Author Topic: Insurance BS (Read 14590 times)

J.R. · « **on:** April 13, 2016, 12:35:06 am »

Guess smooth sailing was out of the question during treatment. Came home tonight to a letter from insurance denying some of the tests they REQUIRED for prior approval to getting Harvoni. State that some of the tests were not medically necessary for treatment. Then why the f¢%~ do you require these tests for treatment approval if YOU deem them investigational, mainly a liver fibrosis test?

Lynn K · « **Reply #1 on:** April 13, 2016, 05:35:51 am »

I would call them ASAP and say what you just said here.

"why the f¢%~" indeed!

gnatcatcher · « **Reply #2 on:** April 13, 2016, 06:47:20 am »

Could their objection be to the type of fibrosis test? I'm under the impression that there are still insurance companies who will fork over the $ for a biopsy but consider a FibroScan or a FibroSure to be of unproven validity.

I'm in full agreement with Lynn's suggestion.

Gnatty

FutureThinker · « **Reply #3 on:** April 13, 2016, 03:52:02 pm »

Hey JR, FT here. I had chosen not to burden y'all with this issue, but......... the primary reason I did not apply for a state IMR earlier last year after my appeals were denied is because I was FIGHTING with the insurance co to cover my fibrosure test! Yes, the exact same thing, JR. It took 6 months for me to finally get them to pay for it. What appears to have been the issue (but I'm still not sure) was the ICD-9 code, or diagnosis code. Somehow it was listed as the code used for "unspecific" hepatitis c, vs. chronic HCV. I think that code may have come from my GP, as my hepatologist's office swears they never use that code. To this day, still not sure if it was the code or just the ins. co playing games with me, or both -- but I had to call repeatedly to all parties involved including the lab, insurance and my doctor's office. A real pain in the you-know-where and took the last bit of energy I had to get it resolved. I finally had to get a bit testy w/ the insurance co, but they finally paid for it. It was only then that I took a deep breath and started the IMR process.

SO -- check everything on the lab's bill to make sure it is correct. Call your MD office to gently inquire if by chance someone made a mistake; ask to get a copy of the lab order. Ask your doctor to call the ins. co for you (mine did). And, just keep calling all parties involved. You may have to raise your voice, which I always do my very best to avoid -- but that's when the issue finally got resolved. Good luck, FT

J.R. · « **Reply #4 on:** April 13, 2016, 10:54:03 pm »

Thanks for the information. Why this chaps my hide is almost exactly a year ago I had the same exact test ran and they covered it. (Glad i've kept my records for past 2 years) my insurance payments dont show the codes used. That was my plan to call the insurance and find out what coding was used on last years test and the lab. My denial letter shows the code used this year so i'll compare. I wanna get my ducks in a row before I get irate with the insurance company.

FT- thats what my denial letter shows "unspecified". Have to inquire what my previous test was classified.

HazelAustralia · « **Reply #5 on:** April 14, 2016, 07:41:34 am »

Crazy. And terrible you should all have to go through this. Best wishes, H.

FutureThinker · « **Reply #6 on:** April 14, 2016, 12:45:59 pm »

Yes JR, get all your ducks in a row. I found that the more I called and asked questions, asked for copies of what the dr sent (my fibrosure request was faxed to the lab and I didn't have a copy of it), asked the insurance WHAT exactly they needed, the more all of them realized I was not going to just roll over and pay this $300+ lab bill. I got a real runaround from the insurance; at one point, the day they decided to pay the bill, I asked the rep how she could work at such a job, harming my health with all this unnecessary stress when I'm sick, vs. doing the job I pay her for to help me! I didn't enjoy doing it, but they gave me no choice in their continual repetition of "it has to go to medical review and will take 30 days." At one point they said the code for was HAV! So, to this day, I am still not clear on what exactly the problem was, but just keep up your fight and hopefully they will pay -- esp. since they paid for it once before! Get your doc's office involved, as mine said they'd never seen a denial for this blood test. Yes, it is BS. Keep us posted, FT

malou · « **Reply #7 on:** April 14, 2016, 06:01:12 pm »

