behind the scenes, insurance insanity

Watch an Insurance Company Try to Drive Me Insane- Part 9,137

I’ve blogged before about Prior Authorization/Non-Formulary Exemption forms.  They are a huge time waster for me and my staff.  This one, however, takes the cake.  It starts off on January 20, when the patient received this in the mail, essentially telling him that his medication was not covered, and to talk to his doctor.

I got a similar letter.

Because the patient has been on this medication for years and is responding well to it, we filled out the appropriate paper work. (There was actually more paperwork than I’m showing, but it was all patient demographic information, so it’s not posted here for obvious reasons).

The patient called us on the 24th to see if the paperwork had been done.  Why, yes, it had, but apparently was never received by Medco.  Note on the date stamps above that the paperwork was faxed twice.

The kicker?  I get this message this morning.

For those of you who can’t read it, I’ll repeat it in BIG BIG LETTERS:  ALISON FROM MEDCO CALLED- MEDCO RECEIVED OUR PRIOR AUTH.  ALISON AT MEDCO STATES THAT THIS MEDICATION DOES NOT REQUIRE PRIOR AUTHORIZATION.

So, patients- you wonder why your health care costs so much?  Why it takes so long to get anything done?
For just this one, simple medication, it took 9 days, multiple faxes, multiple phone calls, and multiple forms.  All to be told, at the end, “Guess, what, fool?  You wasted your time, yet again.”

I wish I could say this has never happened before, but it is a weekly occurrence.

ADDENDUM:

Un-freakin-believable.  I just got this fax.  You’ve got it- yet another prior auth request for the drug- sent AFTER the message saying that it wasn’t necessary.

5 thoughts on “Watch an Insurance Company Try to Drive Me Insane- Part 9,137”

  1. This makes my day, only because it happens to me on a regular basis too.

    It's terrible to think of the money that's spent on the time for staff to fill out the forms and make phone calls, to take phone calls from patients, the paper in fax machines, the phone bills, and the time of the staff at the insurance companies and pharmacies.

    The ridiculous part is that the rationale behind prior authorizations is cost savings. At our practice, the majority of the time we successfully complete the PAs, so the company ends up paying for the medication anyways.

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  2. Thank you for taking the time to make sure your patient gets the medication that is needed. I am sorry you have to go through this.

    I just had an experience where I did not receive notice that the PA was needed for an anti-seizure med I was put on shortly after being diagnosed with brain tumors over a year ago. Because all of that happened quickly — I had several seizures, lots of tests, delivered a baby 8 weeks early, had 2 brain biopsies and learned I had astrocytoma grade II/III within one month– unlike the insurance company, I am going to cut myself some slack for not realizing a PA was needed. My NO nurse was actually told by provider services that the PA would not even work and that I would just have to pay out of pocket for this extremely expensive med. Thankfully I talked to a nice customer service agent at the same company who told me that this was incorrect.

    I found the PA form for my NO nurse. She had to fax it twice and once she put “URGENT, PT OUT OF MEDS” they finally approved the PA.

    Had I and the NO nurse just given up, I had a 30-40% chance of having a seizure (according to the neurologist I had seen about trying to get off the med).

    It was a huge hassle as a patient and wasted a lot of time the NO nurse could have spent on much more important matters. It also wasted a lot of my time and energy that could have been spent on healing instead of stressing.

    UGH!

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  3. This happened to me when I had Lyme disease! After. Every. Office. Visit. After every diagnostic procedure. In the end, I saved up all the erroneous paperwork my insurance company sent me, all the faxes I had sent to them, and bombarded them back with paperwork. About 50 pages all told. I hit “send” a second time just because it felt cathartic. And then I got rid of my health insurance in the interest of getting well. My health steadily improved with a significantly lowered stress level, and while self-pay is financially hard, I feel so much better without having to deal with an insurance company. I will have health insurance for the first time in 4 years starting in the fall. While I am not looking forward to the hassle – er – harrassment – the silver lining is that I will be in an FNP program, and will in future be able to advocate for others who have these PA nightmares.

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  4. My story revolves around the joy of changing procedure codes, and the “it's not my problem” from all parties. My typical three-part scan of the chest, pelvis and abdomen was typically coded as three procedures, with resultant discounts negotiated between the provider and insurer, and then the actual payments to the provider, with the out-of-pocket to me. My costs were about $640. Six months later, needing new scans, I returned and awaited the similar bills. But Medicare, in its wisdom, decided to recode the pelvis and abdomen scans into one procedure code, and the discounts as above did not follow. With the new changes, my out-of-pocket expenses were calculated to be $4074. Exact same procedures, same location, same insurance, and no one willing to resubmit with the original codes. After many hours and endless phone calls, it is still not resolved. Still another six months, and I need more scans (Ain't cancer fun), and paid cash of $864. Lots easier than spending my life on the phone and getting no where. Low point of all of this was being told just to call “the Medicare number” to get it fixed…

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  5. Thank you for posting this!!! I worked for a dermatologist as a medical assistant for a year and a half while studying for the MCAT and applying to medical school and PAs and dealing with insurance companies are the WORST!! I cannot express how much time and energy was waisted by the staff in our effort to get medications covered. The ONLY silver lining was that the experience came in handy during medical school interviews and I've learned some tricks for quickly getting through to real people at insurance companies but it gets harder and harder all of the time.

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