As an update to my previous blog, IBX (http://www.ibx.com/index.jsp) as of 8/1/2014 STILL had yet to correct the errors aforementioned and therefore subscribers STILL do not have their ID cards. Therefore, there are bound to be ongoing problems with access to care, leading to canceled appointments and needless delay in healthcare all because an insurance company has an internal glitch that they don’t seem to be in that much of a hurry to fix. I received a call from someone in their problem resolution department after it was erroneously determined (from reading my initial blog entry) that as a provider I was having some issue with billing. That shows you how much they must have actually ready of my posting. I explained the actual situation and demanded that IBX offer a public apology from their CEO and also that they reimburse on a prorated basis every business affected by their error. Since that time, despite asking for a follow up call, I have received no further contacts. Not surprising, considering the source. I understand that any business is entitled to earn money. That’s what makes our country the proverbial “land of opportunity.” Opportunists, in fact, exist at every level of existence. For instances, there are opportunistic infections and parasitic infections to which we may fall prey, depending on health and physical condition. Insurance companies are like those very same opportunistic infections. Our best approach and treatment for this illness is prevention. Do it at the ballot box, write your representatives, Congress, etc. Start your own blog. Send complaints to the state insurance commissioner (http://www.portal.state.pa.us/portal/server.pt/community/file_a_complaint/9258) every time you have a bad outcome because of a health insurance company. Be an active agent of change.

Prior authorization nightmare

On July 8, 2014, I received a request for prior authorization for a patient’s prescription for Nuvigil (http://www.fda.gov/downloads/Drugs/DrugSafety/UCM231717.pdf), which is a wakefulness promoting drug used in conditions such as obstructive sleep apnea (http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/). My patient’s insurance is through Independence Blue Cross of Philadelphia (http://www.ibx.com/index.jsp). Usually, prior authorizations are processed by Future Scripts (https://www.futurescripts.com/FutureScripts/). On July 17, having not heard anything, I resubmitted, but again heard nothing from Future Scripts. During this time my patient, who was without Nuvigil, was also calling the insurance company. It was not made clear till July 21 that the company Restat (http://www.restat.com/contact/) was responsible for the prior authorizations. A representative from Restat called me to get my fax number, which I readily provided. I completed the form, faxed it, heard nothing by July 24, at which point I sent it again. I still heard nothing until 7/29, when I was contacted by Restat stating that “more information was needed” and they had not received that information from me. When I inquired what that information was and told the representative that I had twice faxed the form that his company had actually sent to me, he responded that they were trying to fax me but the fax was not going through so he was trying to clarify my fax number. Now, I had already received a fax successfully from Restat with what was presumably a request for ALL the required information. And yet, I was being told I had not provided all the required information, though the attempt to request it from me had been unsuccessful as well. Confused yet? Angry? Feel frustrated?

I explained the entire situation to the representative, expressing my concern that the patient had been without medication for the better part of the month as well as my anger and frustration that his company had now caused this patient harm. I told him that to wait 8 days for any attempt at resolution was inexcusable and unconscionable. He defended the company by telling me that they had a lot of requests to process when I asked why it had taken 5 more days after the receipt of my second fax to even respond to me. He listened till I was finished, then again politely requested my fax number, as if anything I had just said I might as well not have. There was no offer to get a supervisor for me nor any assurance that things would be corrected quickly. I hung up, as I had to begin my afternoon hours and could not wait the interminable period of time it would have taken had I requested a supervisor. I called my patient and left a message to file a grievance with the state insurance commissioner (http://www.portal.state.pa.us/portal/server.pt/community/file_a_complaint/9258). I was hoping Restat would overcome whatever internal incompetence had arisen so that they could request whatever information was possibly missing, though the form I had initially filled out contained as much data as is ever needed for prior authorizations. I had even included the sleep study report to prove the existence of sleep apnea in this patient. Though this story ends well – there never was a need for more information, and the prior authorization approval was faxed to me a short time later – it underscores again how insurance companies are playing a very active role in patient care without carrying any of the responsibility that comes along with being a doctor or other health care provider. As I asked in an earlier blog entry, who is monitoring these insurance companies? Why are they allowed to take 8 days to process a prior authorization claim (not all do, some respond to me within the day, though not always with an approval))? I urge all my readers to complain to your state insurance commissioner whenever there is a bad or even questionable outcome with your insurance company. Write to your representative and/or Congress to complain about the insurance industry and their protection under ERISA (http://www.dol.gov/dol/topic/health-plans/erisa.htm). That is the only way we can expect change for the better – get involved.

