Fed Up

Angelina has been on the Dexcom CGM since January 2014.  For anyone that’s counting that’s 15 months.  Two receivers, 3 transmitters, and 18 boxes of sensors.  For every single one of these orders our medical supply company does not ship them to us until they have received authorization from the IPA (Defined as “An independent group of physicians and other health-care providers that are under contract to provide services to members of different HMOs, as well as other insurance plans, usually at a fixed fee per patient.”) that reviews these kinds of claims that are then billed to our insurance company.  The IPA reviews the medical necessity of the device or service requested to determine if it meets the HMOs pre-determined guidelines.  Angelina’s Dexcom has been categorized and authorized as medically necessary since the first shipment (because otherwise we never would have had it shipped to us).

There is only one medical supply company that we are allowed to go through for it to be paid for by our insurance, which we have done since the first order – despite my better judgment and overwhelming frustration with the medical supply company.  Despite this, every single order for Dexcom supplies is initially a denied claim when submitted to the insurance company.  Every claim says “You do not have to pay this unless you signed a written agreement with your provider to pay it. Your plan does not cover charges for, or related to, services or supplies that we find to be experimental or investigational.”

And every claim I send a message saying “This was authorized on XX/XX/XXXX by XXXXX IPA” and attach a copy of the authorization form with dates and relevant claim information.  And every time within about a week the claim is then paid.  In the beginning I used to actually make a phone call and go “This claim was denied. I don’t know why this was denied. What can be done?”  And almost every single time the member services representative would say “I see where this was paid on XX/XX/XXXX  and I see the medical necessity documentation in our system. I’m not sure why this wasn’t approved. I will send it back to claims with a note.  This shouldn’t happen again.”   It was after about the third phone call like this that I realized that whoever is working in the claims department just must not be looking at Angelina’s file at ALL and is just denying the claims right off just to make sure we’re paying attention and hoping we will not appeal/dispute the claim denial and they won’t have to pay it.

For the past several months I have sent a fairly standard, concise, polite dispute email that isimply says “Please see attached authorization from from XXXXXX IPA authorized on XX/XX/XXXX for 90 days, ending XX/XX/XXXX for item #AXXXX.   Today, however, I got an email from our insurance company that says “View your recent claim” and has an fairly innocuous “You have a new claim! Click here to review your claim on our secure web portal” as well as other standard stuff about the insurance company, privacy policy, security, etc.

So, I click. And it takes me to the Explanation of Benefits that tells me our recent transmitter order/claim has been denied because “You do not have to pay this unless you signed a written agreement with your provider  to pay it. Your plan does not cover charges for, or related to, services or supplies that we find to be experimental or investigational.”

Mind you that we had an authorization dated JANUARY 27, 2015 that authorized transmitter, receiver, and sensors for a three month period, expiring APRIL 27, 2015 (that’s tomorrow, in case you didn’t know). We got a new receiver the beginning of February. I sent them this authorization form.  The beginning of March we got an order of sensors. Denied. I sent them the SAME scanned copy of the SAME authorization form.  Today’s denied claim email was for a transmitter that was ordered the end of March, two months into that three month authorization.  I sort of snapped a little.

This was the not so concise, polite, or to the point message I sent them today in response to the claim:

“This is the THIRD claim that has been denied, even though I have provided the same attached authorization for these items from XXXXX IPA. Medical necessity has been WELL established, as I’ve explained and provided documentation for every claim for the past 15 months that my child has been on the Dexcom Continuous Glucose Monitor System and still each and every claim continues to be denied until I send this member services communication and supply (AGAIN) the authorization letters, at which point they are reviewed and approved. I am beyond frustrated with having to appeal every single claim when all of the information has been provided repeatedly already and it seems that someone in the claims department is just checking to make sure we are paying attention to whether or not claims get paid.
When my daughter started on this life-saving medical device we were informed that we had to go through XXXXX Medical Supply as our ONLY option for this device. We have continued to order through this incredibly inefficient and disorganized medical supply company who can never seem to get a single order fulfilled correctly or in a timely manner because they are the only company contracted with [insurance company] and otherwise our claims would not be paid at all. So it is further infuriating that despite using this contracted company that the claims continue to be denied every single time.

Every time I’ve called regarding this same matter I have been apologized to and told that there is in fact medical necessity information in the system and the representative has no idea why the claim was not approved and assured that it shouldn’t be happening. So beyond requesting that this specific claim be reviewed and approved, as per the attached authorization, I would also like to request that future claims for this same medical device actually be reviewed along with my daughter’s likely extensive medical necessity documentation and be approved the first time, as they should be.

Yours,

Jessica Lastname – an incredibly sleep deprived, stressed out mother of a child living with a life-threatening chronic illness”

Now I just hold my breath and wait and hope that our insurance doesn’t mysteriously get cancelled. I do momentarily feel much less stressed out though. That is something I have wanted to say for the past year, at least.

Just For Funsies.

1. Four names people call me other than my real name: 

Mom, Honey, Jess, Jesser (Thanks, Mom.)

