Thursday, October 18, 2007

Depends on Your Definition of Covered

Lets hear it for the health insurance industry! Hip-hip hooray! anyone interested in donating to my health bureaucracy telethon? Didn't think so. Why is that? Could it be that they spend countless dollars figuring out how to avoid paying you? Granted, they must save more than they spend otherwise all that would be left is perverse pleasure. And while perverse pleasure can be fun, it doesn't buy a Mercedes...

I got to talk to a "Customer Service" person yesterday. When I switched jobs, my health insurance switched. I still have most of the same doctors, but when you switch insurance, if you have recurring prescriptions you need "prior authorization" before refilling them. Now, pardon my ignorance, but if I show up at the pharmacy with a written prescription, isn't that prior authorization? I certainly didn't write the prescription myself! Someone had to authorize it before I filled it. My money is on the guy who signed it.

I walked into CVS after jumping through all the necessary hoops to get a couple written prescriptions I have been filling monthly for the last year at the same pharmacy. I handed over the new insurance card. The technician took down the information and explained that the doctor would have to authorize them to the insurance company. Apparently, they need a verbal from the doctor. His signature is not good enough. I imagine this is an attempt to talk the doctor into prescribing a cheaper, less effective medicine. I explained to the pharmacy that the aforementioned hoop jumping used up my buffer and that I was all out. I needed to pick the medicine up later that day. I gave them my cell and told them to call if there were any problems.

I was unable to get back that day, but they didn't call me. I had no reason to suspect anything was amiss. I sent she-who-was-going-to-near-there to pick it up on her way to get the kids at school. I know you will all be shocked to learn that they were not ready. What's more, the technician claimed to not have our insurance information. They were still waiting on authorization for one of the prescriptions and thought it could take up to three more days. But they weren't done. The prescription that was authorized had a maximum quantity of 1 per day. My prescription was for 1.5, so they couldn't fill that. They were able to get the prescription broken into two, though. I could have a prescription for a month's supply at one dosage and a month's supply at half dosage, though. I'd just have to make a co-pay for each.

She-who-was-now-late-picking-up-the-kids bounced the ball back into my court and said she would check back later. My job was to call the insurance company and ask them WTF? The conversation went something like this:

ME: So, why do I need the person who wrote the prescription to tell you that it is, in fact, his signature on it?
HER: It's just a medication that we need prior authorization on.
ME: So, the fact that I have been getting the same prescription filled every month for a year is not enough proof that it is authorized? Especially since he reauthorizes it every month?
HER: But WE have never talked to him.
ME: And you are worried the pharmacy is dishonest?
HER: No. We just need authorization.
ME: Beyond the written prescription on the special copy proof paper that only medical professionals have access to.
HER: Yes. He needs to call us.
ME: Because that is much harder to fake than the written prescription...
HER: I'm sorry, sir. But we need authorization.
ME: Well, I need medicine. And I can't wait another three to five days.
HER: Oh! The authorization just came in. The pharmacy should submit it again and it will be accepted.
ME: That's a fortuitous bit of timing.
ME: Now about the other prescription.
HER: Yes?
ME: Why is that not covered?
HER: It is covered, sir.
ME: No. A dose that has already proven ineffective for me is covered.
HER: I'm showing here that we authorized this...
ME: As two separate prescriptions. I have to pay two co-pays. One prescription has one strength pill and the other has the same pill at half the strength.
HER: (pleased that I get it) Yes, sir. Two prescriptions.
ME: But if it's the same medicine, it is not two prescriptions, is it?
HER: We only cover a quantity of thirty in each dose.
ME: So, if there were 4 different doses, I could pay 4 co-pays and get 30 of each?
HER: Well, you'd have to get your doctor to prescribe...
ME: And this doesn't strike you as bogus at all?
HER: What do you mean?
ME: If I'm taking the same thing at two different strengths, it really isn't two prescriptions. If I take an extra strength Tylenol and regular strength Tylenol, are those different medicines?
HER: Well, no, but...
ME: This is just a way of scamming me out of twenty-five bucks because you want to say that you cover something, but don't really want to cover it.
HER: It is covered, sir.
ME: Then why am I not paying one of the amounts listed on my card?
HER: There are quantity limits on...
ME: Right, right. Quantity limits.
*long silence*
ME: So, that's it, then?
*long silence*
ME: I guess I have to go pay two copays for my prescription.
HER: (happy to be back on script) That's correct, sir. Is there anything else I can help you with?

Why do they always offer more help when they haven't really given any help that could be added to?

ME: Yes. I would like you to relay a message to your superiors. I realize you were just doing your job, so I don't blame you for enforcing their rules. However, I'd like them to know that I do not like this insurance at all. I am going to change at my earliest opportunity. In fact, I am going to tell my company to drop you as a provider.

When she-who-went-back-for-the-meds returned. There were only two prescriptions and two co-pays. And the quantity was for one and a half tablets. :)

The evil part? We are about to do open enrollment at work. My insurance will change as of November 1st. We had already decided to ditch them. I had nothing to do with it. But it was fun pretending I had. :)

There you go, Bill. How's that?