Back in January, somebody called me late on a Friday afternoon to ask if we could get them a medical device. The exact details aren’t super important to this story, but it’s worth stating that the device was medically necessary and fairly routine. It should’ve been a straight shot! But there’s that dangerous word “should,” always tempting the capricious hand of fate to make an absolute muck of one’s tidy plans.
I don’t want to get too deep into the salacious details of medical bureaucracy (nor do I think you truly want to hear them), but it should suffice to say that this simple task sent me on an adventure that spanned 2-4 months and about 18 phone calls.
The trouble was that of all the major players including the device’s manufacturer, the person’s medical insurance, the person’s pharmacy benefits (who knew there was difference), and the 2 pharmacies I worked with, none of them really want to get along with each other.
We had the medical insurance that would cover the device, but the pharmacy couldn’t bill the medical insurance. They could only bill the pharmacy benefits who were, for reasons I still don’t understand, giving the manufacturer the cold shoulder. The medical insurance had a preferred pharmacy, but the manufacturer didn’t supply their device to that pharmacy!
Between all of this was me, running notes back and forth to try to get these offices to cooperate. At some point, I started to feel like I was stuck in a maze. I’d call the medical insurance and they’d tell me “no” and I’d go “okay, dead end, let’s try that other path I saw a bit further back” and try calling somebody else. The theory here is that eventually you run out of dead ends and then you only have the right way left. I think my favorite dead end was when somebody questioned whether our patient actually existed because they’d somehow vanished from their system.
Hanging over all of this was, of course, the temptation to say, “I give up, I can’t do it, I’m sorry.” The person had told me that the other clinics they had tried weren’t able to get the device for them. Would there really have been any shame in saying, “same with us.“?
When I was ready to give up I pushed a little more and finally something gave. The pharmacy benefits approved the device. Yet just when I’d triumphantly faxed the approval off to the pharmacy, I was abruptly told on the phone by the pharmacist in no uncertain terms that they would absolutely not under any circumstances be able to supply the device to this person.
… And then a couple hours later, the person texted me and let me know the pharmacy said they’d shipped it and we would have it in a couple days. That’s life I guess.
I don’t know if the patient was right that no other clinic could do what we did. My feeling is that other clinics have entire billing departments that have been in this game way longer than me, plucky as I may be. But then again, maybe 18 calls is about 15 more than somebody might have in them if they’re overworked and crunched for time? I can’t know for sure.
All I know is I put in the work I would want my doctor’s office to do for me.
I guess my moral here is twofold:
- If you feel like you’re in a maze then keep looking for dead ends because you’ll eventually run out and then you’ll be stuck with the way forward.
- At DawnMD, I want you to feel that we care. Whether its wrestling with insurance on your behalf or something else, I really do mean it when I end an email with “let me know if there’s anything else I can do to help!”
I hope you’ve had a bit of fun with this peek behind the curtain at the sorts of things that go on in my world! Until next time, I hope you have a lovely day and take care.
Dr. Jones’ addendum: When you hear medical professionals complaining about paperwork and bureaucracy this is it at it’s best (ok, worst). This patient paid $3,000 in office charges and device fees the first time ‘round, which is why she sought out our services and why she was willing to wait out the process. This mess that Vivian spent HOURS on, is why no other office would do it. My time in this entire process (actual patient care) totalled about 40 minutes. It took my staff probably around 6 hours to obtain it (maybe more, I shudder to know the real amount of time). Overpriced pharmaceuticals and overpriced clinic fees related to massive overhead/staff burden - this is the crux of our modern US heatlhcare problem. Unless you have someone like Vivian on your side, you get burned. We charged this patient nothing beyond our standard memberhsip fees. It’s a sad commentary. What I hear in this post though is hope, persistence and compassion. This is the attitude of the young. This is the attitude we all start out with. This system is beating it out of us, but we STILL HAVE GREAT PEOPLE within it. That gives me hope as well.