A continuous glucose monitor (CGM) promises a big lifestyle change for patients with diabetes. It offers freedom from fingersticks along with important real-time data about what’s happening in their bodies at any given time.
But these devices are costly, so your Medicare patients are counting on their coverage to make this upgrade financially feasible. Because of Medicare rules, providers often run into roadblocks when it comes to getting their patients the access they’re looking for.
Problem: Denied coverage for CGMs
Most physicians begin the process by sending the prescription to the pharmacy. And why shouldn’t they? That’s where they normally send orders for diabetic supplies such as insulin, syringes, needles, alcohol swabs and other medications that help manage and treat their diabetes at home. So why is a CGM device any different?
To understand the answer to this question, you must first have a basic understanding of Medicare. There are four parts to Medicare: A,B,C, and D. In general, the four Medicare parts cover different services. Therefore, it is essential that a physician understands the difference between them and knows what part CGM falls under. This can be quite complex and confusing, but don’t worry, we are here to help.
Medicare Part A covers the cost of hospitalization. When a patient enrolls in Medicare, they receive Part A automatically. For most people, there is no monthly cost, but there is a deductible each year. Services covered under Part A may include surgeries, inpatient care in hospitals, skilled nursing facilities, and home healthcare services.
Medicare Part B covers a long list of medical services including doctor’s visits, medical equipment, outpatient care, outpatient procedures, and other treatment.
Medicare Part C is also known as Medicare Advantage. Part C is an alternative to traditional Medicare coverage. Coverage normally includes all of Parts A and B, and a prescription drug plan (Part D), and other possible benefits.
Medicare Part D is administered by private insurance companies and covers prescription drugs. Part D is optional and is normally included in any Medicare Advantage Plan.
Because of these complexities of understanding the different parts and coverage of Medicare, medical providers find themselves at an impasse, struggling to help patients access these life-changing medical devices. This is why working with a full service CGM fulfillment supplier can eliminate these headaches and get your patients access to these life-changing medical devices.
Verifying CGM coverage through Medicare
Medicare provides far-reaching benefits to millions of patients each year. But when there are five different Medicare Advantage plans there could be five variations of coverage, each with different requirements for patients to access their benefits. Unless your office has in-house expertise on Medicare, you can quickly end up at a dead end.
Most physicians who prescribe CGM devices for the first time go through their patient’s Part D benefit and send the prescription to the pharmacy. Unbeknownst to them, CGM’s are considered durable medical equipment (DME) and are covered under the patient’s Part B benefit. So, when the patient goes to the pharmacy expecting to pick up their CGM device, they are told it is not covered and are denied. Not only is this frustrating, but it makes for a negative patient experience.
Clearing up the confusion of DME verification
Working your way through the DME verification process to obtain a CGM can be complex and confusing to the uninitiated. Between the paperwork, insurance verification and time on the phone for authorization calls, getting a CGM to a patient takes time and patience. That confusing, bureaucratic process is a barrier for patients who are hoping to start using this pain-free method of diabetes management.
Solution: A full service CGM fulfillment supplier
What’s the solution to overcoming the insurance barrier? Having a dedicated Medicare billing specialist that knows their way around the various requirements is one option. But if you need a faster, more efficient way to get your diabetes patients access to CGM devices, working with a direct CGM supplier is another solution. Quest Health has built a fulfillment solution that gets a CGM device on your patient’s doorstep in 72 hours.
Here’s how Quest Health handles DME verification for Medicare patients from start to finish:
- • Send the patient’s order, prescription and the most recent progress notes.
- • Your dedicated account manager will handle the benefits investigation, the authorization calls and the paperwork
- • Your patient’s device shows up 72 hours after receipt of the order.
Your patients don’t have to wait for weeks to get access to a CGM. We’re a resource to navigate the entire process on your behalf. Our system is set up and calibrated so we can get it done quickly and efficiently, with top-notch service.
Get in touch and we’ll show you how we can get CGM devices to your patients within 72 hours.
Confusion over insurance verification can delay access and shipment of a CGM device for several weeks. Why does it happen?