Wednesday, March 12, 2008

The Frustrating Side of Mangled Care

[Welcome Industry Radar and MainStreet readers!]

Need health care reimbursement? How about meds?

Learn the rules of the game.

Be prepared to deal with things like medical necessity or cost effective alternative.

This is especially so with medication.

For some illnesses, there are only a few meds that work. If you have one of those illnesses, be prepared to do battle to get your claim paid.

Eric Stoner has cystic fibrosis (CF). His maintenance meds run $60,000 per year by his own account.

Last November, I spent weeks politely jostling my inept doctor's office and insurance provider to get one of my prescriptions filled. Nobody seemed to take me seriously or put any priority on my case, even as I stressed that I was quickly running out of my medicine.

I ran into this earlier, except on a much smaller scale.

When I tried to refill a prescription for one of my wifes meds in January I discovered that the doc needed to reaffirm the prescription. Fortunately, she still had a few days supply left.

Still, we had to contact the docs office, give him a phone number and secret code so he could reaffirm the prescription he had written 6 months earlier and was already approved by our carrier.

But this was a new year and a new PBM (pharmacy benefit manager). Even though there are no alternatives to this med, there are less expensive meds (which do not work for my wife) that can be tried. Her dry eye condition has no cure, is not life threatening. It is more of an inconvenience than anything.

OTC meds don't work for her.

The process we went through to renew her medication was annoying but necessary.

I spoke with a friend who is a lawyer. He was eager to take action. "I'm always ready for a good fight," he reassured. "We can send them a nastygram," he explained, which would put pressure on the company to resolve this before it gets ugly.

A nastygram. Gotta love it.

Some folks seem to think they can buck the system by being a bully. Rather than frustrating everyone by trying to rewrite the rules, learn the rules and play be the game.

Of course in this case, you know what is coming next.

Health care should not be subject to the whims of profit-hungry corporations. It must be recognized as a universal human right.

Wonder if Mr. Stoner, who works as a writer, gets to make his own rules in his work? Does he have deadlines, or assignments, or does he just do things his way and send a nastygram when he doesn't agree?

Perhaps jobs should be a basic human right.
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