Monday, January 26, 2015

Skool Nerse Time

Ms. Ged: "Thank you for calling the CrapCare Insurance pharmacy line. How may I help you?"

Mrs. Grumpy: "Hi, I got a letter saying my son Frank's pills won't be covered starting next month unless I submit an appeal form. It said to call this number to get the form. So I'm calling."

Ms. Ged: "That letter just went out last week."

Mrs. Grumpy: "Yeah, it came in today's mail. That's why I'm calling."

Ms. Ged: "We... don't even have the appeal form ready yet. You weren't supposed to call so soon after getting the letter."

Mrs. Grumpy: "Well, it didn't say that.  It said to call, and I am. When will the form be ready?"

Ms. Ged: "Next month. We weren't expecting anyone to call this quickly."

Mrs. Grumpy: "So the form to continue the medication won't be ready until after we've already run out of medication?"

Ms. Ged: "Yeah. I mean, that's when most of our patients call, anyway."


Packer said...

Serously, I think that little blurb should be mailed to the Chairman of the Board of that insurance company, with a copy to the insurance procurement administrator of your wife's bargaining unit, along with copies to the state insurance commissioner.
I think I would buy a share of stock and attend the annual shareholders meeting.

What say you Youssarian ?

Anonymous said...

Haha the funny thing is, Ms. Ged isn't wrong about people calling once they have run out.

Anonymous said...

This is NOT funny.

It IS true.

We employees were notified last Oct. that our employee-contributed health insurance would change, so I asked our human resources person how to ensure that my dependent's medication would be covered and the answer was basically, 'see what happens' when you request it in the new year.

So, refill at local drugstore was requested several weeks in advance, and went to pick it up a week ahead of time to have, voila!!!

I don't have $1,619.58 just sitting around to drop off so started the merry-go-round.

It took literally one week for the company to figure out contact with calls by HR advocate, doctor's office, me. Each contact told me or someone else to call someone else. How many people do you know that can afford to spend 4+ hours waiting on phone calls? A doctor's office? The HR person? Me at work--I'm not a minimum wage earner.

Were they expecting that I should just give up and NOT get the prescription?

I'm glad they're not supplying oxygen. There's not too many people that I know that can 'do' a week or two without oxygen.

Hattie said...

At your service!!!

Ms. Donna said...

Kafka strikes again
Is true. Glad to know MD and RN have the same problems as Jane Q. Public. Suggestion: Find out who the CEO of your insurance Co. is and his/her home address (sic Mary on it) and send that person a copy of blog and letter of complaint.
I know MDs are press-phobic, but a call to a local reporter might help. At least it would embarrass Insurance Co.
Anonymous above is right -- who has time to wade through all this?!! Try it with a damaged brain, as I am doing right now for a test that should be covered!

Candida Gomez said...

That is so many levels of wrong. The appeals form should be ready as soon as the letters start going out.

I also suggest contacting the CEO and others. See if there's a corporate email at which they can be contacted, and copy in several people at that high level if there is.

If they have an FB page, posting there could be interesting, even if it's just a link to this blog post. :)

Nurse Lilly said...

Dr. Grumpy, it's so cute that so many of your readers think that CEO's and other executives would actually care.

Anonymous said...

"Besides, it doesn't really matter if you submit the form or not, it's going to be denied the first time, anyway. The drug's not on our formulary. You have submit the form, and then after we turn it down, you'll have to submit an appeal."

"Oh, how do I submit an appeal?"

"Well, first you have you submit the form."

Oh, for the lolz.

Anonymous said...

Longtime lurker here, I read this blog daily.

I'd recommend using the "executive email carpet bomb" approach described on The idea is that you write an email describing your experience and the outcome you want, along with your contact info, then send that email to as many relevant company managers as you can, including the CEO. Since corporate email addresses often follow the same format, if you know one employee email address (for example, Ms. Ged's) you can figure out the others if you know the names (which you can often find through google). Also cc

I followed this approach when I had a problem with my phone and internet provider, and had spent fruitless hours on the phone trying to get help from CSRs. Within an hour of sending the email I received a phone call, and got the help I needed within the next day. I was also offered a 25% discount on my service for the next 12 months.

Anonymous said...

I've given uo on arguing with insurance companies, cable companies, banks, etc. They basically try to wear you down until you give up.

The only sure-fire way to get around it is to file a complaint with your state insurance department. Mrs Grumpy's case may not have risen to that level yet, but it's worth putting it out there in case some readers have had experiences that have risen to that level.

I'm in NY and this is where you would go in ny:

If you live elsewhere, just google 'State' Insurance Department health insurance complaint. In most cases the insurance company is REQUIRED to provide an answer to your complaint in writing...which usually goes something like this:

Thank you for bringing this complaint to our attention. We unaware of any such case among our subscribers. Upon investigation, we immediately contacted the insured and approved the claim.

For banks it's the Consumer Financial Protection Bureau.

One warning though - DON'T go this route with frivolous cases. Use up all your appeals with the company first, including advising them that you will be filing a complaint with the insurance department should they not expedite resolution. It works once all of that has been less than fruitful.

Anonymous said...

Jump through the prior authorization hoops.
Get prior authorization approved until 2025(!)
Have refill denied because terrible coding and awful user interface use two-digit years and the system thinks your prior auth was good for one day.

Let's hear it for Pharmcy Benefit Mangers and no, it wasn't Medco.

Candida Gomez said...

CEOs and such do care, if you put it in a way to make them care. It's all in the presentation.

Polite, firm, point out this is bad for the company's reputation and ability to attract new customers, remind them that due to the net, bad news spreads quickly and doesn't wait for the Google search. If their subordinates have been hitting grey legal areas, point that out to them and express a hope to resolve this amicably. Above all, no blame unless someone specifically, by name, has been an arse, and no venom. Be professional.

Presentation is key. (To a lot of things.) How something is presented is as important as what's being presented. Complaints of this nature have to be presented in a way to make the contactees care.

MDaisy said...

Nothing like planning ahead...

Tom Bridgeland said...

Couple of comments, as an insurance company customer service rep. First, the most likely reason for that comment was that the particular rep who took the call hadn't been informed of the change, and was trying to bullshit her way through the call. She should have asked her supervisor where to get that form, and then just emailed it to you.
Second, we don't worry at all about people getting the state's insurance commission involved, because, in the great majority of the cases, the error is on the part of the insured person, who failed to read their policy documents. The policies are basically written by the state governments anyway, and they read like they were written by government lawyers, because they were. We have little say in the wording, so if you get confused, it is the fault of the people you are complaining to. Good luck with that.

Anonymous said...

Anonymous on 1/29/15 @ 12:22 am:

As Anonymous 1/27/15 @ 12:28 am said, just mentioning "calling the insurance commissioner" has worked for my dad and me on multiple occasions over the years.

A while back I had a very similar issue (between stock piling & samples I had a little wiggle room before running out of meds). I got my way up the chain pretty high & than things stalled. I left three messages weekly for six weeks with not so much as an automated call. When I went to make call 19 I ended the message with, "And if I don't receive a return call by the end of the business day Thursday (that was 72 hours), my first call Friday will be to the Insurance Commissioner!" By 8:05 am the next day, I had my called (FINALLY) returned & the answer I had been waiting for.

I've also had to take that extra step and call the insurance commissioner & resolution was achieved within just a few days! The insurance companies DO NOT want them involved! As stated above, make sure you've tried everything before calling them & only call them for major issues!

Hope your issue has been (or is on the way) to being resolved!

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