July 11, 2014
ERROR CODE – IBX HAS A NEW OPERATING SYSTEM
On July 1, 2014 Independence Blue Cross in Philadelphia () began utilization of its new operating system. Unlike the smooth operations of their other forms of utilization – utilization management, that is (retrospective case reviews prompting denials of care/payment, prior authorization policies), they are experiencing major glitches with the new operating system. ID cards, which should have been in the hands of EVERY member, are still not available. One local business affected by this learned earlier this week that IBX incorrectly loaded data files resulting in individual subscribers having their medical and/or prescription coverage incorrectly reflected in IBX’s system. Consequently, when providers check coverage status, the error makes its impact by hindering access to services that are seemingly not covered for that individual. Contacting the IBX help desk (1-800-ASK-BLUE) does not help, as operators were telling subscribers that “the employer” made the changes. That was apparently supposed to be corrected, as IBX had already admitted their error, but it should not be surprising that an insurance company would allow that to happen. When that particular business contacted IBX about this repeatedly, they were ultimately promised that the error would be corrected by the end of the business day on July 9. As of yesterday morning, July 10, the problem was still not resolved. Further contact lead to a promise that the problem would be fixed by this morning (July 11). As of this writing, there is no further news.

On November 8, 2013 IBX posted online a FAQ document titled Transition to New Operating Platform . So why, in July 2014, is IBX still not ready? Health care does not simply get paused like a You Tube video to wait for a company that has been woefully inadequate and inept with respect to their customer service. If you have any of IBX’s products and you have to seek health care, keep your fingers crossed that access to care is not denied. I urge all who read this article and are affected by this to begin complaining immediately to IBX. Ask your employers to complain and to keep complaining, every day, both online and by phone, or in person if you live close enough to their Philadelphia headquarters. There are simply NO EXCUSES for this. If you purchase a car with a navigation system, do you have to wait for the GPS company to upgrade before the system will give you your directions? No. This reminds me of the mid-1990’s when the internet was fairly new to the American public and those who used America Online (AOL) would have their internet experience periodically interrupted while AOL “updated its art work.” Remember those days? Sometimes, service would be interrupted and then one would have to undergo the tedious process of logging back on through whatever dial-up service was available. But this is 2014. Do you think IBX’s executive would tolerate ANY delay in the payment of premiums and other fees? Of course not. No pay, no insurance. Your benefits would be suspended. Does IBX, or any insurance company, for that matter, tolerate a provider’s coding error, for instance? No. Reimbursement is withheld, and explanations for why will vary depending upon who answers the phone when the provider’s office calls. So what is IBX’s consequence?

Who is holding insurance companies accountable? Why is this allowed to happen and all any of us can do is wait till they fix their error? Why was this not foreseen last November when they published their FAQ’s? Why has there not been a very public apology from IBX’s CEO to any and all subscribers and businesses affected by their ineptitude? How refreshing would that be if there was a public service announcement from IBX chief executive officer, Daniel J. Hilferty. After all, he did just earn the 2014 Southeastern Pennsylvania (SEPA) Citizen of the Year Award from American Red Cross (click here to learn more) for his support of the Red Cross and advocacy for philanthropy (click here to learn more). But that would be too much to expect. It’s very nice he supports the Red Cross. I just wish that the philosophy and values that underscore his philanthropy would pervade the corporate operations and help to establish a stronger commitment to the discipline of customer service. Back in the 1960’s, it took one person to go up against a large company after a major problem had occurred and things began to change. The Chevy Corvair, with all its problems, led Ralph Nader in 1965 to write the groundbreaking book Unsafe at Any Speed in which he chronicled unsafe practices in the auto industry. (click here to learn more). The Corvair existed from 1961-1974, but Nader’s book forced change to occur. GM harassed him and tried to intimidate him, but in 1966 then GM President James Roche was forced to appear before a US Senate subcommittee to apologize to Nader. So in answer to the question that opened this paragraph, WE are going to have to be the ones to hold insurers accountable. And unlike the 1960’s, or even the 1990’s, we don’t have to write a book to get noticed. Social media, when used properly, is a powerful tool. Go to IBX’s Facebook page and register your displeasure whenever there is some negative outcome attributed to their actions, such as not getting ID cards out in time because of a “glitch” or denial of a medical service or a medication (ibx.com/facebook). Also, call them out on Twitter at @ibx.

