March 22, 2010

A SNAFU on steroids

Well, Blog, that’s what you could call the last ten days of my life. As the U.S. faces a sweeping overhaul of the health care system, I’ve been enjoying my own experience of the “most hilarious antics medical bureaucracy has to offer.” My experience has been with the private sector, but lest you think the government does any better, check out this story about the heinous actions of Medicare, reported yesterday in the Milwaukee Journal-Sentinel. At least my case isn’t life-and-death like hers.

So, let me share the nutshell version of my story, emphasis on the word “nuts”:

  • Last year I got approval for my Freestyle Navigator continuous glucose monitor, known by his friends as “Navie,” including the sensors I stick in myself every five days.
  • Last October my employer switched from United Healthcare to WPS for our coverage. The switch was scheduled to occur in a couple of weeks. Naturally fearful, I immediately went through the process of making sure my sensors would still be paid for under WPS.
  • In November WPS assured me (in writing) that they were. Our coverage switched as of 11/1, and mid-November I ordered a box of sensors. Ordered another in December, and another in January.
  • Mid-January I received my Explanation of Benefits from WPS. I was supposed to pay in full for the November $833.33 box of sensors. (Hmm, used to be $500 under UHC.) I saw a I still had an outstanding deductible from the UHC period of $956.24, so I figured that was why, and expected to have to pay $121.91 for the December sensors.
  • In February I ordered a fourth box of sensors (we are now talking $3,333.32 total).
  • Mid-February I received my EOB from WPS for the December box, and it was still $833.33 patient responsibility. It was then that I took a closer look at the EOB to try to figure out what was going on. THE SENSORS WERE BEING TREATED AS OUT-OF-NETWORK. Please note the interesting fact that the out-of-network deductible is $10,000, and a year supply of sensors at this price costs $10,000. How about that?
  • Thus ensued the last ten days of constant phone calls between myself, my company’s head of Human Resources and his assistant, two people at our benefits coordinator company (I love how businesses have to have those now), my account rep at WPS and their sales guy responsible for our account, two people at Abbott (who manufactures the Freestyle Navigator), and three people at various DME (durable medical equipment) suppliers that actually SELL the sensors. I’d say 90% of these calls have involved me, and we’re at the 18 hour mark for my time.
  • At first, WPS insisted they had no in-network DME supplier that offered the Navigator. They said I would probably have to switch machines to another brand. You cannot understand the horror of that idea unless you’ve gotten used to a continuous glucose monitor like I have with Navie, but please trust me—that is just not an option. I had to prepare a four-page document explaining why I wanted to stay with the Navigator (the research gave me even more reasons to want to!).
  • Abbott insisted there were two DME suppliers in WPS’s network that I could use.
  • WPS then found there was a supplier in-network that I could use, but not one of the two Abbott said. It’s called Apria Healthcare.
  • I tried to get the ball rolling between Apria and Abbott to send me sensors (down to a week’s worth at that point). Abbott insisted before I could use Apria, they had to have confirmation from Byram that Byram was out-of-network at WPS. Didn’t matter that I, the patient, wished to switch. Didn’t matter that WPS, the insurer, said Byram was out-of-network.
  • Abbott finally got that confirmation and began work with Apria for me to get my sensors from them.
  • Apria refused to proceed until they got confirmation from WPS that they insured me.
  • WPS called Apria to do that, and in the process discovered that in fact, Apria was NOT in the WPS network after all. Can I get a really loud “WTF???” at this point, Blog?
  • So WPS has gone back to Byram to try to negotiate a brand new contract with them so I can be covered as in-network with Byram.

Please keep in mind, Blog, that each of these steps took hours to days, and required numerous phone calls and documentation by several parties.  Now I wait.  Some more.  Running out of sensors in a few days.

Here’s basically what I don’t understand: Why doesn’t my insurance provider have a simple database including all FDA-approved medical products, listing the suppliers for those products with which they have contracts? Why couldn’t they have looked at that database back in October, seen the situation then, and dealt with it? Why can’t DME suppliers trust insurance companies to be familiar with their own contracts? Why can’t I, the patient, choose where I want to buy supplies, like people do with drugs and pharmacies?

And apparently if I were uninsured, I could buy sensors direct from a supplier for as low as $417. Why do I have the feeling my being insured by WPS will prevent that supplier from being willing to sell to me direct?

Patients and doctors have lost so much control of medical treatment in the U.S. And I have no reason to think (see the Milwaukee Journal story) government control is going to improve that one bit.

Blog, I promise tomorrow to return to our regularly scheduled cheerful and humorous content. Just had to get this off my chest....


