I will start this post off by saying that I used to work for Liberty Medical Supply in the pharmacy. I didn’t handle medical supplies, or really even have that much interaction with our patients. But, when you work for a company you understand the structure and the process. So, going into this whole messed up situation I have insider knowledge and I have been trying to use my knowledge to help these people help us. Unfortunately, it hasn’t changed a darn thing, which I can’t say is particularly surprising. As a bit of an aside, I left my job at Liberty in 2009. The day after I walked out of there for the last time (which was not necessarily supposed to be my last day) I had myself committed to a psychiatric hospital because I was stressed to the maximum and was suicidal, a big part of which was because of my job. I had a mental breakdown. During my 8 day stay I was diagnosed with bipolar disorder. That place, quite literally, drove me crazy. A big part of that is the disconnect between departments, the micromanaging that happens within the departments and the quite obvious lack of concern of the people that work there and run the place.
So, now, having to deal with a medical supply company for Angelina I am finding that it wasn’t just Liberty that is run that way. And dealing with a different medical supply company who is giving me the run-around is bordering on being traumatic for me. I wasn’t really expecting that. But, all of that really doesn’t matter to the story, but I feel the need to share because I have a unique, personal perspective going into the situation that follows.
We have an HMO. When Angelina was diagnosed with diabetes this past March I was a bit apprehensive about having an HMO and dealing with a very medically involved chronic illness. When I went to order her insulin pump in June, I was expecting to have to jump through hoops to get things approved and paid for. However, I was pleasantly surprised when we were able to go directly through the pump manufacturer (Medtronic) and they handled everything, including getting the prescription from her dr. Insurance approved with no issues and we had the pump in hand 10 days after I first contacted medtronic to tell them we wanted to order it. We get her pump supplies directly from them every 3-ish months and have never had any problems.
When we decided to attempt to order her CGM I, again, was expecting to have to jump through some hoops. A lot of insurance companies don’t want to pay for a CGM system, especially for kids, because they are expensive and don’t always improve the clinical outcome and control of diabetes. Our insurance’s clinical policy bulletins (the written criteria they use to decide whether they will pay for something or not) said that in order for them to cover a CGM for a child that the child would need to have experienced repeated episodes of low blood sugar below 50 that required the assistance of another person to treat despite making adjustments to insulin treatment. While Angelina has experienced low blood sugar in the past, after starting the pump we were seeing a lot more high blood sugars so I thought we were going to have a fight on our hands. However, after an initial snafu with medtronic about the prescription the insurance didn’t give them any fuss over covering the CGM.
After we returned the medtronic CGM and decided we wanted to get the Dexcom I was nervous that insurance would say no since they hadn’t been reimbursed yet. So, I called our insurance a week after we returned the medtronic CGM and the person I spoke with called medtronic while we were on the phone and was told that we had returned it and it would take approximately 30-60 days for them to process the return and apply the refund to the insurance. I asked if that meant we needed to wait and the person at the insurance company said that we didn’t. They had it on file that the return was being processed and we should be able to order the Dexcom right away. Angelina obviously already met whatever criteria they required for them to cover it so we shouldn’t have any issues.
A few days later I called Dexcom and was informed that we needed to have her dr send in their certificate of medical necessity, which is essentially a prescription that also tells why the Dexcom is required for the patient. I got an email from the dr on Dec 19 letting me know that she faxed in the CMN and we should be all set. Two days later, on Saturday, I got an email from a rep at Dexcom letting me know that our insurance requires us to go through Edgepark Medical Supply for the Dexcom and supplies as Dexcom is not contracted directly with the medical group. I was informed that Angelina’s prescription and all of her information had been forwarded to a rep at Edgepark and I should hear from them shortly.
I decided to go ahead and email the Edgepark rep and let them know that Angelina had an existing account, even though we hadn’t ordered anything from them. I made sure that I put all of her current insurance information in, etc. The only issue I had is that when I searched for her endocrinologist they didn’t have her info at the clinic we see her at. The only office info they had for her was for the diabetes clinic at Children’s Hospital Los Angeles, which is not in any way even affiliated with the clinic we go to, which means CHLA has no record of Angelina as a patient.
So, in my email to the rep I mentioned this information and provided the correct office information for the endocrinologist. Mind you, this was on December 21st. I got an email auto-response stating that the rep was out of the office until Dec 23. Edgepark was also closed for the holiday on the 24th and 25th. On Dec 26th I decided to call the rep since I never received a response to my email or a phone call. I got her voicemail and I just asked for her to call me back. Two hours later I finally get a call back and she tells me that the insurance was verified and what our coverage is. But then she tells me that they have the RX from the dr but they needed logs and blood work results and they had faxed the request to the dr’s office and were just waiting for a response.
I called the dr’s office to see if they had received the faxes and, if so, if they could get them sent in that day since I knew the dr is only in our clinic on Thursdays and I wanted this Dexcom ASAP. I got the run around at the dr’s office and had to leave a message with the receptionist, who very obviously had no clue what I was talking about. The nurse called me back a little later and said that they hadn’t received any faxes and besides which the dr wasn’t in until the following week due to the holiday. I pulled up the edgepark website and Angelina’s profile and much to my chagrin saw that the dr’s office information they had in her profile was for her office at CHLA. I called the Edgepark rep back and got her voice mail again. I left a message stating that they were sending the faxes to the wrong dr’s office and left the correct phone and fax number. I also emailed the information to the rep, just to be sure she got it. I didn’t hear anything back.
