Yet Another Health Care Story

This is Health Care in the United States in a nutshell…

Over four months ago my doctor prescribed a new medication for me. This was a change in medication for a long-standing condition that my insurance company is well aware of.
The pharmacy where I get all my prescriptions (because it is the only one my plan allows) informed me that the insurance did not go through and was requiring prior approval. I advised the doctor’s office and they said they would take care of it.

Next call to the pharmacy the claim was still not going through pending prior approval.
Back to the doctor’s office. They assured me they had sent it in, but saw that it was not approved and would resubmit. This began a cycle of calls to the insurance company and the doctor’s office in which the insurance company said that they had sent the PA back as incomplete because it was missing information and the doctor’s office saying that they had entered everything.

Fast Forward to March. After hearing yet again from the insurance company that the doctor’s office wasn’t responding and the doctor’s office claiming that they had re-submitted the request two weeks more recently than the insurance company was claiming they had seen an update I finally set up a conference call with both at the same time. The results of this call were

1. The last person I talked to at the insurance company was wrong, they had received the recent submission.
2. The recent submission had also been bounced due to missing information
3. The piece of information that was causing the automatic kick out (turns out this is not the same as a rejection, the form was being auto processed out on the missing field with no human intervention) was an end date to the prior approval request.
1. Apparently for a prescription prior approval to be considered it must have a start and end date.
4. The insurance rep providing this information could not make the changes directly, the doctor’s office would have to re-submit.
5. The insurance rep gave the nurse an 800 number to call for quicker processing and advised her not to use the online system

Because it was late in the day when this conversation took place and because the rep said it took at least 24 hours to process the request once it came in I gave it a couple of days before I called the pharmacy and asked them to re-run the prescription.
Still not going through. Back on the phone with the insurance company. This time the automated system at the front end told me that I had a recent prior approval and that it had been rejected. The first rep I spoke to couldn’t explain why but offered to transfer me to the PA department. “Yes, Please”. Then after several beeps and static the call dropped.

A total of four calls (the first three were dropped when they tried to transfer me) to the company finally got me through to a PA representative who could look at the submission and the rejection. He read through it several times muttering to himself things like “ok, that’s the right diagnosis” before he found the issue. The doctor’s office had entered exactly the correct diagnosis code for this medication, but prior to doing that had answered NO to an earlier question that should have been yes. The question was “Does the patient have XXX”, where XXX is exactly what they had put in the code. At this point, we don’t know why the nurse answered no to that when that is exactly what the doctor said I had, but the upshot is that now that the PA has gone in, been reviewed and rejected the doctor’s office only gets one more try to re-submit before it is frozen and requires an appeal.

So over the course of 4+ months, there have been at least 3 or 4 re-submissions that apparently didn’t count due to the lack of an end date. Once the end date was added the form was rejected because the wrong box on line 1 was checked. The Caremark PA rep can’t update the form even though he could see that the diagnosis code was clearly correct. And if everything doesn’t go right next time the whole thing goes into an even more complicated appeals process.

Here’s the real kicker though. I have what is considered “good” insurance. This is coverage that would cost me upwards of $600/month if I was paying out of pocket. As health insurance in the US goes I am probably in the top 5-10% in terms of coverage and access, and I still can’t get a prescription filled because of clerical and procedural errors. That is the state of health care in the richest country in the world.

The only upside is that I can state with confidence that at least 4 different people have jobs just to tell people like me why we can't be treated.