more fun with PBM appeals

The PBM denied the first appeal (more on that later).

The form called "Important Information about Your Appeal Rights" provides a number to call "for information on how to designate an authorized representative."

I try looking on the PBM website first and cannot find an authorized representative form.

I call that number to get the form. Person #1 gives me a URL that leads to a 404 notice (big surprise).
She transfers me to Person #2 at a new phone number.

I ask person #2 for the information on how to designate an authorized representative to file an appeal.
She has no idea talks to her supervisor.

She comes back and tells me that her supervisor says I have to fill out the form and send it in.
I explain that I am calling because I need the form.

"Oh," she says, "my supervisor says you have to get it from the website."

I explain that neither person #1 nor I could find it on the website.

"Oh," she says, "I have to transfer you to person #3 at yet another phone number!"

At which point I am disconnected.

I am in Hell.


i don't know how other people do this

I submitted a claim last month on behalf of a family member for a compound prescription medication (eye drops with a higher percentage of active ingredient than readily available).

The claim was denied by our PBM because, according to them, it "contains non-covered ingredient(s). Your prescription drug plan does not cover this medication."

The denial did not identify which of the "ingredient(s)" were allegedly not covered.

The compound prescription had four (4) listed ingredients, including sodium chloride (at a cost of seven cents).

Here is what I had to do in order to appeal the claim.

(1) I looked at the original form from the compounding pharmacist and developed a hypothesis that there was only one active ingredient.
(2) I went to the website of our PBM and searched their current formulary. I found the same delivery system of the same active ingredient (at a different concentration) listed, and printed out the page proving that the active ingredient was covered.
(3) I went to DailyMeds and printed out the drug information, including the ingredients list, confirming my hypothesis about which of the four ingredients was the active one and also proving that the three inactive ingredients in the compounded prescription were also used as a buffer in the formulary drug.
(4) I filled out the appeal packet, explaining all this and attaching the denial letter, the claim showing the list of ingredients, the page from the formulary showing that the medication was generally covered and the drug information showing that the inactive ingredients were the same.
(5) I mailed the appeal certified mail, return receipt requested, because I don't trust these people to keep track of anything anymore.

The worst part of all this is that the compounding pharmacy charged us less than the listed price of the formulary drug. So going this route should save the PBM money.

Of course, just denying the claim outright was even cheaper.

At first.

But I have to wonder. What do people do without good research and verbal skills and some knowledge of chemistry?


the further adventures of radiology department a

Part One here.

I was looking at my EHR with Radiology Department A two days ago, as one does, and I noticed that, despite my best efforts, an actual doctor there--let's call him Doctor X--took the time to reread my film a couple of days ago, and repeated his recommendation for followup testing. Sadly, this waste of his time took place a full week after I sent an agonizingly detailed letter documenting the results of the actual followup testing (including the radiologist's report from Radiology Department B).

I faxed Radiology Department A another copy of the agonizingly detailed letter, with a cover sheet to the attention of Doctor X, apologizing to him for the waste of time, thanking him for his conscientiousness in followup, and reassuring him that I had not only followed his recommendation but provided Radiology Department A with a copy of the report a week before he reread my film.

I called Radiology Department A and reviewed my fax with an office manager, whose name and direct line I now have. She said she would kill any ticklers in the EHR to end any further followup.

I suppose I shouldn't have done this, but I went back to my EHR for Radiology Department A last night, just to double-check.

And there I found a Visit Summary for the followup appointment that I cancelled twice on the phone, and once in writing. This may be the fault of Epic. It really makes me want to pin somebody's ears back.

I now await a bill/stern letter from Radiology Department A for my "missed" appointment. If this happens, I will start naming names.


possibly the most boring post i will ever write

Apparently, my health insurer Aetna, which is actually not an "insurer" at all but a TPA, is changing PBMs from Express Scripts to CVS Caremark.

To decode that last sentence and its significance:

A "TPA" is a third-party administrator of the health benefits that are being provided by a large company which is actually "self-insured."  When you are dealing with health benefits you need to understand who is actually providing them because you need to understand the rules that govern them and the pressure points if you need to complain when things go awry. For example, generally speaking, a self-insured plan isn't going to fall under the jurisdiction of the Commissioner of Insurance for your state, so cc'ing them on a Stiff Note is really not much of an implied threat. Self-insured plans fall under the loving care of the feds, in particular the Department of Labor and the Internal Revenue Service, but they tend not to be that consumer-oriented. Also, they're really busy.

