Sep 27, 2013 1 Share

Managing Meds

Pills with word "Help" spelled out.

In a column I wrote several months ago I told you about our trip to the Social Security Office to get the ball rolling for Bill’s retirement, and how under the Family Benefits provision, Cody would no longer receive SSI but receive a monthly sum from Family Benefits.

As a result, Cody’s Medicaid program changed from a “non-spend-down” to a “spend-down” in which we pay a nominal amount to the state each month for him to continue to have coverage.

We did all the paperwork and made all the calls and a few weeks later we received a notice from Medicaid stating all was in order. But it turns out there were a few details they failed to mention.

One would think after all the information we provided and given modern-day technology, that knowledge would have been passed along to other key organizations—you know? Like the fact that when Bill retired Cody would no longer have private health insurance in addition to Medicaid, which I felt we made very clear to all parties involved. That communication didn’t happen.

Last week it was time to refill Cody’s medications so we called the pharmacy to let them know as we always do. Bear in mind this pharmacy is also directly affiliated with the hospital where Bill worked for 18 years. Bill, being the social butterfly that he is, was on a first name basis with all the staff. They had been informed of his retirement and that we would no longer have the same health insurance plan once his official last day arrived and that Medicaid would be Cody’s sole coverage. So there should have been no confusion, right? Yeah—not so much.

Several hours later we received a call from one of the pharmacy employees who stated that Bill’s insurance was rejecting access for Cody’s refills and so was Medicaid. Once again I explained that Bill no longer had that plan and that Cody’s only source of medical and prescription coverage was from Medicaid.

“Yes, that’s showing up,” she said.

“If it is showing up then why are you attempting to bill my husband’s prior insurance plan?” I asked, bewildered.

“It is the Medicaid office who is still showing he has other coverage. You’ll have to call them.”

So once again I contacted the MO Healthnet office to find out what was going on. After navigating through all the recorded prompts I was put on hold to wait for the next available agent. As I sat there listening to an endless loop of really bad elevator music it seemed like hours before my call was answered by an agent.

I explained the situation to him and he said he would fix the problem and that I should contact the pharmacy again to have them bill my husband’s prior insurance once again and when it was rejected to then bill Medicaid and that the rejection notice should accompany their billing correspondence.  “Ok.” I said, exasperated. And the call ended so I could relay the message to the pharmacy.

Upon speaking to the pharmacy employee once again I told her what the agent at the state had said. She instructed me to stay on the line while she tried again, which I was happy to do. But it still was not going through. She stated she was still getting an error message that Cody had other insurance and that they should be billed first.

 “I don’t know what else to do. That’s what they told me to tell you,” I explained.

“Until they have it out of their system that he has other insurance we’re just going to continue to get rejections,” she said.

Her compassion and understanding were evident but unfortunately it was going to take more than that to fix the problem. So I initiated a fourth phone call.

I ran the gauntlet through the recorded prompts and was placed on hold once again. This time the elevator music was distorted and scratchy like something you would hear in a haunted house. I swore that while I was waiting I could feel my hair turning gray. Finally an agent answered and after explaining our dilemma one more time she asked to put me on standby while she did some checking. She wasn’t gone for very long this time when she came back and said that the pharmacy was coding it wrong. When she told me I was going to have to call them back to tell them I thought I might be in for a psychotic break! But then she gave me a telephone number that the pharmacy could call and the people at this number would help her submit this bill correctly. A fifth phone call ensued.

I conveyed the info to the pharmacy and waited to hear if they had gotten anywhere. Another several hours passed when they called to say everything was all straightened out and we could pick Cody’s meds up the next day. I was so relieved.

But why did all this have to happen? I realize certain things can’t be transmitted in certain ways for privacy and security reasons. But was this truly a HIPPA issue? Or was it a case of someone not doing their job? If it was HIPPA, then perhaps it was a case of HIPPA gone too far.

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I can relate!

We are having similar snags (both major and minor) with all that you have mentioned - medical coverage, pharmaceuticals, private insurer vs medicare...One thing that has helped us is to have guardianship for our 18 yr old son. ...that removes the further conflict of Hippa and confidentiality...but it's never, ever easy.  And you and I are educated epoeple - what about all the parents who have no idea who to contact??!! Please keep writing - your articles are excellen and I shar them with other parents all the time. Sher