This can't be normal - do I have a doctor?

[Else]

I realize it can take a lot of battling to get medication, but I wasn't expecting this.  I've really lost confidence in my doctor's office support staff.  I was expecting an insurance battle.  Or a PBM battle.  But not from my doctor.  It's why I went downtown.  It's why I waited so long for an appointment.  To work with people who knew how to do this.

Since the get-go I've kept a notebook because my memory is useless.  Always.  Time, date, name and action taken.  The ball has gotten dropped at every turn.  I have been following up but I've taken care not to pester either.  I had all my ducks in a row before the first doctor appt.

I'm not sure how you follow through effectively if the person you're talking to isn't being straight with you.  "The prescription was faxed on 5/19"  Prescription actually received by Spec. Pharm. 5/28. 

Spec. Pharm faxes doc's office on 6/3 that insurance will reject without "letter of medical necessity."  Leaves additional v/m messages on 6/5 and 6/9 as well.  No response.

Doc's office sends Prior Authorization Form on 6/4 to insurance.  What?  Wasn't that part and parcel of sending the prescription?  I told them at my first appointment in early May that Harvoni required a PA and had even printed the harvoni-specific PA form from my insurance's website.  The nurse wouldn't take it. "Oh, we don't need that."  Yeah!  Yeah, you really do. 

Called doctor's office today.  Asked to talk to anyone who wouldn't put me through to v/m.  Finally got nurse on the line and she couldn't write a "letter of medical necessity".  Quote:  it's not like we have templates for those kind of things.  She said she'd try to talk to the doctor this afternoon and maybe doc could call my insurance's "verbal PA line". 

Then she online-messaged me the following : I just spoke to a representative from your insurance and he says that a denial was issued on June 8th and the letter was mailed out yesterday 6/9/15 to you. I cannot do an appeal or write a letter of medical necessity without knowing the content of the letter. Let me know when you receive the letter and we will proceed with appeal.

Here's the problem with that message - I checked with my insurance contact.  She was faxed that denial letter on June 8th by my insurance.  Then two copies were mailed, one to me, one to doc's office.  How does my receiving the letter snail mail facilitate her knowing the contents???  It makes no sense.  By the time I get my letter, she'll have two.

My insurance contact also told me that a "peer to peer review" is still an option for the first two weeks after a denial.  So my doctor can still talk to them.  And why is the nurse writing a letter of medical necessity in the first place?  And scariest of all, she seemed truly uncertain as to how to write one.

No, scariest of all is that they usually handle the appeals.  I'm afraid to let them.  Where is my doctor?   

[Lynn K]

I remember calling express scripts and they attempted to read my denial letter.When I saw finally saw the thing they had all messed up what they said didn't really even match the letter.

But yeah they said they fax the denial to the doctor and mail a copy to the patient.

I can understand the doctors office would have to know the reason for denial to speak directly to issues that but they should have received the faxed letter.

Also every case is different so the doctor would have to answer the specific denial based on your situation. I think maybe that is what they mean by there isn't a template.

I had a lot of missed fax issues as well on who's end I cant say for sure. I ended up speaking to Express scripts having them send a fax the calling the doctor to make sure they received it them in reverse when it was sent back. That was the only way I got things moving if I could I would have faxed things myself or better yet hand carry.

I can feel your frustration at trying to get the darn ball rolling. Plus you have to get denied twice to ask for help from My support path it is all a very long drawn out process.

Sorry to hear things aren't going better for you with all this.

If your approving pharmacy is express scripts/Accredo you could try appealing directly to this address providing your subscriber ID, contact phone number, and describe your situation.

ExpressRxHelp@express-scripts.com

I was denied initially as well and found this address by accident but it is how I was able to get the medication I had a specific person working my case who was friendly and knowledgeable.
 
When I described by situation with a comment about being frustrated enough to consider contacting the local media about how they treat their patients with significant health problems they called me the next morning and I had the meds in hand 2 days later.

I also cited clinical trial data and professional articles with attached links.

Sorry this is so difficult for you and everyone else who has had difficulty in getting their meds

Best of luck to you
Lynn

Lynn

[Else]

Thanks Lynn,

Just modified the heck outta this post out of embarrassment.  Pointless details; whiny too.    I'm barking in the wind. 

Finding that balance between being proactive/ self-advocating, and acknowledging that there are protocols in place to facilitate volume is hard sometimes. 

Me with my "this is how it should be done!!!  "  Aw geez.  Yeah, IF it was all about me.  IF my doctor pored over my file instead of making rounds in the hospital checking on patients due for or recovering from liver transplants.  And maybe these hospitalized patients are dealing with all that AND share my 'seeking meds/insurance' woes.

Even my thread title is lame.  "This can't be normal."  I've read enough posts here to know that YES, it is normal.  Not ideal, but normal enough.

One denial down, one to go.  Then Support Path.  I owe a great deal of thanks to this board for educating me on its existence.

[newbie1111]

think i would find a new doctors office. You know it is in our power to control our bodies and who cares for them.  There isn't just one doctor out there, and they are all certainly different, some caring, compassionate, some wreckless, and non-caring, and lazy. So it is all up to an individual as to whom they have help them treat and care for their body.  If a doctor does not follow through with me, or does not give a care to follow through with their part, well then,, I don't care to follow through with them.  That is my choice.  And I have fired plenty of doctors in the course of my treatment, pre, during, and after.

[Else]

Thanks Newbie.  You're right.  The thing is, this is a new doctors office for me.  The G.I. up north here is telling my G.P. that he's telling his patients to wait until the price comes down.  That nobody can get the new medications.  Not true, of course.  But for his practice, that's the call they've made.  So my G.P. told me it was a good thing that I was going to a hepatologist downtown - that "at least they know how to get the new medications."
So, that being said, they are swamped with new patients.  And the part where it's bogging down is the part of the process they don't get paid for.  In a perfect world, they would hire more support people to handle the paper shuffling and insurance games.  But back to the previous sentence.  They don't get paid for it.  I'm not making an excuse for them - just acknowledging the reality.  At least I'm not with a doctor who won't even write the prescription.
At this point, I think my power lies in persevering.  I'm not giving up.  I'm not going anywhere. And I WILL get my medication. 

[David]

Else- keep your spirit up and keep sailing as steady as she goes. Trust me, I know what it is to be frustrated with your health care provider. Hang in there- you deserve treatment as much as anybody, and sooner or later, you will get it.