I have had the occasional patient wonder why they had not been called back in “x” amount of time.  The end of day Friday seemed to offer a good illustration.  We have a patient in a facility receiving extra treatment who is on No More Spots for a condition.  The NMS is extremely expensive and as such has to go through prior approvals and a third party research before the patient is allowed to receive it.  Understand that these are like bank loan applications.  We have the “fun” of filling them out and getting them to the appropriate location.  Back to the subject at hand.  The medication was prescribed to be given at home, and as the patient was receiving facility care at time of refill, the pharmacy didn’t want to send NMS.  I was told the patient called and was informed that the facility was going to have to provide the medicine.  That would never happen.  NMS is not available from your regular pharmacy.  I decided to tackle this Friday afternoon.  Per the information given, I called the insurance company and after 20 minutes two different times and being transferred to at least 4 different departments and then back to the first one that wasn’t able to help, I finally threw in the  towel and decided to try the pharmacy.  I was transferred between another 3 departments and the pharmacist before receiving the word that they needed approval from insurance to send the prescription.  Sigh.  This time, I looked on the account and called the number on the scanned insurance card.  I finally received an agent who would not say if there was coverage of NMS while the patient was in facility, but did provide the number for the pharmacy insurance coverage office.

I called that number next and verified that the patient did indeed have a prior authorization which covered NMS through the next couple of years.  They gave me a number for the pharmacy help desk in case the pharmacy needed assistance in filing the claim.  With this new knowledge I called back the pharmacy and was given to another office that instructed that they needed to know what insurance the patient had, or if they were paying for the facility stay by cash.  I stated that the patient had insurance and they said that it was an issue of double billing the medication.  Bink. Blink.  It’s a specialty medication that isn’t available anywhere else.  How could that be double billed?  I was passed to another agent.  This one stated they needed to have the facility director sign off on a particular form and once that was processed, they would send the prescription.  I said that was fine, let’s get this form over here.  Some information was presented, and then I was informed that their department dealing with this form had gone home  for the weekend and we would hear from them on Monday.  It was now a good bit after 5 on a Friday.

I told the doctor what had transpired, and that I was just pushing the ball up the hill.  The doctor noted the reference to Sisyphus and stated so. I later was thinking on the subject and decided the Sisyphus was cursed to push the ball, we could just call it job security.

As for the work list, this effort to obtain one form to get medication for one patient took me well over an hour and a quarter.  So when you are wondering why the nurse hasn’t answered yet, and notes they’re busy, understand we aren’t playing Solitaire.  We are playing “Press Number 3” with a computer at the insurance company.

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