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?
11.11.2016
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.
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.
11.09.2016
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.
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.
11.08.2016
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.
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.
11.04.2016
hello, my name is...
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.
11.01.2016
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.
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.
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