2. Four jobs I’ve had: 

Pancreas, Pharmacy Tech, Cashier, Nanny

3. Four movies I’ve watched more than once: 

Eurotrip, The Girl Next Door, LOTR Trilogy, Twilight Saga

4. Four books I’d recommend:

The entire “In Death” series by J.D. Robb, Any book by Nora Roberts (Nora Roberts and J.D. Robb are really the same person, but I just love her writing so she gets two mentions), Think Like A Pancreas by Gary Scheiner, and  The Dusk Gate Chronicles by Breeana Puttroff

5. Four places I’ve lived: 

Kansas, Florida, California

6. Four places I’ve visited: 

New York City; Niagara Falls, Ontario, Canada; Savannah, Georgia; San Francisco, California

7. Four foods I prefer to not eat:

Liver, most fish, custard/Flan or anything with a similar squishy texture, any thing that has a texture of soggy bread

8. Four of my favorite foods:

Asparagus, Mashed Potatoes, Pasta, Curry Chicken

9. Four TV shows I watch: 

Grey’s Anatomy, Grimm, Supernatural, Bones

10. Four things I’m looking forward to: 

JDRF Type One Nation Summit, My 12th wedding anniversary on March 15th, A cure for type one diabetes, Christmas

11. Four things I am always saying:

What does the Dexcom say?, I’m so tired, Can you please stop talking for one minute?, Why don’t you ever talk to me?

This fun post brought to you by Bigfoot.

Take A Deep Breath and Count to 10

Back in December one of my favorite D-moms posted an article about diabetes and depression in children.  It is an anonymous D-mom’s story about her 11-year-old son suffering from depression and ultimately ending up in a psychiatric hospital for stabilization.  The story touched me in many ways, at first because I have a child who is 11.  Second, because I’ve personally had the experience of spending some time in a psychiatric hospital for severe depression.   The story made me feel very deeply for this family because it was hard to imagine watching my own child go through this same sort of downward spiral and not fully realizing exactly how deep that spiral had gone.  And then having the added fear of not only hearing your child say they want to end their own life, but then also trying to make arrangements for them to be safe, when everyone you talk to at the facility they are going to doesn’t understand or know how to manage their diabetes.  And because your child is depressed and suicidal they can’t manage their own care because, in case you didn’t realize it, too much insulin can be a deadly.  Lack of insulin can be deadly. Having suicidal thoughts and not getting proper treatment can be deadly.  I don’t want to even think about how helpless that mom must have felt having to make those arrangements.

A few weeks before this article I had been growing increasingly concerned about Angelina’s mental health.  Her therapist had also expressed some concern about her moods and was concerned about depression.  She had become more withdrawn in her therapy sessions and about every third session she wouldn’t speak at all, but sit and sulk.  At the beginning of January we met with her psychiatrist (who prescribed medications for her ADHD) and I had briefly mentioned we were concerned about depression and requested that she reach out to the therapist. I signed a release form and hoped that the therapist would be able to explain better than I was what was going on.  The psychiatrist seemed unaffected and said that mood swings were common at this stage.  We discussed how her current ADHD medication didn’t seem to be working well for her anymore and she prescribed a new one to try.  She suggested that we keep an eye on things and follow-up next month.

Things continued this way at therapy for the month of January.  The first week of February we met with the psychiatrist again and again I expressed concern about depression, as well as the therapist’s concern about depression.  She seemed to take things a little more seriously this time, but we still mainly focused on how things were going with the new ADHD medication and general talking points “How’s school?” Fine. “How are your grades?” I don’t know. “Are you hanging out with any friends?” No, I don’t really have any friends.   Those were about the only words muttered by Angelina in our 25 minute visit before she sort of curled up on the end of the sofa and started at the floor.  Any further attempts to engage her were met with stony silence.  At 20 minutes into the appointment, after nearly 3 minutes of no one saying anything the therapist says “We’ll follow-up in a month.  If she’s having more bad days than good we can possibly discuss medication.”  and we scheduled our next appointment and left.

That brings us to the past month. There are still more good days than bad, but there are more of those days where one minute things are fine and the next minute her entire attitude, mood and disposition change and she is sullen and completely withdrawn and refuses to speak or interact. About 3 weeks ago Angelina’s therapist asked me back to talk alone for a few minutes, and I ended up talking to her the entire session time while Angelina sat in the waiting room.  We discussed the possibility of antidepressants and her response was “I’m a therapist.  I don’t automatically jump to medication to try to help people.  But I’ve been seeing Angelina for a year and a half and in the past few months she talks to me less and less and I’m at the point that I don’t know what to do or how to reach her.  I can’t help her if she doesn’t talk to me. It’s obviously your decision, but at this point I think medication might be a good idea.”  About a week after our last visit with the psychiatrist I mentioned to my husband that we had discussed medication for depression.  I was a bit surprised when his response was “No. She’s already on enough medications. I don’t think that’s necessary.  A lot of kids this age deal with depression.  She doesn’t need to be medicated.”  And for the past few weeks we’ve dug up this discussion a few times, always meeting at a stalemate.  We were finally able to reach an agreement yesterday.

Today Angelina saw her psychiatrist and tomorrow she sees her therapist and will start taking an antidepressant.