Things Never Seem To Get Easier… Just Different

I want to preface this post with the fact that I LOVE our insurance. We are very fortunate to have excellent coverage for a reasonable cost (It’s an employer sponsored group plan so they pay most of the premiums).  They have liberal coverage policies, despite being an HMO, but they do require some hoop jumping for some of the items we need.  I have heard from others though (including medical device reps) that our insurance company is one of the easier companies to work with.

With that being said, this is a ranty, venty post about our freaking insurance company! LOL.

Angelina has been on the Dexcom since January 2014.  If you read my posts from that time period they are ALL about the issues we had getting the Dexcom in the first place– most of which were related to Edgepark not being on top of things, but some of which were related to the fact that the things they needed to be on top of were how to get authorizations for our insurance and process things.  It was a mess.  And it continued to be a mess every 3 months when we needed new authorizations up until January of this year when I finally found a rep at Edgepark who was willing to go the extra mile to follow through on things with the insurance and the doctor’s office to make sure things were moving along as they should be.  It was further complicated by the fact that because we have an HMO the authorization request is sent to the local IPA, which manages most of the healthcare claims to make sure they meet the criteria for medical necessity that is set by the larger insurance company.  But the bills are then sent directly to the larger insurance company rather than to the IPA.

However, despite this complicated authorization process and all authorizations being approved, every single claim for Dexcom supplies has been initially denied when the claim was submitted directly to the insurance company.  Every single claim comes back “This claim was denied because [company] does not cover services or supplies that are considered experimental or investigational.”  At which point, every claim, I email or call the insurance company and tell them (or send them a copy of) that the item in question was pre-authorized by the IPA and medical necessity was already established.  You would think after 18 months of this they would get it.

This does not make sense either. This is “clinical review” directly from big insurance saying kid meets medical guidelines for six months.

In January 2015 it was time for a new prescription for all things Dexcom, and also time for a new authorization for all things Dexcom.  That meant that the authorization would cover us for 1 receiver, 1 transmitter, and 1 order of sensors before it expired. This is like getting a BINGO because it means that when I call to place the order for any of these things they should be sent to us within a few day since we wouldn’t have to wait for Edgepark to ask the endo to submit for authorization, and then wait for her to do that when she is only in our clinic one day a week, and then wait for the IPA to review the request and make a decision and then send that back to Edgepark.  In the beginning, this usually took about a month each time.  When I found my favorite Edgepark Rep in January, this process took a week and then we had our shiny new receiver in hand.

Anyway… In March we were due for a new transmitter.  The orders for the receiver and sensors has already been done under the authorization and I had 30 days before the authorization expired.  Never one to look a gift horse in the mouth I ordered our transmitter on the exact date the warranty expired on the previous transmitter and 4 days later I had it at my door.  This time though, when the claim was initially denied and I emailed our insurance company with the authorization information (which, mind you, I had already submitted to them twice in the previous month for the receiver and sensors) it came back ‘not approved’ again.  I didn’t notice right away because it was the first time that one of these claims wasn’t just automatically approved when I pointed out we had the authorization and all the previous claims had been reversed and paid after all.  So, one late night towards the end of April I sent a very ranty message to the insurance company about how I was sick and tired of having to appeal every single claim for this device that we had been getting for the previous 18 months and how each and every time they reversed their decision and paid for the darn thing. Every single time they did a clinical review I was sent paperwork that said “we show that the patient meets the clinical guidelines for medical necessity for this device”.  Every time we needed a new authorization paperwork was sent in to support the ongoing use of the Dexcom and was authorized by the IPA. So why now was this claim NOT being processed and approved.

I was sent a response apologizing for the delay and told that it would be sent to the claims department for re-processing since it was denied in error.  And then, a few days ago I happened to be looking at our claims listing and see that this claim is still ‘Not Approved’.   I emailed again, and again was told it would be sent back to claims department for review.  I never have received any further communication beyond that, no email or letter stating that it was denied or why this claim is such an issue.

And then, this morning, I called Edgepark because I got a call on Friday requesting that I call to confirm our next continu-care order for Angelina’s sensors that are due for refill.  Imagine my surprise when I call and am asked if our insurance changed because it is showing that insurance will not pay for her sensors.  When I asked why, I was told that they could not place the order with our insurance because the previous claim was denied and they are showing that Angelina does not meet medical guidelines to receive the Dexcom sensors.

So confused. Says approved for all things Dexcom, two things got covered, one thing STILL not. Why?

A call to the insurance company informs me that the Dexcom is only covered under two diagnosis codes, and the one that was submitted with the Dexcom claim is not one of them.  The rep I spoke with said she saw that the last claim was sent to reprocessing but was going to come back ‘not approved’ again based on this information.  So, this has been escalated to an appeal and I have requested a case worker going forward because this ish is bananas.  Meanwhile, I am stuck in limbo waiting for the appeal before we can order sensors.  Fortunately we have some extras so Angelina will not go without for now, but I am just beyond fed up with this messed up system.

***********************************************
In other news… Angelina is switching from her Medtronic pump to the Omnipod.  We are doing the “No Tubes Attached” (previously ‘Cut The Cord’) program, which will allow us to purchase the PDM at a discounted price and then get pods filled through our insurance.  Now I am just waiting for the claim for that to see if they will actually cover this.  I am especially nervous about the whole Dexcom thing right now because of the timing with switching to the Omnipod mid-tubed pump warranty.  And also because Angelina was due for more medtronic supplies in mid-April but I skipped the order because I wanted to be sure we did not overlap and risk insurance saying they wouldn’t pay for pods, but now we are down to bare bones with our medtronic supplies and I have nearly gone through our entire stockpile that I had managed to amass over the past two years.