breast forms and insurance

Houndmommy

 I got an amoena contact breast form.  The boutique charged my insurance $450 but the unsurance paid $317.36 and told me that the boutique could not bill me the difference as this was the contractual amount.  The boutique is billing me the difference claiming that because this is a high end form, insurance doesn't fully cover them and they have the ability to charge me the difference.  My insurance never pays what they are billed for services. She clains that if I'd gotten a cheap form the insurance would have paid in full. If I had bought the cheapest form available, the iinsurance would still have paid less than was billed. I am pretty sure that I have never had an instance where my insurance has paid the amount that they were billed for anything.  I am caught in the middle. I hate the fact that I have to by bras and such at a "boutique".  I just want to go buy bras the way I used to (and hopefully with this contact form I can and I guess I can drive an hour to Nordstroms). Anyway, thanks for letting me vent.  I am just so tired of dealing with all of this. 

TokyoSing

Houndmommy, you are right about insurance companies reimbursing only part of the cost of bras and prosthesis.  Mine pays 80% of whatever the prosthesis costs. It could be 80% of $40 or 80% of $350.  Even Nordstrom will charge you whatever the insurance company refuses to pay.  My last bill from Nordstrom was $3.05 cents. I think the bra was a little over $40 (including tax). They (Norstrom) will claim from your insurance company first and then bill you the difference.

nagem

If your insurance company is indeed contractually required to pay 100% and is refusing to do so, your employer may have a human-resources specialist who can do the troubleshooting for you. I finally turned my records over to the person at work who does this, and it turned out that there was no way I could have done it on my own. As a mere subscriber, I could reach only insurance-company employees who were paid to put me off. As the professional in charge of my company's insurance, my human-resources person could reach a higher, decisionmaking level. I managed to get all the money I was owed. But it was a lot of work since I had to organize the paperwork and explain all the shortfalls to the human-resources person so she could pursue it. By the way, you may want to experiment with improvising your own forms and bras. There are threads on this board about making your own microbead forms and adapting ordinary camisoles and sports bras to hold them. Plus some camisoles come with pockets (Lululemon yoga tanks do, and they;'re not too expensive if you buy them on sale). I find my homemade items more comfortable and just as real looking as the specialized stuff.

jacee

My insurance, BC/BS told me there are upper limits on every billing code, and yes they pay a contractural amount on what is submitted. But, if the charge is above what is allowed for that code, then you can be billed for that amount...even if you've met deductible and your out-of-pocket has been met. Just dealt with this recently, not with a prosthesis, but hospital charges.

otter

I, too, got a "surprise" bill from the mastectomy supply store after I thought I'd paid them what I owed.

My mast bras and breast form were covered under the "Major Medical" provision of my health insurance, which is a group plan administered by BC/BS.  The annual coverage goes by calendar year (Jan-Dec).  I pay 100% until my deductible is met, and after that I pay 20% of the "allowable" amount.  (I don't know the actual name for that, but it's basically what my insurance company says is the reasonable cost for something, based on bids or competing vendors or something.)  The mast supply store I used advertised that they billed BC/BS directly.

I bought my bras and breast forms late in the year, after I had already met my deductible, which I think was around $100 back then. When I went to the cashier to settle the bill, she calculated what I owed based on what my insurance would allow for bras and a prosthesis and what my co-pay would be on that allowable amount.  So my bill consisted of my 20% (my co-pay) of the "allowable" amount, plus the difference between what my insurance considered the "allowable" price and what the bras and prosthesis actually cost.  It was quite a lot -- I could have bought 4 or 5 of my regular, pre-BC bras for what my out-of-pocket cost was that day.

About a month later, I got another bill from the mast supply store, with a note saying it was what I owed after the "settlement" with my insurance company.  This was in addition to what I had already paid!  I never did figure out what happened, and I was too confused and ticked off to call and complain.  I had heard there were stores that would do what this store was doing. 

It works differently with my doctors and hospital charges -- almost all of those are "preferred providers," which means they have an agreement with BC/BS to accept whatever BC/BS says is the "allowable" cost for the service.  I might owe a deductible or a co-pay out-of-pocket, but as long as the service is from a preferred provider, I cannot be billed any additional charges even if the actual cost is higher than the allowable cost. 

I guess I learned the hard way that the mast supply store I used was not a "preferred provider." The deductible for my Major Medical coverage has gone up to $300, which would pretty much pay for any prosthesis I would buy in the future.  So I think I'll just pay cash next time -- maybe I can negotiate a lower "cash" price!

otter

StefS

Otter, I think you hit the nail on the head. It's if they are a preferred provider with your insurance company. When I got my first prothesis, there wasn't any preferred providers in my area. I called the insurance company and they agreed to let me go to a local store, pay for the prothesis and send the bill to them and they paid in full.

Of course, it's time for a new prothesis and have a new insurance company so this could be interesting.

Houndmommy

Thanks for all of your comments.  I got good news this morning - the boutique called me and said they spoke with my insurance and that it turns out they can't bill me the difference.  My insurance is pretty straight forward..... I met my deductible (it is $11,000 by the way) and once I meet it, then everything is covered at 100% and if there is a difference between the contract amount and billed amount, I can't be billed for it.  I was confused due to a paper I signed in which I agreed to pay if my insurance didn't pay at all.  ANyway, it is resolved and I am relieved.  I am glad I persisted in trying to get info and understand the situation.  I almost gave up and paid it.  Unfortunately the boutique owner doesn't seem to really understand commercial insurance.  Everything she talked to me about had to do with Medicare (I'm no where near Medicare age) and so it was like we were talking 2 different languages.  Even in the end when she was telling me about having to write off my differences she kept refering back to things that had nothing to do with my insurance.  I 'm guessing most of her clients are Medicare recipients. 

Kim

ibcmets

I was searching for post mastectomy bras & camisoles and found a site that had the same type of Amoena products for 1/2 the cost that the stores sell them for.   Of course, I found this after pruchasing a couple items from a mastectomy store.  The site is "thepinkbra.com".  Compare their prices against what you're paying for items.

Terri

TokyoSing

This question is about breast forms and does not have anything to do with insurance.  Does anybody use adhesive forms?  I haven't, and unless I have a sports bra on, the side with the prosthesis kind of hangs out when I am in "downward dog" or forward bend".  What adhesive forms are good?  Will they stay put even on a hot sweaty day?

Houndmommy

Terri - thanks for the tip.  I'll check them out.

TokyoSing - the form I just purchased is an adhesive one.  I haven't used it attached yet as you are supposed to wait about 4 - 6 months post radiation.  I asked generally about the form on this site and only got one response that I remember.  They liked the form.  I also read abut the form on the Breast Free site (I think that was the place) and they addressed the question you are asking.  Check there.  It seems to me that they coiuld be "iffy" with sweating but I'm not sure.  Oh yeah, the one I have is the Ameona Contact.  What I really liked about the form was that when attached, it hangs like my other breast.  It looked very natural.

Erica3681

Houndmommy,

Terri is right, the thepinkbra.com has prices lower than what you're likely to pay at a regular retail shop. It's also true that almost all online sites, not just that one, feature lower prices than your local retail establishment. Unfortunately, in my experience the online sites don't process insurance for you. You'd have to purchase the items yourself and then submit to your insurance company, which can be a hassle. For that reason, I normally buy my annual insurance allotment of breast forms and bras at my local shop, then if I want to supplement that I use the online sites.

MetroMedicalOnline and Park Mastectomy are examples of other online sites that also offer lower prices.

Barbara

BreastFree.org