The next day (Friday, Dec 27) I received a call from a different Edgepark rep calling to tell me that they had everything that they needed, but when they called to submit the authorization to the insurance company through the IPA they were informed that Angelina’s coverage was terminated as of Nov 1. That meant that I now had to call the IPA directly to get things straightened out. I called them, and the person I spoke with went over all her info with me and confirmed that they were showing her coverage was terminated. Funnily enough, we had just received Angelina 3 months of pump supplies the week before this phone call. And, when I got the phone call we were sitting at Angelina’s therapist’s office. Her insurance was working just fine. The rep at the IPA said they would put a rush on it and get things straightened out. Well, I never heard anything after that and it was after 5pm on Friday.
Monday morning (Dec 30), first thing, I called the IPA to find out if they had fixed the problem. The person I spoke with thought I was crazy when I asked if the coverage was now showing it was active. Her response “The coverage has been active since November 1st. I’m not sure what you’re asking for.” (!!!) So, I called back the 2nd rep at Edgepark to let her know the insurance was straightened out. She then informs me that everything is not ready to go, but that they have to fax insurance authorization forms to the dr’s office that the dr must submit to the insurance to get authorization for the Dexcom. I told her that they had the wrong office info in their system and gave her the correct phone and fax number and she said she was faxing it right now, while we were on the phone. She said that once the dr submitted it to the insurance it should take 3-5 days for the insurance to make a decision and they would let edgepark know if it was authorized.
I didn’t hear anything for the rest of the week. I was hopeful that the dr’s office had received the fax and that the dr had filled it out and submitted it on Thursday. So, I gave it a few days for the insurance to hopefully review it. Then yesterday (Jan 7) I decided to call edgepark and I got our reps voicemail. I left a message saying I was just checking up on things and to please call me back (which I still haven’t gotten a call back). At that point I decided to contact the IPA and see what the status was. If it was approved I was going to call Edgepark and let them know to move things along. Well, imagine my surprise when the IPA says they have not received any authorization request for anything.
So, now I’m getting a bit ticked off. I call the dr’s office and the receptionist won’t transfer me to the nurse, which I asked for by name and I know is the person I need to speak with. The receptionist tells me they don’t have any record of any faxes in Angelina’s file. I finally call Edgepark and instead of trying to reach the rep I had been working with I just speak with someone in customer care. This person tells me that they still have the CHLA office info for the endo but she will update the file to reflect the correct office. We go over the information as she’s putting it in and then I hear “Oh. That’s weird.” She then tells me that she tried entering in the information that I gave her but then as soon as she hit enter it all defaulted back to the CHLA information and won’t let her update it. She instead gets all the office information and enters it into the special notes in Angelina’s profile and says that she will have to transfer me to the prescription department and that someone there will have to manually fax it to the dr’s office with the info in the special notes.
I get transferred to the prescription dept and am told that they can’t do anything since it’s for a CGM and that it has to be handled by the CGM dept. However, everyone in the CGM dept left at 5pm (it was 2:30pm PST – but they work on EST, so it was 5:30. Did I mentioned I started my call at 1:45pm and was on hold for a while?) and I will have to call back.
That brings us to today. I called Edgepark at 8am PST, which is 11am their time. I asked to be transferred to the CGM dept. I spoke with a different rep and when I told him that the insurance auth forms needed to be faxed to the dr’s office because they had not received them his response was “It looks like we have everything we need from the dr. Nothing needs to be faxed.” I explained that it was the insurance auth papers for the dr to submit to the insurance and that they needed to be manually faxed because they were not going through the system. He then tells me that he shows they were faxed to the correct number on Monday, Jan 6. Well, I tell him, I spoke with the dr’s office yesterday and they haven’t received any faxes so it needs to be sent again, manually. He assures me he will fax the forms manually.
This is where my experience working at Liberty comes in. I used to work in the dept that was responsible for faxing and calling the dr’s offices when there were problems – either the dr hadn’t returned the faxes in a timely manner (the system would fax it automatically every 48 hours) or we had gotten the forms or RX back and there was a problem. A lot of the time, we had the wrong fax number for the dr’s office and the info needed to be updated and refaxed. But, sometimes, the info just wouldn’t fix in the computer system. In those cases, you had to print the forms and actually walk to the fax machine around the corner and dial the fax number with your own fingers and put the paper in the fax machine. And then, if you were thourough (which, let’s face it, most people aren’t in a grunt type job like that) you called the dr’s office back to make sure they received the fax. Of course, manually faxing and then following up with a phone call may take an extra 5-10 minutes of your time, and for some people that’s just way too much time to spend on any one person’s problem. Especially when that rep isn’t getting paid any more money for putting in more effort. And, in some cases, may actually get in trouble because they took too much time on one person and may not have met their minimum quota for the day. I know, because working at Liberty I was written up more than once for not meeting my call quota for the day because I actually took the time to resolve issues and show some follow through.
So, here we are – three weeks from when I originally contacted Dexcom and still no Dexcom. As it stands, if the dr’s office didn’t receive those faxes today and the dr doesn’t see them tomorrow then we have to wait another week before she will see them (assuming they get there eventually). After that, we have to wait 3-5 business days for the insurance to review and decide whether to authorize. And then, blessed then we may finally get Angelina’s Dexcom shipped. I’m so over this crap. I wish I just had a couple grand laying around that I could just buy the darned thing outright.