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[IP] Darn Insurance Companies



I posted the following message the other day, but it got bounced for
some
reason.  Could you please post it for me?  Thanks, and Happy New Year.
-lee-

* * * * * * * *

(cross posted to Diabetes and Pumpers Ink lists)

This is a long post, but it's a slow season, so maybe you'll find the
time to read it.  This story should interest any diabetic who has had
to do battle with his or her health insurance provider to obtain
coverage for supplies.  It's especially of interest to those on
Medicare who have supplementary coverage, and most particularly to
ones who like myself use an insulin pump.

Every one of us, probably, has his own horror story about trying
unsuccessfully to reason with the bureaucratic intransigence of
health insurers in general.  My little tale illustrates the fact that
when you are faced with such an attitude, you should not cave in but
redouble your efforts and persevere.  Here's the story:

In May, 1997, I turned 65 and automatically went on Medicare.  It was
at the same moment that my CDE at the Joslin convinced me that I
should try an insulin pump.  Thanks to the efforts of the MiniMed
rep, I managed to get all the documentation in before the deadline
(my birthday) when my then-current insurance (HMO Blue) would end and
Medicare (which does not cover insulin pumps) would kick in.  HMO
Blue covered only $2,000 of the cost of the pump, but MM offered a
$900 discount, plus a five-year no-interest loan on the remaining
cost, so it wasn't impossible to bear.

When I went onto Medicare, I had to find a supplementary insurer and
chose Medex, another Blue Cross "product," opting for "Medex Gold,"
the highest-costing flavor, because it alone offered me a mail-order
pharmacy option.  (For those not in the know, the "mail-order
pharmacy option" typically allows you to order all your prescription
by mail, post-free, and you can get up to a 3-month supply of any Rx
for a single co-payment.  For HMO Blue, for example, I paid $10 for a
3-month supply of any single Rx; on Medex Gold, I now pay $15 - still
a good deal by any measurement.)

As soon as I could, I ordered supplies for my MM pump, sending in a
doctor's Rx and a check for $15 to Merck-Medco, the mail order
prescription-filler for BC/BS of Mass..  To my surprise, what I got
back was a 3-month supply of insulin syringes, but they also returned
the Rx to me, along with a note saying that the "tubing" (meaning
infusion sets) would not be covered.

Now this obviously didn't make any sense.  After all, what good to me
were the insulin reservoirs if I didn't also have the tubing that
transports the insulin from the pump into my body?  I asked this
question of Merck-Medco, and they referred me to Medex.  I called
Medex and they said to write them a letter.  I wrote a letter, and
they wrote back saying that of course I could have the tubing, but
since Medicare doesn't cover pumps or pump supplies, Medex would only
reimburse me 80% of the tubing costs.  (For me, using ten sets per
month, that would have come to about $25 per month.)  

The seeming inconsistency of covering the syringes but not the tubing
in their mail-order program, they explained, was in fact a mistake
due to a "coding error."  However, the letter went on, since they'd
already covered the syringes once, I could keep on ordering them from
Merck-Medco: "due to our error, we will not inconvenience you," they
said.  I could get the tubing through either a local pharmacy (try
that and see who carries it!), or through Diabetes Support System,
paying 20% of the total retail cost.

But it *is* an inconvenience, I said, in another letter.  "You have
no idea how hard it can be for a diabetic to keep track of his
supplies, especially if you're on a pump and have to get part of what
you need to keep in running from one (mail-order) source and the rest
from another (a retail pharmacy)."  If Medex can allow Merck-Medco to
supply the syringes, wouldn't it be simpler all round if they also
supplied me the tubing?  If I can get one, shouldn't I be able to get
the other?

In closing, I urged Medex to reexamine their policies and consider
opening up their coverage to insulin pump supplies, since they
already cover insulin, syringes, meters, and so on.  At the bottom of
the letter, I typed:

   "cc Mr. Jerry Condon, Mass. Division of Insurance"

(In the meantime, realizing that I was fighting an unequal battle
with a huge medical bureaucracy, I'd done a bit of digging (mainly
looking through the Mass. State Government listings for the word
"insurance") and, through a series of phone calls, established that
the state of Massachusetts, notably consumer-friendsly, does in fact
have an agency that heard consumer complaints and followed up on
them.  I called them up and got Jerry Condon.  Sure, he said.  All I
had to do was write a cover letter and send them copies of my
correspondence with Medex, and they would follow through.)

And it worked!  In late November I got a Ms. Flora Squillante, Senior
Insurance Compliance Analyst, saying that her office had heard from
Medex and my problem had been resolved.  With it came a letter from
BC/BS, setting forth the terms.  After reiterating all the garbage
about how Medicare doesn't cover pumps or supplies therefor, and how
Medex normally pays for 80%, it went on:

"We have made arrangements, however, for Mr. Lockwood to obtain his
necessary supplies through our mail order pharmacy, using the Prior
Authorization program.  The Prior Authorization program for Mr.
Lockwood's infusion sets is good for a one-year period.  Each year,
we will require an updated letter from Mr. Lockwood's physician for
the next year.  Etc., etc."

(Obviously, they are requiring a new letter every year just in case I
should stop being diabetic.  I understand.)

So, I now invite anyone on both Medicare and Medex Gold who is using
an insulin pump to join me in getting reimbursed, as we should, for
our supplies.  And anyone else who feels that this might serve as a
precedent he can use in his own struggle with an insurer, be my
guest.  I don't feel at all that I'm taking advantage of Blue Cross -
which pays its CEO several hundred thousands of dollars in salary,
and which almost went bankrupt due to mismanagement.  We pay good
money for our health insurance.  Anything we can get by way of
coverage, we deserve.

That's my credo.  And a very happy new year to all.

-lee-