About This Blog

As time permits, in-depth musings on myriad subjects will be posted. Abbreviated adages will be announced via Twitter.

Tuesday, July 12, 2016

Like a Monkey at an Event Horizon

PBS offers this great series of short talks on space & science called Space Time. One of these talks involves black holes and whether or not events inside of them actually happen and gives a phenomenal demonstration involving a monkey and My Little Pony, in which the monkey is perpetually trapped at the event horizon (edge) of the black hole with My Little Pony observing.

For several weeks, now, we have been that monkey, seemingly trapped at the event horizon, where the black hole is the vast, apparent nothingness that is healthcare—health insurance, in particular.

Until now, United Healthcare (UHC) has provided stellar health insurance for our family with minimal impact and cost to us. But, now, when we really need it (for approval of a Tier IV [re: stupid expensive] medication to put Nicholle's MS back in check), UHC is failing us. Badly. To the point where the physical, mental, emotional, and (potentially) financial health of this family is in peril.

When the previous medications were determined to no longer be effective for Nicholle, her doctor prescribed Lemtrada, a near-miracle disease-modifying therapy (DMT) that—while not outright curing patients of MS—has fast-tracked many to living as close to "normal" of a life as they can with minimal symptoms.The infusion center that is part of her doctor's office filed what should have been the necessary paperwork for insurance approval and what-have-you. There was a lot of what-have-you.

Not including Nicholle, there were four (4) parties involved:

  1. Doctor's office/infusion center
  2. Insurance company (UHC)
  3. Specialty pharmacy (assigned by UHC; BriovaRX, in this case)
  4. A liaison between the drug maker (Genzyme) and Nicholle (MS One to One)
Somehow, somewhere, the ball got dropped in that pharmacy approval for the medication through UHC was denied due to benefit exclusion (her employer did not include this particular drug for coverage through UHC) and a medical approval option has put the doctor's office in its own orbit around the same black hole.

Because the stress was having a tremendously stressful impact on Nicholle (and stress isn't good for MS—to say nothing of the fact that Nicholle has work to do), I got involved in an effort to learn where the ball got dropped.

A call with UHC member services pointed back to the doctor's office; a seemingly simple phone call for the medical appeal was all that was purported to be needed to get the medical approval greenlighted. UHC even tried calling the office while I was on hold to get said greenlight to no avail. So, I called the doctor's office. (I also called MS One to One and spoke to our rep. Both she—and the MS One to One program appear to be wholly useless existing as a superficial security blanket that "someone is on our side" to advocate for us and keep us covered. The only thing I feel covered in after the conversation with them is excrement.)

After several minutes of sometimes heated, sometimes emotional discussion with the infusion center nurse who handles insurance stuff (for lack of a better term; these events have left me drained on every level, save rage), it was asked what it would take to make me happy at the moment, to which I responded: A conference call.

For whatever reason, the phone systems at the doctor's office cannot handle conference calls, so it was the handy iPhone 5s to the rescue that got me and the nurse connected to the doctor's backdoor channels to UHC.

Oh. My. God.

After several minutes navigating the infinite loop of UHC's automated system, we finally reached a rep who who was about as useful as an umbrella in a hurricane—even less-so than our MS One to One rep. The new UHC rep pulled up an authorization request that was denied at midnight.. Fifteen hours before the current call to UHC was placed and eight or so hours before the authorization request was even submitted to UHC. Now that's efficiency.

The nurse at the infusion center was told she could submit a peer-to-peer review appeal for the denied request (which she had attempted previously; denied requests cannot be appealed), and the call reference number provided by the rep was not inline with bona fide reference numbers provided to this nurse multiple times a day for other calls for other patients. Patients who have had no difficulty in getting approved for their medication. From UHC.

What would it take to make all of this better? Well, a genuine cure for MS would be phenomenal, though not at all likely right now. Getting Nicholle greenlighted for insurance or other financial coverage (and the drug in her system to do its thing ASAP) would be the next best thing, for we are fast-running out of time for not only alleviating her symptoms but also ensuring I can be by her side should she need me. (Because teachers have summers off, you know.)

This was long. And rambling. But so has been the black hole-like experience in which we've been trapped since sometime in early June. And we're tired of monkeying around with this whole process.

Thanks for reading.