Hopefully, by the time you’ve read this the problem will have been corrected. And hopefully, there will have been no serious consequences. But I truly hope that reading my blog will spark you to take action whenever you don’t like the outcome your insurance company has delivered. Every person counts, every voice needs to be heard. Silence represents hopelessness, or worse, apathy and tacit approval.

Many people have difficulty affording medications. This is often the case even for those who DO have health insurance. Sometimes, it is a case of people needing to take numerous medications for various illnesses and those copays can add up in a hurry. Other times, it is simply a matter of being unable to afford the copay because of financial hardship.  It’s important for people to know, however, that there are resources available that may not readily be general knowledge. Some people may have doctors who are aware of these resources, as I am, but many doctors may not be aware or don’t have the time to find these resources. I always encourage patients to join the process of advocating for themselves.  One very important website is Needy Meds, an organization whose website is a clearinghouse of links to other websites, including drug company patient assistance sites, sites to purchase generic medications at a greatly reduced cost, as well as links to national and state level assistance foundations and other resources based on illness.  There are also links to programs to help pay for MRI & CT scans as well as camps, retreats and scholarships at this website. Browse their website at http://www.needymeds.org/. There are links to download various patient assistance forms that patients can either e-mail, fax or download and print out to bring to their doctors.  It’s also important to know that most pharmaceutical companies have patient assistance programs that allow a patient access to brand name medications at no cost. In most cases this is the case ONLY if a patient does not have insurance.  Also remember that doctor’s offices often have sample medications, but before taking one that may be very expensive and often not allowed by your insurance without prior authorization you should ask your doctor about the supply and the cost if the drug cannot be covered by insurance. It would be problematic to start a medication with a 3-4 week supply (often enough in many cases with antidepressants, for example, to establish that it is effective) only to find out it won’t be affordable or available once prescriptions are sent to your pharmacy.

For those of you who live in the southern Chester County area of Pennsylvania, also know that there is an excellent clinic in West Chester that provides free or steeply discounted medical and dental services for those without insurance – Community Volunteers in Medicine (610-836-5990). Visit their website at: http://www.cvim.org/. There are clinics like this all across the country. Local hospital residency programs also run low cost clinics staffed by residents who are under the supervision of attending physicians and are often a place to receive excellent, often cutting edge care.

When a person is ill, whether it is a mental illness or a different medical illness, one of the most important things a person needs is hope – hope that care will be accessible AND affordable. It’s a shame that insurance may guarantee the former but not the latter, because without the latter things can become downright discouraging and/or demoralizing very quickly. Using resources like these and others that you might find is a way to become more empowered in your own health care. Remember, your care should be a partnership between you and your doctor. If your doctor is not aware of these resources, tell him or her. It’s your chance to educate your doctor as part of an ongoing relationship in which you should always be an equal partner.

How many of you have been to your pharmacy to pick up a prescription, only to be told, “We cannot fill that because your insurance company requires prior authorization.”? You went to your doctor, you got your prescription, you go to the pharmacy, and it should be a simple matter of paying your copay and that’s it, right? Unfortunately, insurance companies have become increasingly intrusive in this particular practice of denial of care. And why? If you ask the insurance company, you’ll get canned answers, such as “that is what your plan allows,” or “you should talk to your employer about a change in your benefits.” They’ll never admit the real reason is cost containment, so even though they are involved in the clinical decision making process, they hide behind administrative double talk and escape culpability. While it is true that medications are costly and drug companies spend a huge portion of their budget for any given drug on marketing and sales, it is still unconscionable that an insurance company can deny your care because they need to produce a positive result for their stockholders. Take a look at what their upper level administrators and executives earn. Often, they earn as much or in some cases more than some of the highest paid athletes. It’s hard to believe with that kind of astronomical revenue there cannot be some sort of trickle down effect to make care more affordable. And before you think that the court of law may be a place to air these grievances, consider this:

ERISA, the Employee Retirement Income Security Act of 1974, is a federal law that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries. Unfortunately, insurance companies saw an excellent opportunity to use loopholes present in the act to immunize themselves from legal liability in medical malpractice. Deny an admission for a suicidal patient and that patient is discharged and commits suicide? The doctor and the hospital have all the liability. Determine a treatment to be “experimental” and the patient dies or significantly worsens? Too bad, it’s on the doctor and/or hospital to come up with a better solution.  Every day doctors have had to wrestle with their own set of medical and personal ethics each time a potentially expensive decision had to be made. And I would like to believe, and indeed I think statistics would back me up, that most doctors would ‘err’ on the side of patient safety and health no matter what the cost. So who pays for all of that? Not the insurance companies. We do.

There exists a whole cottage industry of prescription benefit management companies that may be independent from or subsidiaries of insurance companies. These entities are truly an industry that, while certainly providing jobs for many, offer no actual service or product to the country. Their sole existence is focused on saving money for insurance companies. Doctors have often gone to work for these companies with the hope they might be able to promote positive change from within, but in most cases they end up as gatekeepers too and if they allow too many non-formulary agents, they might see themselves out of a job. Doctors and their staff spend hours of unreimbursed time fighting to get medications approved and they have to justify almost every decision to someone who, in all likelihood, has far less training and may very well be reading from some closely guarded algorithm sheet when determining whether or not a medication can then be approved. Often, even after successful completion of the forms, the company will then place a follow up call for “clarification,” which is a relatively newer phenomenon. And this call, if unanswered or not responded to in some timely fashion, may hold up the prescription further and is typically made seeking to verify what’s already been stated. It took me 8 weeks and a whole lot of digging around online to find people in authority who I then called before I got a disabled patient’s medication for restless legs approved. Eight weeks! Eight weeks! In the past I worked as the medical director of an outpatient day program and had to do what is called a “doctor-to-doctor” review because apparently there were questions about why the patient still needed treatment. The doctor doing the review with me made a suggestion to add some other medication that the I felt was not appropriate. After I thanked the reviewer but said I was not implementing the suggestion, the other doctor subtracted one of the newly re-authorized days. When I asked why, and I quote verbatim here, he answered “because I felt like it.” Because he felt like it.

In my practice, I maintain a well organized database of prior authorization forms for all of the insurance companies I encounter. In many cases, the insurers will not make these forms readily available, as it seems that they want to send me their form at the time of the request for prior authorization. Searching their websites is often an adventure I’d rather not have, as the forms are often either unavailable or difficult to find. If I know a medication is going to be a problem, I will fax the requisite form in before my patient even gets to the pharmacy and I always warn patients when I think there is going to be an issue. I often suggest that if my patients are unhappy with an insurer’s decision they submit a grievance to their state’s insurance commission. Here are the links for patients who may be under my care or live in the general vicinity:

Pennsylvania: http://www.portal.state.pa.us/portal/server.pt/community/file_a_complaint/9258
Delaware: http://www.delawareinsurance.gov/services/filecomplaint.shtml
Maryland: http://www.mdinsurance.state.md.us/sa/consumer/file-a-complaint.html
New Jersey: http://www.state.nj.us/dobi/consumer.htm

Many times, with the proper form, the process, while an unwanted addition to patient care, is seamless. In about 25-30% of the cases, though, there is a glitch of some sort. There is always an appeal process, but what I have been doing and have found more effective is traveling the e-mail and phone chain till I get a hold of a medical director. It never pays to engage in a hostile fashion, so usually I approach this on a friendly basis and have been pleasantly surprised at times that the person on the other end of the call is willing to help. In one recent case he admitted that his company’s process was flawed (the process of getting this one person’s medication approved was monumentally tedious and frustrating but it got done). He agreed to set in motion changes to streamline their process as a result of this call. I feel it is important for people to be educated about this part of health care so as to be able to engage doctors in meaningful dialogue about it and be able to participate in the process when and where it is possible.

SPECIALIZING IN: Adult Psychiatry, Psychiatric Evaluation Medication Management, Individual & Marital Psychotherapy

Dr. Daniel Block is a Compassionate Psychiatrist and Staunch Patient Advocate who has been in private practice since 1993.