A PBM is a "pharmacy benefits manager." This is a subset of TPAs in charge of arranging for payment (or not) of medications and (some types of sort-of DME, see digression below) prescribed by the clinicians who are paid for by the benefits administered by another TPA. Because that is more efficient (it actually may be, for all I know. Pardon my momentary cynicism).

The PBM switch has apparently been in the works for a while, and I am pretty sure that the transition was contemplated to occur in 2017 (like, January 2017).

The hotlink on Aetna's website to the press release announcing its "strategic alliance" is, of course, broken (when I pointed this out to the Health Advocate she actually snorted).

The "Q and A for Aetna Members" says "we will keep your employer informed."

The employer (of the consort of the Dark Goddess) knows nothing of when or how the PBM transition will be implemented. For all I know the deal fell through or was blocked by the Justice Department on antitrust grounds.

Our family is strong-armed into ordering a great deal of our medication (and certain types of sort-of DME, see digression below) through a PBM or face stiff financial penalties for the "luxury" of using a retail pharmacy. I have no information about how our scripts currently residing at Express Scripts currently eligible for refill will or will not be transferred to CVS Caremark, and when. Maybe it will be seamless. I should note that historically there has been considerable lag time between the time when we mail our prescriptions from Washington state to the processing center, which always seems to be in Florida, and the time the prescriptions are shipped from some other far-flung part of the country. When I can coax a clinician into e-prescribing, that reduces the transit time of one leg, but only one leg, of the journey.

My promised digression: one of the great oddities of my current PBM is that, if you get a "prescription" for medication that is available over-the-counter (for example, low-dose aspirin), the PBM will provide it essentially free (because this sort of preventive medication is regarded as a good investment in your health). Also, there are certain types of "durable medical equipment," or DME, also available over-the-counter, but that if "prescribed" are also provided more cheaply than if just purchased at the store. The oddity goes up to eleven when you realize that DME includes items that are not durable at all because they get used up, for example, lancets and glucose monitor test strips. And the rules on what DME you are "allowed" to buy from a pharmacy in order to have coverage are Byzantine. This summer I found out that my pharmacy was not a DME provider for crutches, but it was a DME provider for lancets and test strips, which was a distinction that was never satisfactorily explained to me.

Aside from the possible gap in fills, here are significant differences between the 2017 formularies of the two PBMs (the new one, of course, seems more restrictive than the old), so which PBM will be in place for the future is actually important for me to track down.

I have asked both Aetna and Health Advocates for information and we'll see who can clarify it first.


i made a difference today

I found out this morning that my paralegal wasn't intending to vote today because she didn't think she was eligible for a replacement ballot. Based on her quick check of the King County website, she thought her voter registration was no longer valid (she is an intelligent person, just intimidated by the process). I asked her cautiously--I am her boss, after all--if she wanted me to talk her through the process of getting a replacement ballot, which she did.

We went to the King County Elections website together, and were able to confirm that she was still a validly registered voter and eligible to vote. With her consent, I printed out a replacement ballot for her. Then I handed it to her and told her to go vote for whomever the hell she wanted, but to please go drop her ballot in the ballot box across the street from the courthouse (two blocks from our office). And gave her time off to do it.

Someone voted today, because of me, who would not otherwise have had a voice. I feel good about that, and I really don't care who she voted for.


hello, my name is...

I competed for several years in extemporaneous speaking in high school.

I took classes in college where the exams were 100% oral. And in Russian.

I have been going to court since 1984. I make my living with my voice.

I rarely use a word-for-word script any more. Sometimes, to show off, I have given major talks/arguments without any notes at all. Invariably, however, I prepare notes in advance, and they always start out the same way: Introduce self. 

Then I put my name in parentheses in my notes.

Why? Because stress makes us stupid.

Although it hasn't happened yet, it is still entirely possible that I might someday forget my own name at the beginning of a presentation.


the other side of defensive medicine

I wrote a stupid and annoying letter today.

The letter itself was very polite. But I wrote it because I was afraid, and that is what is stupid and annoying.

What was I afraid of? Being branded a "noncompliant" patient.

Why am I afraid of this? It's like a stink you can never get off.

What did I do that created this fear? I cancelled a followup x-ray at Radiology Department A because I don't have a doctor at Hospital A any more. All the rest of my local care is at Hospital B right now, so I wanted the follow-up to be done at Radiology Department B where all my other doctors are.

(Parenthetically, the reason that I don't have a doctor at Hospital A any more is that my doctor there quit Western medicine to become an energy healer, but that is another tale for another day.)

