Insurance Red Tape


After getting the Dexcom, I started the process to get a pump.  That process actually was not that bad.  My doctor was reluctant to sign the paperwork, but I managed to convince him.  Because I have a Medicare Advantage plan, I had to have a fasting C-peptide test to prove that I had little to no insulin production.  Medicare does not pay for pumps for Type 2 diabetics.  I am not sure whether you want to say I passed or flunked that test.  My test came back as <0.1 with the range being 0.9 – 4.3.  The lab repeated the test with a different range and that came back as <33 with the range being 297 – 1419.  I guess it is official – I am a Type 1 diabetic!  I already knew that 26 years ago, but now I qualify for a pump.  Three weeks and two days after I went to the lab for my C-peptide test, the supply company called to say that they had approval to send the Animas Ping. 

Getting the pump was actually the easy part.  I had no idea how hard it was going to be to get insulin for use in the pump.  I knew from reading online that Medicare covered insulin for use in pumps differently than insulin used for MDI.  I looked up in the manual for my insurance and it said that the insulin for a pump gets covered under Part B of Medicare and not my drug plan which is Part D.  I have to pay 10% (under Medicare without a supplemental plan, you have to pay 20%).  It also stated that I could not purchase that insulin at a regular retail pharmacy.  I called my insurance to find out where I could purchase it.

At first, they gave me the name of some pharmacy in Pittsburgh.  I had never heard of them and wasn’t too thrilled about the idea of doing mail order insulin.  They said that it had to be a DME provider.  One of the names they had was the company I used to get my pump and Dexcom from, so I did not have a problem using them.  I called & talked to the pharmacist, but when he found out how it had to be billed, he transferred me back to the pump department.  I ended up leaving a message for the guy I had worked with.  He called me back later to say they checked into that and they were not set up to provide the insulin that way. 

I called my insurance back to get the name of the pharmacy in Pittsburgh.   I called the pharmacy and called back again at the beginning of the week.  Both people I talked to assured me that the insulin would be shipped UPS.    My mailbox is across the street in the apartment complex I live in.  When the weather is bad, whether ice or rain, I can’t get over to my mailbox and I don’t want insulin sitting there.  I had my doctor send a script to them.  Last Thursday, I walked over for my mail and the insulin was sitting in my mailbox.  I called and the guy I talked to was a real jerk so I called my insurance.  I was told that I could send it back and I should do that right away because until the credit was processed, I would not be able to get the insulin from someone else.  I shipped it back & they had it the next day.

I was given a bunch of other names to try and either they did not carry insulin or they could not bill it the way my insurance needed it billed.  There were also at least 4 different people with my insurance making calls each time I called.  It was getting very frustrating and I felt like I was going to be the first person in the world to return a pump because I could not get insulin to use in it! 

Last Friday, a week after I first started trying to find insulin, I finally thought I found a place that I could get it from.  It is actually someone local that is about 20 miles from me so I won’t have to do mail order.  At first, she didn’t understand why it needed to be billed that way and said she never heard of that before, but she was at least open to listening that it was different.  Unfortunately, when she tried to put a test claim thru, it came up as my regular co-pay amount.  Late Friday afternoon, the guy I had been working with earlier in the day from my insurance called me back & he told me which set of numbers on my insurance card would get it put thru right. 

I waited until Monday to call them back.  I was supposed to have my doctor’s office fax the prescription to them.  She did not carry what I need (Apidra in the vials) so would have to order it.  She wanted me to come in when her billing person was there and gave me the days & hours that she worked. 

I called her again this afternoon just to make sure that my doctor’s office faxed the prescription and they did.  She said that her billing person went thru the process.  She said they also had to prove that I was Type 1 and asked if I had the C-peptide test done.  They needed to get my doctor’s office to send that to them.  She had to order the insulin yet but I will be able to pick it up this week.  When I go in, I will take my copies of the C-peptide test just in case they had problems getting it from the doctor. 

Monday, I called my insurance again to make sure that the credit was put thru.  I sent the insulin back signature required and they had signed for it on Friday.  The credit was not showing on my account.  The person that I talked to Monday said that it usually took about 3-4 weeks and could take up to 6 weeks for the credit to show up.  I asked her how I was supposed to get insulin if it took that long.  She put me on hold then said if it was a medical necessity, they could put a rush on the credit.  I would say insulin is a medical necessity!  I also told her that I only have 30 days to decide if I like the pump or not so if it sits here for 30 days before I can use it then decide I don’t like it, they just wasted a ton of money. 

Besides the fun trying to get insulin, I went  in for a new pair of orthotics.  I actually went in exactly one week after getting the C-peptide test done.  They have to get approval from my insurance before they start making the orthotics.  It normally only takes a couple days for the approval and then it takes them about a week to make them.  It was taking forever and after the pump showed up, I thought I would call and check the status since it had been over three weeks.  They told me that they were still trying to get approval from my insurance company.  She said that the insurance changed the process.  She called the doctor that wrote the script but she didn’t think he understood exactly what she needed because he never sent it.  She then faxed something to my PCP but did not hear back from him.  She said it had only been a couple days since she faxed my PCP.  After I hung up, I wondered if she had my current PCP’s name so I called her back – luckily, I called because she had the wrong one listed.  I gave her his information but did not have their fax number.  She also has to prove that I am diabetic. 

I am going to call her next week to make sure she has everything she needs.  I have an appointment with the doctor that wrote the script for the orthotics, so if she doesn’t have what she needs, I will make sure he gets it done. 

For the orthotics, it doesn’t matter whether you are Type 1 or Type 2, you just have to be diabetic.  My PCP can fax the C-peptide and that will be enough proof for me.  I am thinking that I need to hand copies of that test out every time I go to a new doctor or supplier! 

It is crazy because they have been paying $300 a month for insulin, over $1k per quarter on test strips, they bought the Navigator, a Dexcom and now the Animas Ping.  Although I understand they needed proof that I was Type 1 before they paid for the pump, you would think they could figure out that I am really a diabetic to process a $100 pair of orthotics.
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