JR. just an fyi, procedure codes changed in October of last year to CPT-10. Much more complicated and demanding. They may have used the wrong one, keep after them! ML

malou · « **Reply #8 on:** April 14, 2016, 06:02:03 pm »

sorry, double post

J.R. · « **Reply #9 on:** April 15, 2016, 02:22:55 am »

Malou- my coding shows CPT-0001M.
FT- ya think they would try to help you but we forget they're a for-profit agency. If they showed us all the loopholes and how to get the insurance to cover they'd be out a job. Have had this work sponsored insurance for 20 years and first time I had a letter of denial for a procedure.

malou · « **Reply #10 on:** April 15, 2016, 10:22:51 am »

Ok, so I mis-stated myself earlier. The CPT coding did not change, but that code, CPT-0001M is the correct code for a lab study.

It was actually the diagnosis codes that changed, to ICD-10 codes or the diagnosis codes, they changed on October 1st. I just saw FT's post, and he was spot on. The ICD-10 codes for HCV are:

The following ICD-10-CM Index entries contain back-references to ICD-10-CM B18.2:

Hepatitis K75.9
C (viral) B19.20
chronic B18.2
viral, virus B19.9
chronic B18.9
type
C B18.2
type
C B19.20
chronic B18.2

I would do as some have suggested, and call the MD's office and suggest that they look at the coding for the reason for the workup.

dan98584 · « **Reply #11 on:** April 20, 2016, 07:55:52 pm »

Welcome to the game. it's like a tennis match, you and the doc just have to keep hitting the ball back at them. I was approved for 6 month treatment for ribo and Savaldi after they initially balked and recommended another drug that was for the wrong Geno type. Between myself and the hep C specialist we turned the heat up and provided all the documentation they wanted. now ready to start 4th month and they call last week wanting verification and authorization again. After the initial 6 month approval. So while they are being dumber then rocks, I am sitting here with a 4 day supply left, waiting for them to pull it together. will be on the phone every day with them and the specialist turning the heat up again. they will only approve it 28 days at a time.

FutureThinker · « **Reply #12 on:** April 20, 2016, 08:06:34 pm »

Dan, how aggravating!!!!!!!!! You seem to have this under control and know what to do, but you are absolutely correct: it is a tennis match, back and forth, back and forth. I'm keeping fingers crossed you get this glitch fixed asap as we all know only too well how much you need those drugs!

JR -- I agree with having insurance for a very long time and when you finally need it, it's nothing but a pain in the butt. I really don't know how those people can work there and sleep at night (I've said this many times on this forum). The insurance co will deny for ANY little discrepancy they can find; like I said, at one point they said it was the "unspecified" HCV code, then they said it was for HAV, not HCV, so look it all up and see where that takes you. So frustrating ... but at least you're undetected at this point!! Keep us posted and good luck, FT

dan98584 · « **Reply #13 on:** April 21, 2016, 09:11:17 pm »

Just got off the phone with the mail specialty pharmacy for the second time today. They say they have everything straightened out for my next 28 day supply (fingers crossed) Delivery is set for Sat afternoon Fedex, I run out Monday morning. I would be stressed out if I hadn't blown so much steam off on em this morning. Positive thoughts, positive thoughts Dan :-)

Luna7 · « **Reply #14 on:** April 22, 2016, 10:31:18 am »

How annoying Dan

I'm going to be right where you are in 3 weeks, worrying that they get it together and send my next months meds on time.
This must be something new (only sending 4 weeks at a time), as I don't remember reading about it before.
I understand why they don't send it all at once, but they don't seem to understand the stress it puts us through.

dan98584 · « **Reply #15 on:** April 22, 2016, 12:51:43 pm »

yes originally they told me several times on the 4th refill, I could get a 90 day rx but that all went out the window when we arrived at 4th month. it's all about cost. a 28 day supply of Savaldi is $28,000 ribo not as bad.

