I have been so lucky with my brother-in-law, L this past year. He has been pretty healthy for a guy with MS and relegated to a power wheel chair. The year before he was very sick off and on and required boat loads of my time. But this year, he has just been doing remarkably well, which led me into this complacent place of thinking all is well in the medical world….at least with L.
And actually, he’s fine–ish. But we are now in a push to get some testing and medical work done before the end of the year. And I just forgot how to do things, and how things would be done to me.
On Monday, L needs an ultrasound to check a worrisome kidney cyst. Okay, I set up the test at the correct hospital and the correct facility of the hospital. His Medicare insurance requires him to go to certain facilities. Sometimes the ordering physician knows that and sometimes he doesn’t. But after 10 years, I KNOW it and so I set up as many of these tests without their “help”, so we don’t have insurance issues in the future.
I make sure the test is between his breakfast and his dinner, because even though he’s gained at least 40 pounds in the last three years, he gets really cranky if he misses a meal. I get that….it’s part social, part his inalienable right, and part “I’m hungry!!”. Okay, no sweat.
I call the ambulance transport and set up transport to the facility and the eventual doctor’s appointment to discuss the results of the test. And I even make sure the blood work is scheduled to be done at his apartment as a “home draw”, which requires a request to the lab directly from the doctor’s office, because I am not PERMITTED to ask the lab to come to his apartment, since he is wheelchair bound and has no transportation….ONLY the doctor can do that. (who of course, doesn’t ever remember that and so must be reminded by me, and then the lab calls me to make sure they can come at a convenient time…UGH does this really make ANY SENSE TO ANYONE????)
And then I realize, three days later, and three days before the test. Oh crap, I didn’t get PRE-CERTIFICATION for the ambulance, which must be a gurney and not a wheel chair transport (which we will discuss another day) because he must be put on a table for an ultrasound and he cannot get out of the chair and onto a table by himself.
So…………….I call for the pre-certification:
“Hello, I’m calling for a pre-certification.” (This of course, after pushing 42 buttons and getting disconnected, and being asked at least four times: “are you calling for a pre-certification?)
“Okay, can I have the name of the member, his ID number, his date of birth, his first born.”.(okay they didn’t ask for that, but they might as well have)
And after I get it all squared away, I think…
“Now, you will have to have the ambulance transport company call us to request that.”
“Well, I’ve tried that before. First of all, they won’t do that. Second, in order to request this you need the prescription, the diagnosis code and the physician’s name, am I correct?”
“Well, yes, so that we can approve that it is medically necessary for him to have transport.”
“Well, the ambulance company does not have the prescription, I do. And furthermore, I wouldn’t give it to them, nor do they want all this medical information on my brother-in-law. Not to mention that I’m pretty sure it would violate like 100 kinds of HIPPA laws to be passing around his diagnosis and doctor names and medical test information, don’t ya’ think?”
“Umm, well………Can you hold for just a second?” the nice lady at the insurance company says to me (the mean lady trying to get ambulance transport for the hundredth time with the same argument for the past three years)
“Okay,” she says as she comes back on the line, “can you give me all of that prescription information?”
“Of course,” I say. NOW, I hope against hope that we are really almost there.
“Well,” she says, “that will do it!” Very bright and chipper I might add!
“Oh, no, no, no,” says the voice of experience, “I need an authorization number,” knowing full well that the ambulance company won’t transport without it.
“Well, okay, I can give that to you, but this has to go to our medical team to determine if it’s approved. You will get a confirmation in 2 to 3 days.”
“Okay,” I say, “just give me the number.”
Because I know their dirty little secret. They will approve this BY MAIL in a week, if I’m lucky. But I will not cancel the test, because they will put on their approval that the transport is approved for the day of the test, effectively making it retroactive. But if I wait for pre-approval, I will magically have to know when the approval will come in to schedule the test since they only approve a specific date. Don’t overthink it. It’s complicated and stupid. I’ve played this game so many times, I just know how to do it. Trust me.
You just have to Laugh……………………..
Cathy Sikorski
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