EPIC FAILURES In Navigating Healthcare & Insurance Systems

Even though it was written by a doctor, this post still rang true for me.  I took several of these calls over time as a customer service rep, & I would try to help people sort out the messes.  In fact, even after my promotion, this most likely was what I would be doing yet today (if I was still at work and not on disability). I’d be helping both employer groups & members.  I’m still in “recovery” mode…because part of me misses helping people, but part of me doesn’t miss troubleshooting messes like this in the slightest, especially when it came to dealing directly with specialty pharmacy issues…

Yet, it’s not only these situations that cause failures, headaches, & breakdowns in the system for people.  I was just having a discussion with a few people in my transplant support group the other day regarding pre-authorization issues for drugs, which I also took an equal percentage of calls on.

These roadblocks are perpetuated under the guises of tightening formularies (drug lists) in an effort to save money, raising drug prices, or factors of both.  These can cause serious issues for people when they run into them.  Especially transplant patients, who typically don’t have the “luxury” of waiting 24-48 hours extra for the mess to be straightened out by their doctor or insurance because they can’t afford to miss a dose of an immunosuppressant, anti-fungal, or other important drug critical to prevent them from going into rejection.  I’m just pointing this out as one clear example.  There are several other illnesses that share this pain point too.

I took so many calls complaining about those hassles that I had the “appeals” process burned into my brain & could recite it from memory.  Did what I could when I could to make sure overrides were in place for “bridge” supplies until it was sorted out. “Have the doctor write what’s called a letter of medical necessity,  in it include, the following information…..blah blah blah.  In addition, write in any details about how someone can take no other alternatives, or including bad reactions to similar drugs….or anything else that might help your case…the stronger the appeal the better.” It’s all coming back to me now, even still in a damn tape loop in my head. Hopefully, I won’t need that loop myself for me any time soon.

I only encountered one issue temporarily with such a pre-authorization snag, it was for my GERD medicine at the time.  Luckily it was something that resolved painlessly & I just switched to another drug that worked just as well. Yet, if I were probably to compare now, half of my drugs would probably show up on Aetna’s drug list if Aetna was my plan manager.  They aren’t though.  It’s my employer & their TPA (third party administrator) of choice, an affiliate who acts as insurer & pharmacy benefits manager (like the post above was complaining about) in my case, I’m lucky to have a situation where it does actually work (knock wood).

In fact, Rapamune was not specialty drug when I started with this last employer like it had been for others. Then a drug list change was made when the generic came out. The generic, sirolimus, needed to be filled through specialty.  However, the switch was smooth & I was used to it from past pharmacy fills with different employers & different insurances, but I know it’s not always this easy.

Don’t even get me going on drug pricing,  separate drug deductible & copay issues,  & the generic versus brand debate.  “Ain’t Got Time For Dat,” as the saying goes.

Often, my employer’s use of using a third party insurer has caused some confusion & hiccups with doctor’s offices too & their one-size-fits-all standard servicing.  I remember those same calls & scripts (I made in my head to spit out when need be) & speaking to billers & offices trying to verify for a frustrated person. Then also trying to reconcile incorrect bills resulting from claims being sent to wrong place or wrong address & not being on file, or God forbid being billed out of network for using an incorrect TAX ID number.  My former oxygen supplier I had to call twice to straighten out an incorrect billing to finally get my claims to go through properly.

My former mental health office still claims I owe them, yet I don’t know how that can be since I paid out of pocket for the majority of visits & had to send in claims myself until my insurance company got wind that they were in-network & made a call to them to pull them up short, along with me sending the explanation of benefits showing them that I was in fact due a credit because they were in-network & my responsibility was less than what they actually charged me per visit doing it “their way”.

Then, eye exams I had to pay out of pocket for because even though I had an appointment two weeks in advance, they didn’t bother to try to verify (during the week) until I was in the door on a Saturday, and then SURPRISE! They couldn’t. But I, in turn, had to pay the price for that.   I also remember haggling with urgent care offices over how they bill, & then in turn, ME being correct, yet never being issued a refund & their refusal to verify my benefits even with my full policy up on my phone as I was ill with bronchitis or some other infection where I could barely talk.  Also hospital pre-certification hassles…. the list goes on…and on.

Ah, the headaches that come with insurance!  Even when you know the inside baseball to navigate the system, it’s truly maddening at points. I’m not even going to touch on the skyrocketing deductible/out of pocket issue relative to premium payments (what you pay a month for what you actually get).  That’s a whole other animal I’m not going to take on today because it’s the weekend & I want to enjoy it.

Yet, all of this was why I was always sympathetic to listening to people complain & why I tried & wanted to sincerely offer help.

Luckily, I was actually allowed to because my calls were not timed.  I was not penalized for helping people sort out issues & listening.  But a majority of companies are in fact set up that way, & that’s also part of the issue in getting things resolved.  They say it’s customer service, but there’s actually very little service being provided.  It needs to change.

Drugs were only the tip of the iceberg.  But what most people realize, is that these broken pain points have been part & parcel of the system for years, before health reform.  It’s just brought to people’s doorsteps more often now, so there’s a quick rush to judgment as to where to lay blame.

But I agree, the system is a mess period. Regardless of whom or what actually broke it years ago.  On the other hand too, some things can be successfully avoided if the person does actually get to know their plan.   But that’s another area that I’ve pointed out has a shortfall, offering true coaching & skills in leveraging a plan.  Plus, if the plan and benefits change every year, it can be quite a bit to keep up with, even if one is on top of things.

So I get it.  I also know the pain points increase when one’s health is not at optimum either.  That also leads to compounded frustration because the last thing someone needs when they are truly sick is to spend half their day on the phone working around a Epic fail.  (I’ve done it & I don’t have the patience to relive those experiences here at the moment. I just seemingly learn a little more each time to successfully combat most of it, so I take comfort in that.)

I’ve often wondered with as many services there are for house cleaning,  odd jobs,  virtual systems, why there is not some kind of solution to offer people in the way of coaching on health plans or finding an independent navigator to help take on some of these issues.  I know the HIPAA card is in play, but sometimes too it’s a convenient thing to hide behind.  I know some call centers do “act” like they offer these services to people. That said though, there’s always something else fueling it behind the screen, either in the way of metrics or dollars or helping the employer versus truly helping the person, this is of course, how they make their dollars.

Yet, where is the protection for the “everyman” or woman, their family, outside his employer. Who protects their interest & looks solely after them?

It comes in dribs & drabs with certain issues, but there needs to be some kind of virtual assistant or someone who has solely the individuals interest at heart. (Because everyone else in the system has someone looking out for them & their interests, except for the every man).

Idealistic, yes.  Doable, I hope so at some point. I’m also a firm believer in the teach a man to fish philosophy when it comes to troubleshooting problems.  (Do with someone, not for them, so if it happens again, they have a better plan of attack to begin with.)

My life is a bit less stressful now (obviously) in being out of this “mix”. But I still feel the pain & pressure at times & even occasionally in my own situations as they arise.

I do what I can to help out family, friends, & others I know when situations like these come up or at least try to help them get what they need.  But really I often think…. there has to be a better way.  For everyone involved.  (For professionals too, think of how much time is actually taken away from our care cutting through administrative red tape like this? Even instances where the doctor is actually willing, sympathetic, & proactive.)






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