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Monday, January 21, 2013

On The Battle Front

So the other day, I find myself in the middle of the living room, fists clenched in rage, screaming at the top of my lungs: 

This was not an attempt at "primal scream therapy" but a reaction to the latest developments in the series of developments that have been occurring over the past month.

This was a reaction to our messed up, corporate-run, money-grubbing health care system.

Though, I must admit, screaming did momentarily feel rather good... But don't tell them that. They'll bill me for a therapy session.

Since December, I have been trying to achieve three simple things under this new medicare insurance plan. They are:

1. Order/get Bob's nutrition/feeding tube supplies
2. Continue Bob's home draw for PT/INR blood work
3. Get Bob back into rehab

This should be simple stuff.

But alas it's been nothing but a battle.... make that three battles...

On The Home Draw front:

In our last episode, you will remember that Dr. Big Cheese had refused to sign the referral form sent by the insurance company. Bob's regular doctor was, first, on vacation. Then, called off to cover hospital rounds for another doctor on vacation. Meanwhile, I am getting all this conflicting information from various nurses in the doctor's office:

Nurse 1: It is NOT our office policy to order home draws through home health agencies.

Nurse 2: A home health care agency will NOT send a nurse to do PT/INR. They just don't do it.

Nurse 3: You have to have "two skills" for a home health care nurse to come to your house. Does Bob have an open wound? If he does, we can send a home health care nurse for wound care and PT/INR.

(okay, get a knife. I'll give him a wound....)

Nurse 4: I'm sorry, but his insurance WILL NOT PAY for a home health care nurse for PT/INR. Trust me on this one. I've dealt with it before.

Finally, finally, finally, last week Bob's doctor returned to the office AND signed the referral. Yes! But, the referral then went to The Referral Department. The Referral Department sent it to a place called Associated Nursing Care (or something like that). I call Associated and they tell me, they never received the referral. Plus, they (Associated) do not take Bob's insurance...... so, I'm back on the phone to The Referral Department to tell them they didn't send it and, by the way, it's the wrong place to send it to. So, they are going to send it to another place.

Meanwhile: On the Feeding Tube Supplies Front:

The infusion pharmacy where Bob gets his supplies tried to run the authorization through and it was denied by the insurance company because Bob is "over the age of 24" and does not have a "congenital birth defect called [insert some long medical term here]". The pharmacist tells me to call the insurance company because they are not following "medicare guidelines" on this one. I try to call the insurance company but keep getting a recording saying that I am "out of the area" and can't make the call. So I call the insurance agent who signed us up, she gives me a number to call for a place called Care Centrix.

I call Care Centrix and they tell me they need the script for the feeding tube supplies and they need to do the authorization. I tell them the infusion pharmacy has the script, plus Bob's doctor is on vacation so I won't be able to get a script until god knows when. But why do they need a script if the pharmacy already has it? They then tell me our infusion pharmacy is "out-of-network" and we cannot use it. I tell them, no it is not. They then tell me that Bob's doctor is also "out-of-network". I tell her that Bob's doctor is NOT out-of-network because, you know, I put Bob on this STUPID INSURANCE PLAN because his doctor and pharmacy WERE LISTED IN-NETWORK. Then, she tells me that they might be in-network for the insurance company and they not in-network for Care Centrix.

Huh? By now, I am completely confused.

So, I call the infusion pharmacy back and they tell me that they are certainly in-network and that I don't have to go through "Care Centrix" which is just a middleman type company contracted by the insurance company. They work like a referral department. Jeepers. So, now I am supposed to get Bob's doctor (who was still out of the office) to sign a "Request for an Urgent Medical Review" to be sent to the insurance company. I call the doctor's office and talk to someone in "Authorizations" and give her the info and she assures me she will handle this.

Meanwhile, back at The Rehab Front:

Outpatient Rehab has not received the referral for PT from The Referral Department. So I have to call The Referral Department again and ask them to fax another referral for PT.

Then, back at The Home Draw Front:

The Referral Department sends the home draw referral to another agency, who I call and find out that a) they never received a referral, and b) by the way, they do not do PT/INR. I need to get a lab to do this. This person also tells me that no agency will send a nurse just for PT/INR, they need to be doing at least two "skills" etc. etc....

I am beginning to doubt myself as everyone is telling me this is not going to work.

So I call The Home Health Care Department of the insurance company whom I talked to once before, who told me that they would pay for a home health nurse to do the PT/INR and ask where I can have The Referral Department fax a referral. She gives me a number and I call The Referral Department back with this information. 

Meanwhile, on The Feeding Tube Supplies Front:

I am running out of Jevity for Bob. I already cut him back to four cans a day (from five a day) and I now have only 2 days worth of feeding tube nutrition. I call the pharmacy, have they heard anything? No they haven't, but she finds two cases of "donated" Jevity and says she can send them to me but I have to pay a $10 delivery charge. I take the two cases.

I call the Authorization Department and she tells me she has filled out all the required forms and the doctor has indeed been in and signed them and she faxed them to the insurance company. And not to worry...

Meanwhile, on The Rehab Front: 

They received a referral with the wrong insurance information on it and they need a new one. So, I call The Referral Department again...

Back on The Feeding Tube Supplies Front: 

I get a call from Care Centrix leaving a message to return their call. So I call. It turns out the Authorization Department has sent all the forms to Care Centrix instead of where ever they were supposed to go. And after being transferred six million times, I get connected to someone who tells me that the forms are all addressed to our infusion pharmacy, not Care Centrix and that it seems Authorizations sent the infusion pharmacy paperwork to them by mistake.

