Member Story | Monica and Carlos

From frustration to freedom to travel

From frustration to freedom to travel

A health plan client’s member (Carlos*) contacted Carenet’s Strategic Engagement Advocate (Monica) for assistance with obtaining a portable oxygen concentrator that he needed for upcoming travel.

Prior to reaching out to his Advocate, Carlos was angry about an ongoing struggle to get his health plan to approve payment for the portable oxygen concentrator that he needed in support of his business travel.

He was being told they would not pay for a second unit since they had paid for a home oxygen unit for him previously. Carlos believed that he could receive exception approval for the portable unit since he travels more than once per month for work, but he wasn’t receiving consistent information via his health plan’s written benefits policy, or their member service line.

Extremely frustrated, irate and running out of time before his next International trip, Carlos explained the situation and his ongoing struggles in his initial call to his health plan’s Advocate – Monica. He stated that he required that Monica relieve him of his aggravation, and handle the situation until the oxygen unit he needed was in hand. He also wanted the unit arrive prior to his next trip – in less than 30 days.

Monica did the legwork needed with the health plan to confirm that Carlos was eligible for the second oxygen unit due to his regular travel requirements, and was able to obtain information about the in-network Durable Medical Equipment (DME) providers for Oxygen. She immediately went to work contacting each of the three DMEs to check on availability of the portable oxygen concentrator that Carlos needed. None of the three in-network DME suppliers had the needed unit in stock, and the earliest availability was three months out.

The Advocate then located another DME who had the unit in stock, but they were not in-network for this health plan. Monica and Carlos joined a three-way call with the health plan to request a network deficiency review to allow this DME to supply the needed unit.

At Carlos’ request, Monica handled multiple follow-up calls with the health plan to check the status of the network deficiency review, cleared all hurdles and delays, then contacted Carlos when it had been approved.

Monica then worked with the DME provider to ensure that:

  • The order had been placed
  • The claim would be filed so that it would be paid as in-network per the approval coming out of the network deficiency review
  • The unit had been shipped

Carlos was very pleased when the unit was delivered one day before his next international business trip.

He then asked Monica to inquire about his out-of-pocket costs. When Monica checked on this for Carlos, the health plan indicated that they would not know how much Carlos would need to pay out-of-pocket for the unit until the claim was filed. While Carlos was traveling, he asked that Monica continue to communicate with the health plan to get the out-of-pocket cost details. Monica cate was able to complete this task by the time Carlos arrived back home.

Carlos was thrilled with the above and beyond service Monica provided to resolve a ‘very frustrating and time-wasting issue’. He was also happy to be able to travel for business and pleasure without worrying about his oxygen concentrator.

* Member’s name has been changed to protect his privacy.

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