Government v. Business, revisited

When conservatives say that government should be run more like a business, I hope to God they’re not referring to the insurance business.

Let me start by saying, the facts of the case I’m about to explain are mostly undisputed. The involved parties are: me, my wife, my daughter’s doctor, my daughter’s specialist, our insurance company, and our pharmacist. Here are the pertinent, undisputed facts:

1. My daughter has been correctly diagnosed with a condition that generally responds to medication.
2. This condition should be treated.
3. There is a relatively new medication that sometimes works when other’s do not.
4. This medication is not normally covered by insurance, unless the other alternatives have been tried first.
5. My daughter has taken all of the available, relatively cheap, alternative medications; which did not work.
6. My daughter’s doctor has submitted the correct documentation in order for insurance to approve the medication.
7. My daughter’s doctor wrote the prescription one month ago, and we attempted to get it filled immediately.
8. Our pharmacy is in possession of a properly completed, hand written prescription from our daughter’s physician.
9. Insurance has approved the prescription.
10. We have attempted to pick up the prescription more than once, AFTER insurance “approved” the prescription.
11. We still have not been able to actually purchase the medication.

That last one bears repeating: we still have not been able to purchase the medication. Why on earth not? Now we get into the disputed facts:

1. Insurance claimed that Beth’s doctor did not send them anything on a timely basis. In fact, Beth’s doctor provided us with FOUR fax transmittal receipts, showing they did submit the documents on four different occasions – to the fax number provided by the insurance company. The first fax was less than one week after the doctor wrote the original prescription (immediately after we learned it would be necessary – based on my hunch, that insurance would not cover the script without some extra effort). The last fax was found right after Cheryl lost her temper with the unsuspecting insurance customer service rep. I find it amazing that force of will can affect the physical world in such a manner. I was taught in high school that matter could be neither created nor destroyed – but apparently it can be teleported with sufficient emotion.

“Nope, we still haven’t received it.” **ANGRY RESPONSE CENSORED** “Oh, here it is.”

2. The pharmacy did not submit the insurance claim correctly. In fact, in a rare display of dedication from a low wage, pharmacy tech, this author watched the pharmacy call the insurance company on two separate occasions – so that the insurance company could walk them through the process to make sure it was submitted correctly.
3. Beth’s doctor is not authorized to write prescriptions that are covered by our insurance company. In fact, we got prior approval to see the doctor – which we verified with our insurance company on the morning of our appointment. Further, insurance had approved two prior prescriptions written by this same doctor (less than three months ago). And finally, I called them on my cell phone from the pharmacy lobby – and they assured me the prescription had been approved. Why would they tell me the prescription was approved on the phone – as written by this doctor, and then deny it when the pharmacy submits the claim? How, in the name of all that is holy and good in this world, can my daughter’s prescription be approved by the insurance company, but the pharmacy claim be denied? Is it approved or not? It seems to be a black and white issue, a boolean variable, one or the other, MAKE A DAMN DECISION AND STICK WITH IT, #@$ !@%& *&!!

Here’s the score, as it stands today: one month, 25 phone calls, two trips to the pharmacy, two hours in the pharmacy lobby, 60 cellular minutes (30 of those cellular minutes spent in said lobby – the other 30 spent long distance from New Hampshire), zero prescriptions filled, AND TWO IRRITATED PARENTS.

I am pleased to announce that this month is the benefits open enrollment period for state employees. We have until October 15 to make a change to our chosen health insurance provider.