 hours. Prompt delivery is critical to patient engagement and adoption of new therapies. Not only will you have happier patients, you’ll also see better patient outcomes.
Your clinic submits the following to Quest Health Solutions:
- • Most recent progress notes
- • Completed script
- • Insurance information
We assign a dedicated account manager to your office and provide you with their direct extension to answer any of your questions.
- • We review the documents
- • We verify patient insurance
- • We qualify and approve the patient based on Medicare coverage criteria
Once this is complete, we can process and ship the CGM device within 24 hours via two-day USPS priority mail.
Quest Health Solutions is a one-stop shop for all your patients’ CGM device needs. To learn more, contact us today.