Tuesday, February 3, 2015

This System Is Very Broken

Last night my rheumatologist's nurse - one of the most amazing people on the planet - gave me a call. It was 7pm, well after office hours, but she still wanted to make sure that I knew that my doctor had submitted all the paperwork for my Orencia last week. In fact, she told me that he had done it from his laptop during my appointment. So mere minutes after we had made the decision to try the new medication, my doctor had already sent my pharmacy the information they needed via e-fax. 

After the extremely useful (i.e. severely depressing) conversation I had with the specialty pharmacy yesterday, I dropped both my kids off with their respective care-takers this morning and prepared to spend a good portion of my only child-free day doing more battle with the pharmacy. Here's how that went:

I placed the call at 11:12AM. It took over five minutes to reach a human. I decide to hope for the best and try again from the very beginning. When a human answered, I asked to set up a delivery of my Orencia. The agent asked for my member ID, my name, and my birthday – which I give to her. She asks me to hold. I wait. I wait some more.

Would delivery on Thursday be ok?

Hallelujah! You are seriously going to give me the medication I requested? I am so excited!

Can you confirm the shipping address?

I certainly can!

Will you be available to sign for the shipment?

This is something that annoys me. The pharmacy will tell me what day the shipment is arriving, but can’t give me any indication what time of day it might arrive. So my options are (a) to sit at home literally all day long waiting for it or (b) to accept liability if the package is lost or stolen. But today I am so excited about the prospect of getting my new medication that I happily accept the liability so we can move on. Then:

Oh. Wait. The system is not letting me process the claim. It says there’s no prior authorization. 

My bubble of excitement bursts. And here we go again. Here’s the nonsense I was expecting. I explain that I spoke to someone yesterday about the very same issue. I explain that I called my doctor and confirmed that he had e-faxed the paperwork over a week ago.

The only prior authorization I see is for Enbrel.

I repeat myself. She repeats herself. I repeat myself again.

Let me see if I can get a rep on the line for that. 

I hold for almost a full 10 minutes. Finally: 

Thank you for holding. The rep in the pre-certification department is unable to find any prior authorization for the Orencia in your file. All we can see is the one for the Enbrel. 

This is a nightmare. I repeat yet again that my doctor e-faxed the paperwork last Monday. 

They can’t find anything in the file. She went back a couple of weeks to check the fax system.

Did you hear me say that it was an e-fax? 

The system is only showing prior authorization for Enbrel. 

I take a deep breath. I say that it sounds like they have recieved the prescription for the Orencia but they are missing the prior authorization. Is that correct?


I try to explain that clearly my doctor knows how to work their system as he has managed to send the paperwork for Enbrel in the past. I ask why he would have done it properly for the Enbrel but not for the Orencia?

We sent a prior authorization request to your doctor yesterday.

I ask why they waited a week to send this request if they had the prescription but knew the authorization was missing a week ago.

We had to process the prescription first. And the insurance said it was denied because there was no prior authorization.

This makes no sense and we are going in circles. I want to cry. I tell her that I feel frustrated because my doctor is telling me he sent everything but she is telling me they don’t have it. I ask her what I am supposed to do.

Have your doctor send the prior authorization.

I repeat, for what seems like the hundred billionth time, that he had already sent it the previous Monday. 

Well we can’t process the prescription without prior authorization.

Finally, I tell her I am in a lot of pain. I tell her I am struggling to take care of my children. I ask whether there anything at all she can do to help me with this situation. 

I can try to call your doctor directly.

I try to politely accept her offer while seething inside. Are you serious?!? Why wasn’t this offered to me yesterday?!? Or 20 minutes ago for that matter?!? I get placed on hold for at least another ten minutes. Finally:

I just had your nurse on the line. She is going to send in the form we sent yesterday. And once we get prior authorization we can set up delivery. 

Great. How long will that take?

24-48 hours. 

And then I will have to call back to set up the delivery?


So, literally a full forty-five minutes later, I get told that the best I can do is wait two days and then call again.


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