FutureThinker · « **Reply #16 on:** April 22, 2016, 01:10:02 pm »

I'm sending some positive thoughts on this refill situation: My sp. pharmacy has called me ~ 10 days prior to the end of the medicine to schedule my delivery, so hopefully yours will be doing this, too, Luna. The refill delivery has been about the only aspect of this process that hasn't been a hassle! So keeping fingers crossed. FT

Luna7 · « **Reply #17 on:** April 22, 2016, 03:51:11 pm »

Thanks FutureThinker

Hopefully it will go smoothly. They said to call anytime and they are open 24/7, so just maybe if they see I'm concerned they will reassure me.
Too many cooks in this soup though, so prone to mistakes happening.

I just took my first pills! Waiting to feel something...silly..lol

FutureThinker · « **Reply #18 on:** April 22, 2016, 08:23:09 pm »

I remember sitting on my couch after taking my lst Harvoni, just waiting for stars or something!! I think we all probably have some reservations/fears upon taking that first step to SVR...... FT

dan98584 · « **Reply #19 on:** April 23, 2016, 04:50:10 pm »

well Saturday afternoon the meds arrived. last dose would have been Monday morning. thus starts my 13th week without missing a dose. Best of luck JR with the tennis game. Don't give up it's easy to get frustrated.

FutureThinker · « **Reply #20 on:** April 23, 2016, 06:10:56 pm »

Dan, thanks for letting us know your progress will now continue as scheduled. Enjoy the rest of your good weekend, FT

Luna7 · « **Reply #21 on:** April 26, 2016, 10:13:50 am »

Great Dan...that it arrived on time

I'm concerned about the medication traveling in hot trucks, as Daklinza specs say it needs to be stored at a certain temperature, with 76/78 being the upper range. When mine arrived it felt hot, and I wonder how hot it would need to get, and for how long, for it to become less effective.

When the specialty pharmacy called I mentioned this, and they might mail it out with some ice. I live in a very hot area.

Lynn K · « **Reply #22 on:** April 26, 2016, 01:46:46 pm »

From what I have read temporary excursions of higher than desired temps are ok just do not store your meds in a hot place.

I wouldn't sweat it too much

Baxter · « **Reply #23 on:** April 27, 2016, 09:51:42 pm »

Quote from: Lynn K on April 26, 2016, 01:46:46 pm

From what I have read temporary excursions of higher than desired temps are ok just do not store your meds in a hot place.

I wouldn't sweat it too much

Hey - I saw what you did there!

I find it really disturbing that they're shipping these meds out with an expected delivery date just a day or two prior to the last bottle running out. To me, that's just an unconscionable game of Russian roulette. Anything can happen - if a bottle gets lost, it would take several days to get it replaced, and someone could easily miss 3 or 4 day's worth of dosing. That could literally be the difference between being cured or not being cured, between living and dying. That's a terrible practice, and I can't believe they're getting away with it. What possible reason would they have to justify going right down to the wire like that? I'd be on the phone reading them the riot act, and probably complaining to my state medical board as well. IMO that's absolutely indefensible.

That's one of the relatively few things I like about my clinic. They schedule me as much as a week ahead of my 4, 8, and 12 week dates, just in case something goes wrong and I miss an appointment. And they have a bottle of Harvoni right there to give me at each appointment. They apparently have quite a stock of them, and they just give them to whomever is in that day and due for a bottle. That's at least one thing they do in an efficient and professional manner.

Lynn K · « **Reply #24 on:** April 28, 2016, 12:51:39 am »

Ahh caught my dry humor there good one

Yes of course receiving our meds on time and in good condition is not a laughing matter.