  1. Holy Crappy, Blog! Man, Diane - what a pain in the ASS! First off, please do what you must to order more sensors so you're covered and don't run out - thereby putting your health in danger and second, I LOVE your tenacity! Yeah! Keep on keepin' on! I know you will!
    What the hell, you've put in hours upon hours into this, please don't quit now despite the stupidity and expense of situation. I know you won't.
    I've been there but not fighting such a serious medical need - just a 17 thousand dollar hospital fee, many years ago and that was after the fact and did NOT challenge my health as this does yours.
    I can't see you losing this battle if you continue to persist without pause but maybe I'm being naieve (spell?). This situation sucks. I'll keep you and this on my mind...would you keep Blog up to date so we can know the ending of this story?

    Big Loves,

  2. Thanks, RAbecca, for your concern and support! The short and simple account is that the contract with Byram is more or less a done deal and my new supply is supposed to ship to me tomorrow. I won't believe it until I hear it's in the mail, but this phase seems almost resolved. Next we get to wrangle about the cost of the past orders when it was out-of-network and we didn't know it. We'll see on that!

  3. I can definitely relate to this. Every year my husband's company changes insurance and in the months immediately following the switch over we get hit with bills from one places saying the other should have paid, or telling me prescriptions I've been taking for years are no longer covered. Our co-pays go up and down for the exact same medicine year to year. It's beyond maddening.

    Medicare has issues definitely. I'm not sure what the right way to fix it is, but it can be a royal mess. The new healthcare who-ha that was just passed isn't govt run, tho. I just wanted to clarify that. The thing that passed was a ruling that said everyone needed to have insurance if they didn't. Govt is trying to get insurance companies to lower rates and accept everyone because it's now the law. That's govt's involvement at this point. There is no public option and govt isn't in the healthcare business (besides Medicare.) In other words, someone can't get ins from the govt.

    Healthcare has been a mess for a while. That conversation you describe is a familiar one. My biggest frustration came when the level of our insurance changed, but yet was staying with the same company. We were getting bills from the company saying they didn't have a record of us, when in fact they did. It's like whoever was at the ins company could not walk down the hall and give the right person the piece of paper. Finally we got on a conference call with both parties (at the same company!) in an effort to work it out. Why couldn't they have just done that?

    My favorite was when I worked full time and had to get an injection. My ins company rejected it, and I ended up having to put it on my credit card because it was several thousand dollars. I had insurance. Worked full time. This is the problem with insurance today. People talk a lot about govt, but yikes, the private healthcare business hasn't been too great either. These big companies have gotten so big they feel they can do anything. There's no way smaller companies can even compete.

  4. My nightmare is nightmarish, Cherie, but I swear you are the queen of nightmarish insurance SNAFUs. Horrific.

    I get what you're saying about no government insurance (yet, and that's a big yet), but there is still WAY too much control over our choices in the hands of the government under this new law. For example, I truly am curious if it will go to the Supreme Court to decide if it's Constitutional to make it mandatory for U.S. citizens to buy a service. No precedent for that certainly and I don't see how it's Constitutional myself. There are some good things about the plan, but that's one of the elements that scares me a lot. That's not freedom in the sense America has always known it.

  5. I hear you, and good points. That's one of my concerns too. I know there is a lot that needs to be put into action yet, and some of these things may change going forward. (The stuff that is going into effect in 2013-16 for example). Dealing with insurance stuff is so crazy sometimes. It's like all the common sense is gone! When I read posts like yours I am reminded of the stress these companies cause us, and for no good reason.

  6. I've got to say, after trying to do the WPS thing from November until April 1st, that I'm SOOOOOOO happy that my doctors will be covered by Mike's insurance. We've not been able to see any doctors since November. I had to spend 3 hours one night trying to find where to go when I had the spider bite that was becoming ever painful. It's now 2 months later and I've been sick this ENTIRE TIME all because of this bite, or antibiotics from it or whatever. Now I can finally go see a doctor and hopefully return to normal.

    Meantime...Mike cracked a tooth last Saturday. Since our insurance switches April 1st and since most dentists are closed on Good Friday the poor man has to be in pain until April 6th.

    I don't know who WPS is working out for but I doubt it's many people!

  7. What a big pain!!! I'm glad you have a new option, Jen. Sorry Mike has to suffer all that time though, that blows!

    I was told another associate had a problem with bad information from WPS. I guess it got straightened out, but Upper Management was not happy. Matt told me the other day how bad he feels about losing his doctor. And I'm just going to pay the out-of-network to keep my main doctor; not worth it to give up the only good G.P. I've found. Who knows...another carrier switch may be in the offing! But in the arena of health care in the US, we can all expect constant change of one sort or another. :-( Anyway I hope you get yourself (and Mike) fixed very soon!