By now, I'm tearing out my hair....

So I call The Authorization Department who tells me they are sure they sent it to the right place, as she talked to someone at the insurance company. 

So I call our infusion pharmacy who says she'll call the Authorization Department and try to figure out what's going on....

Meanwhile, back on The Home Draw Front:

Finally, I get a call from a home health agency telling me they are sending a nurse to do Bob's PT/INR!

And whoo hoo! I am dancing through the house, a sort of primal dance therapy--if you will, because I won this battle!!!! Yes! Yes! Yes! And all those nurses can take a flying you-know-what, because I was right!!!

Meanwhile,  on The Rehab Front:

I call Outpatient Rehab to find out if they got the new referral with the right insurance information and talk to someone new in the office who tells me that she doesn't know a thing about this and can she have a therapist return my call?

 Huh? This makes no sense to me at all.

Then, back on The Feeding Tube Supplies Front:

The infusion pharmacy calls and tells me that the Authorization Department not only sent the forms to the wrong place but sent the wrong forms. They were supposed to request a "Urgent Medical Review" and sent instead a "Pre-authorization Form". The infusion pharmacy assures me that The Authorization Department now knows what forms to send and where to send them and they are going to take care of this...

I am beginning to feel like I landed smack dab in the middle of Kafka's THE TRIAL....

Then, on The Home Draw Front:

Friday, the nurse shows up to test Bob's PT/INR (I could just kiss her!) which is sky-high, which I was afraid it might be since he hasn't had a test for three weeks, so I'm back to adjusting the warfarin dosage, back to weekly testing.  Then the nurse looks at the authorization forms discovers the insurance company only approved THREE VISITS.  And this for a weekly PT/INR.

Good grief.

Meanwhile, back on The Rehab Front:

I call Outpatient Rehab back, hoping and praying to get connected to one of the usual women in the office who know what's what. I do. And find out that they finally got the right referral form and are in the process of "verifying insurance" and getting "authorization".

And on The Feeding Tube Supplies Front:

This morning, I called the insurance company, who then connected me with Care Centrix again, who told me they received a "medically necessary authorization" to ship Bob's feeding tube supplies but had closed Bob's case as I wanted to use our infusion pharmacy which is "out-of-network"...


By the way, the reason I want to use our infusion pharmacy is because they cover the co-pay for Bob's supplies as a charitable donation.

So I called the infusion pharmacy and left a message....

And now, right now, I am fully dressed in battle armor waiting for a return call.

Things should not be this difficult.


J.L. Murphey said...

Your gotta to love the system. I go round and round with ours too, but stick to your guns, lady. You are doing the right thing.

Our insurance company and Medicare wanted my husband's case to be reviewed by their nurse. No problem, I give them a call. I explain by hubby's condition, his erratic symptons llike going from a very rapid heart beat and blood pressure to almost none, his meds to speed up his heart rate and blood pressure and meds to lower them, the oxygen, the monitors...oh, I also tell them I am retired emergency life flight nurse. The "counselor's" head was spinning by the time I finished all she could say was, "Mrs. Murphey, you're doing a fine job. We won't be bothering you again."

Why is it like pulling healthy teeth to get the care for our spouse that we already know they need?

Anonymous said...

Holy hoops Batman (Wonder Woman)how many more do you have to jump through? Talk about the left hand not knowing what the right hand is doing, that's ridiculous. I had some occasional problems with insurance for my wife, but nothing like you are having. One suggestion that you might try with your insurance company is to ask for one or two people and their extension that you can call and work with. That way they'll know you, Bob's problems and needs, and hopefully better assistance than dealing with a different person every time you call. Because of all the problems my wife was having over the years, our insurance company actually assigned us a person to work with as needed. What a blessing with a single contact when needed.

I do hope and pray all those people get their act together for you and all those headaches disappear. You sure don't need them with everything else you have to deal with.

Hugs, Dan

GirlWithTheCane said...

That's what passes for care in the US?

That's criminal.

I wish I had some good advice for you besides "document everything" (which you're obviously very good at) - names, dates, what they said they'd do and what they failed to do when they said they'd do it.

I hope that you catch a break soon.

Jenn said...

Are you dizzy? Good grief! From all that spinning around you certainly must be dizzy!!! I can't understand why there isn't ONE person to process ALL the necessary paperwork! Why previous information from the previous insurance could not be incorporated to expedite/make a smooth transition to the new insurance. As for the blood draw, well, I guess three authorized visits can be looked at as it's something to start with. But girl, I'm so with you on your frustration level. I know I'm not actually living it, but, in a way, I'm living it with ya. Hang in there, Joan of Arc! OY!

Rebecca Dutton said...

When an insurance company gives me a hard time I start every phone conversation by asking who I'm talking to. I only get a first name but I think it helps temper that person's response. When it really got bad I put them on speaker phone which I also think helped. As a final step I put a tape recorder next to the phone. I never actually used it but I think it gave me confidence that came though in my voice. I am praying for you.

Anonymous said...

May God continue to bless both of you as you wander around in the health care world. I love your blog and hope to be visiting often. My hubby had a stroke 5+ years ago and the daily fights with the doctors, insurance companies and the stupid world have just about worn me out. All I can say is ---go girl, go!