I had to order every month and they would not let me order until I had less than 10 days on hand. Somehow I forgot how to count to ten correctly and I think I may have told them I had less then 10 days when I really had 12-14 days on hand

Oops my bad so ashamed ok not really

Best to all

Baxter · « **Reply #25 on:** April 28, 2016, 04:24:01 pm »

Don't feel badly, I went one better - I was supposed to start on a certain date, and I actually took the pills home and waited 3 or 4 days before taking the first one. So even if worse comes to worst, I'll always be several days ahead of where they think I am. I wanted to make absolutely sure there was no chance anything like that would ever happen to me.

Luna7 · « **Reply #26 on:** April 28, 2016, 10:15:01 pm »

Quote from: Lynn K on April 26, 2016, 01:46:46 pm

From what I have read temporary excursions of higher than desired temps are ok just do not store your meds in a hot place.

I wouldn't sweat it too much

Thanks

Luna7 · « **Reply #27 on:** April 28, 2016, 10:15:54 pm »

haha you guys are tricky with the pill counts...wish I would've thought of that.

drummerman · « **Reply #28 on:** April 28, 2016, 10:19:24 pm »

Quote from: Luna7 on April 26, 2016, 10:13:50 am

Great Dan...that it arrived on time

I'm concerned about the medication traveling in hot trucks, as Daklinza specs say it needs to be stored at a certain temperature, with 76/78 being the upper range. When mine arrived it felt hot, and I wonder how hot it would need to get, and for how long, for it to become less effective.

When the specialty pharmacy called I mentioned this, and they might mail it out with some ice. I live in a very hot area.

Don't worry about this.. I went through the same thing. My meds arrived on a summer day and the interior temp was about 100 degrees. I called the online pharmacy and they were of little help and offered to send a replacement with dry ice.... but it was so hard to get the meds in a timely manner I said I would just keep them.

I immediately called Abbvie and talked to a tech. (you have to ask for one). Nurses sometimes don't know. The tech explained to me that the storage temperature is for long term storage and that they actually run tests to make sure that drugs in shipment reaching high temperatures are still viable. The storage temperature if for storage not shipment. He assured me the drugs were fine. I then called my sister in law, a head pharmacist at our v.a. and she confirmed this information. Glad I held on to the hot drugs, cause this online pharmacy would have found someway to screw up the new shipment. Anyway, I cleared and am not 7 months UND. Don't worry about it.

dm

drummerman · « **Reply #29 on:** April 28, 2016, 10:27:14 pm »

Just found this from one of my old posts:

"Just talked to abbvie pharmacist on phone. She asked me how long I thought is was at 96 degrees. I guessed 6 hours. She said according to their stability studies, the medicine is fine. I then asked her what if it had been at 96 degrees for 20 hours , she checked her chart and said that it would be fine. I asked her what the extreme was time wise, and she wouldn't /couldn't tell me. She had to have "case by case" basis. I guess I could have just kept throwing times at her until I got to the one where it goes bad. She could not tell me how abbvie instructs online pharmacies to ship because that was not her dept."

Luna7 · « **Reply #30 on:** April 28, 2016, 10:37:17 pm »

Quote from: drummerman on April 28, 2016, 10:19:24 pm

Don't worry about this.. I went through the same thing. My meds arrived on a summer day and the interior temp was about 100 degrees. I called the online pharmacy and they were of little help and offered to send a replacement with dry ice.... but it was so hard to get the meds in a timely manner I said I would just keep them.

I immediately called Abbvie and talked to a tech. (you have to ask for one). Nurses sometimes don't know. The tech explained to me that the storage temperature is for long term storage and that they actually run tests to make sure that drugs in shipment reaching high temperatures are still viable. The storage temperature if for storage not shipment. He assured me the drugs were fine. I then called my sister in law, a head pharmacist at our v.a. and she confirmed this information. Glad I held on to the hot drugs, cause this online pharmacy would have found someway to screw up the new shipment. Anyway, I cleared and am not 7 months UND. Don't worry about it.

dm

Thanks...
Calling around is a bit of a trip to crazyland. Each person says something different, and they act like they for sure know the answer. And not just about this issue.

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Author Topic: Insurance BS (Read 14590 times)