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....