Friday, February 5, 2010

I am not as crazy as the system

Mr. Sane’s employer just changed insurers, and you most likely know how crazy that gets. Compound that with dealing with the mental-health bureaucracy and it gets even crazier.

I need a refill on my meds soon. Believe me, no one wants me to go off my meds. This is the medication I introduced to my daughters as the “nice Mommy pills,” because before them, I was a screaming banshee. I don’t cuss; my Mom describes me as someone who “wouldn’t say s**t if she had a mouthful,” but when I’m on a low, I go straight to dropping F-bombs. Nah, no personality change there. Not to mention that for this particular med – not one you’ve likely ever heard of; it’s not advertised on TV – going off it can mean that when you go back on, it might not work, and while we took the time to find a new med that did, I’d probably revert to banshee mode. And going off it and back on again increases the risk of its one major side effect, which just happens to be potentially fatal.

However, because this is maintenance medication, insurers want you (in this case, me) to go through their mail-order pharmacies. The prescription has to be written for a 90-day supply; you have to mail it in, yada yada yada. The first problem for me right now is that unlike dealing with a local pharmacy, who is quite happy to take the prescription bottle from your other local pharmacy and transfer your prescription, the mail-order pharmacy wants a completely new prescription. And no, the doctor can’t phone it in.

So, problem number two: I may need to go in for a visit, even though I’m not due for months. I have no idea if/how this is going to be covered. The Summary of Benefits says that coverage for Behavioral Health Services (oh, there’s another rant there; this is SO not “behavioral” – except for the whole banshee thing) depends on the setting in which it is provided. That’s all it says. For any details, I need to check the Certificate.

That’s problem number three. We never got a copy of the Certificate. We got a letter saying that if we sent it in, the insurer would mail us a copy in about a month – or we could check it online. I went through the rigmarole to enroll in their online access a while back only to discover that the Certificate wasn’t available online yet. So I tried again recently – only to be told that to access it, I needed “contract-level permission.” This brought about a call to Mr. Sane’s HR department, who told me to call their insurance broker.

The nice lady at the insurance broker’s kindly e-mailed me a copy of the certificate, which says regarding the company’s mental behavioral health coverage: “See the Schedule of Benefits for any applicable deductible, coinsurance/copayment information.” The Schedule of Benefits says the same thing the Summary of Benefits said. Perhaps Capt. Yossarian could explain it to me, if he really existed.

Actually, the Schedule of Benefits does say one other thing – “Coverage for the Inpatient and Outpatient treatment of Behavioral Health conditions is provided to the same extent and degree as for the treatment of physical illness.” (‘Cause this illness SO isn’t physical.) I take this to mean that I can go to an M.D. in Psychiatry the same way I would go to an M.D. in any other specialty. However, the nice insurance-broker lady said I should call for pre-certification to make sure my doctor was in the insurer’s system.

Which brings up problem number four. I see a doctor at a Major Teaching Hospital, which means I really see a resident. An attending physician drops by, mostly pro forma, at the end of the visit. It’s the resident, not the attending, who issues the prescription. All the attendings at the hospital are listed as in-network; the residents aren’t. I’m not sure of who my resident’s current attending is – they change frequently. And, at the moment, I’m not even sure of who my current resident is – the one I’ve been seeing is finishing his residency, and he said my next med check (at least when it was supposed to be scheduled) would be with a new resident, and I’d get a letter (which I haven’t gotten yet) informing me who my new resident would be.

So – does the insurer care who signs my prescription? What happens if I need an office visit? I call the pre-certification number, and the nice lady there assures me all is well; the docs at Major Teaching Hospital are all on the plan, and the only thing I would need pre-certification for is if I needed psychotherapy. It would stand to reason that if the insurance is OK with the doctor, it would be OK with a prescription from that doctor. But the pre-certification lady can’t speak for the prescription contractor... and very little of this process stands to reason.

So, all it took was a few sessions online, a passel of reading, and a bunch of phone calls to find out that my meds are probably covered. Now I just need to get the actual prescription (which may or may not involve making a new med-check appointment, hopefully sooner than the month or so it usually takes to be seen), get it to the pharmacy, and wait for it to be sent to me. Why on Earth would anyone want to reform a health-care system this efficient?

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