I thought I was really on top of things when I called Radiology Department B to get them to request all my films, scheduled the new appointment when the films arrived, and then and only then called Radiology Department A to cancel, explaining that the follow up was being done at Radiology Department B because they still had doctors practicing evidence-based medicine there and I had no clinician at Radiology Department A.

And then.

The next day I got an anxious call from Radiology Department A. We need to you be seen.

Well, I called and cancelled yesterday because I have the same appointment somewhere else. You just sent the records.

Oh. We don't have a record of that. It's very important that you be seen.

I explain again about my old doctor leaving Western medicine and my consolidating all my care to Hospital B.

This morning I checked on the EHR portal of Hospital A. Sure enough, they're still flagging me for overdue follow ups.

That's when I accepted: I'm in the Hotel California. Hospital A and Hospital B are, although nominally nonprofits, competitors rather than cooperators. There is no real system to track the transfer of care. Moreover, weeding out all flags from a big database is really, really hard. From their perspective, I represent a potential liability because they spotted a potential problem and recommended that I follow up. I get that. Unless I prove that the loop is closed they can deem me "noncompliant" and get rid of their exposure that way.

So I sucked it up. I wrote Radiology Department A a letter today, thanking them for all the lovely care (and they really have been nice over the years), reminding them that I have transferred care, and why, and enclosing a copy of the results of the follow-up x-ray from Radiology Department B.

Now that ought to do it.

Update: well, that was naive.


dear sergeant

I would like to express my appreciation to you and your marshal for meeting with me on Tuesday afternoon, October 18, 2016. We met to discuss the incident earlier that day in which my personal mobility aid was confiscated before my entry to the Maleng Regional Justice Center, and I was required to use a completely unsatisfactory, presumptively unsanitary, and stigmatizing substitute mobility aid in order to obtain access to the courthouse.

Although I appreciated the promptness with which we were able to conduct at least an initial discussion of the incident (indeed, the very promptness and informality with which the meeting was set up may have been a contributing factor), the meeting itself raises an additional concern for me.

I offer the following thoughts for consideration of future meetings of this sort:

You and your marshal, two very tall and imposing men in full sheriff's regalia, directed me, an officer of the court, to a secluded conference room in the courthouse library, to receive my concerns. I laid my cane down—which had been confiscated from me by one of you just hours before as a dangerous weapon!—on the table between us, within my reach, as we spoke.

Many, if not most, people would find providing unsparing criticism face-to-face with two authority figures, particularly law enforcement, alone in a confined and secluded space, a highly intimidating prospect.

I am not asserting that there was any conscious intent to intimidate me. Your choice of venue for our discussion, however, which I was hardly in a position to challenge as an officer of the court bound to cooperate with law enforcement, reflects a lack of understanding of its effects. I would imagine that it is automatic for you to seek to control any situation that you enter, given your line of work, but there is such a thing as overcontrolling a situation. You may also have been wishing to provide confidentiality for a discussion that might be expected to touch on my disability. If so, I thank you for that, but there are better ways to address that concern.

It occurred to me after the fact, but only well after the fact, that, had one of you made a snap judgment, during this meeting, that I was making a “threatening” or “aggressive” move towards my cane, and that I therefore needed to be "subdued," I would have had no way of establishing that the facts were otherwise. Given: the initial suspicion with which my innocent cane was met (to the point where someone who actually had held it in his hand believed that the head was made of metal, rather than resin); the intensity of my feelings about the situation to which I had been subjected; and my tendency to wave my hands around when I talk, I wondered in retrospect if I placed myself at greater risk than I realized by acquiescing in your chosen venue for our meeting. I also wonder now if I should have insisted on a witness/advocate on my own behalf, which was not presented as an option for me, before going forward with our meeting. Indeed, if our recollections differ about what was said during this meeting, since it was not recorded, I have been placed at a (numeric) disadvantage.

You were both clearly taken aback by the intensity of my distress, or at least the force with which I articulated that distress. I am somewhat relieved, in retrospect, that my impassioned plea for treatment with dignity was not misevaluated as potential aggression.

Although I was not daunted at the time by the venue of our discussion, I am sending this followup letter because I suspect that my background and temperament make me unusual in this regard. The difficulty of protest when deprived of access to an accommodation, even for a person such as myself, means that such slights occur much more frequently than are ever brought to your attention. In fact, I did find my initial interaction at the courthouse entrance highly intimidating, and I had to compose myself before I could place my initial call to the ADA coordinator. An intimidating venue, however innocently selected, adds an additional barrier to such issues being brought effectively to your attention.

I hope that you can receive this additional feedback in the spirit in which it is intended. You did ask me in my meeting what suggestions I might have for the future, so I may I add to my suggestion that you develop a coherent policy for mobility aids a suggestion that you use less discouraging venues for the discussion of ADA complaints. I don’t know if there is a usual protocol for these meetings that was bypassed in my case.

As a family law attorney, I want safe courthouses just as much as you do. But as a family law attorney, I also want everyone without ill intent to have access to those safe courthouses. Arbitrary denial of access serves no one. Remember: every cane is a “stick."


every cane is a "stick"

I went to the King County Courthouse this morning, and had my walking stick confiscated (I got it back eventually). The deputy handed me a nasty bogus cane that someone had abandoned there for my use in the courthouse.

The rationale for this was that my walking stick could be "used as a weapon" against me, and that they had taken it away from me for my own protection. The deputy never gave me a satisfactory answer to my inquiry about what would stop someone using the substitute all-metal cane against me as well. What he said to me was, "I have to let you use it," which to my ears sounded a lot like he was expressing skepticism that I was actually, you know, disabled.

After making inquiry of the courthouse ADA coordinator, filing a formal complaint with the Sheriff's Office via email from my meeting, and hate-tweeting about it, which was probably useless but satisfying, I took a meeting this afternoon with the deputy and his boss, the supervisor of the security unit at this particular courthouse. This meeting was probably much more enjoyable for me than for either of them.

Because of the apparent distrust of my disability, I began by putting my disabled parking permit wallet card on the table to establish the bona fides of my use of the cane, and it kind of went downhill for them from there.

Here is my debrief of the meeting, more-or-less as sent to the ADA coordinator:

I believe that I have sufficiently convinced the Sheriff's Office that my personal cane is not a deadly weapon, so that I will have no problem bringing it into the courthouse in the future. They may hide when they see me again.

I was surprised to learn, however, that although the Sheriff's Office does have a detailed list of permitted and forbidden items in the courthouse (scissors have to be blunt, wrenches less than 7", etc., etc.), it doesn't have ANY guidelines on mobility aids and which of their features might cause them to be excluded from, or admitted to, the courthouse.

The list prohibits "sticks."

I pointed out that every cane was a stick, and so this policy could be used to arbitrarily exclude ALL cane users from the courthouse, which would be discriminatory. It really didn't give me any guidance on which of my walking sticks and canes might pass muster and which might not. Depending on the deputy and the day.

They used the example of knitting needles being forbidden, but I pointed out that most people don't need to use knitting needles to walk. Then they tried to distract me with a question about service animals and whether people "need" them, and I told them to stop trying to distract me because I could talk for hours about those policies.

They said that the "probable" reason that the folks in the Seattle courthouse let me through (which happened a couple of weeks ago) was that they don't have any substitute canes to hand out in Seattle the way they do in Kent. This reason makes no sense. If my cane is a danger in Kent, it's just as much of a danger in Seattle. I am not sure they really accepted my point that you can't just take away someone's personal mobility aid and expect them to be happy using some random cane with a handle in a shape that they might not find useful that's been touched by who knows what people with what diseases. And what do they do about people in wheelchairs?

It ultimately came down to the guard at the time (1) thinking that the handle to my walking stick was metal, which it was not, and (2) not liking the (blunt) beak on the cane. Neither of which he bothered to tell me at the time, he just made his weird proclamation about how it could be used as a weapon against me. So I spent some time talking to the deputies about cane handle designs, showing them, as an example, my additional cane with a "derby" handle, which also has a similar shape, and a point on it, and pointing out how the lack of guidance/understanding of the personal choices involved was a problem.

I said that when it came right down to it, I wasn't going to make a scene at the metal detector, and they were the bosses of what comes into the courthouse, but that it wasn't right that the burden should have been on me to prove that my mobility aid was safe, or for me to be stigmatized by being forced to use something with hazard stripes on it (really?!) rather than my mobility aid of choice. They never really articulated to my satisfaction why my wooden walking stick with a resin handle would "threaten someone's safety or well-being" (to quote the King County ADA website) that much more than the all-metal cane they made me use. Might it be *slightly* riskier? Maybe, for the sake of argument. Enough to justify confiscating it? Ridiculous.

As a family law attorney, I am (statistically speaking) as likely as anyone at the courthouse to be a victim of violence. I don't have a problem with a no-weapons policy! I have a big problem with being required to use mobility aids that look a certain way because the guards lack even a basic understanding of how hard someone might try not to look disabled.