Pre-authorization - help me understand!

I got started on a CGM in the middle of last year and the pre-authorization was completely transparent. My doctor’s office has staff to deal with pre-authorization and after I told my doc I was ready to start, they pretty much instantly did the pre-authorization and the next day the specialty pharmacy was calling me asking me where they should ship it.

HOWEVER my employer switched my insurance company on me on Jan 1 of this year. It was supposed to be exactly the same plan and benefits, just processed by a different company.

Since this batch of sensors only lasts me through Jan 14 I knew I had to start making phone calls to get the pre-authorization through the new insurance.

I call the doctor’s office Jan 2, they say they’ll put it in, should be good next day.

Call the pharmacy Jan 3, no it’s no good.

Call the doctor’s office Jan 3 they ask me more questions about my new insurance and say I ought to be good the next business day.

Call the pharmacy Jan 6, no, it’s no god.

Repeated the cycle above several more times through all of this past week, and each time I’m told they’ll put it in, but the next day the pre-authorization has not gone through.

The doc and the pharmacy tell me, that I cannot call the insurance company directly, I have to work the pre-authorization through the doctor’s office. Is this true? Should I be bugging the insurance company directly?

Should I be bugging the HR/benefits deparment where I work, instead?

If I can’t get a pre-authorization, are there discounts that Dexcom or partners offer to folks who don’t have insurance, or whose insurance is screwed up and refusing to pre-authorize? Or maybe a Dexcom/Dexcom partner knows how to kick-start the broken pre-authorization process?

When my former employer switched me from Medicare/United HealthCare supplemental to United HealthCare Medicare Group Advantage, I lost coverage on my Medtronic sensors.

Question is, where in the process is the breakdown. In getting my Libres, the vendor (Edwards) needs updated info every 6 months for Medicare. So they send the form/request to Endo, (but not until I actually call in my order), who often claims not to get it, and then sometimes they don’t fill out fully or correctly. Sometimes the form goes to the wrong office. Yet no one tells me there’s a problem until I call/message. Then I can push.

You can always call your insurance company. You’re the actual patient/insured. You might be able to find out generally where the delay is. Wrong form from pharmacy? Missing info for Endo. Or maybe some internal delay at Insurer. You won’t be able to fix any of it on your own, but you’ll know where to be the squeaky wheel.

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I encountered a very similar issue and unfortunately, they told me the Dexcom won’t be covered due to the plan my employer chose…the prior authorization has nothing to do with it, whichever plan that was chosen by corporate is how they section u your dexcom. You can try to speak to the insurance company or the 90 day pharmacy, but it sounds like you’ll either pay $4000 per year for the Dexcom or become of the new libre miaomiao2 xdrip converts… if its the latter, welcome to the libre club…and many others will soon join after they are forced to the Dexcom g7 and can’t play with restarting sensors and transmitter batteries anymore

@Tim12 Call your insurance company. On the back of your insurance id card should be several phone numbers. I’d start with Member Services. If you need to speak with someone else/some other department, such as the Pharmacy or DME, Member Services will tell and hopefully transfer you and/or give you their phone number.

Are you on G5 or G6?

I’ve been working this process for a month. I have a hangup trying to switch sensor models because I haven’t been using it for 3 years and its still under warranty.

I think that you ought to be able to call member services at the insurer. Who is the insurer? I’ve never heard anyone say that I couldn’t call my insurer. How are you supposed to ask questions about your plan or fix billing mix ups? That’s unusual and kinda suspicious business practice. You have the right to call anyone you do biz with. Your an American.

If your on Dex, maybe you should just call them and tell them that you had 3 sensors fail. They will ship more. That will start the process moving. If you need advice about how to do this, ask.

I would bother all involved parties. You have to in order to figure out what’s going on. Its a lot of work. I’m sorry this is happening.

G5 or G6? I could send you a couple. I’m faster than Dex shipping. This seems like a prob that will take a while to fix.

Thanks for the hints everyone! I called my Doctor’s office this morning and 13 days into the new year, and maybe 40 phone calls by me, I now have pre-authorization for new sensors.

Mohe0001, it’s not that I was told NOT to call the insurance company. It’s just that my doctors office and the pharmacy, they said that as a patient I had no input into the prior authorization process.

Well, I suppose my input was calling my pharmacy and doctor every work day since the beginning of the year, and that input was important in making the authorization happen (but not directly to the insurance company).

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I understand now. You beat me to the end of the process.

If your company is big enough to be self-insured and are using a company like Cigna, UHC, Aetna, or the like to administer the plan, you should definitely contact your HR department and relay your experience.

After all, if you had this experience, how many others in your company had a similar one? Even if it didn’t effect your performance or morale, would it have if the problem dragged on?

This is part of the hidden cost of having a chronic condition. If your HR folks can help the insurer figure out that they must do better, then that’s a good use of their time and is probably part of their mission.

Yes, you got my situation exactly. Yes, in the interest of improving it for everyone, will try to make useful comments!

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To work through a stalled prior authorization, here is what I have done: Find the “medical policy” the insurer uses to approve/deny coverage. Every insurer has these…they are written almost like a checklist so the reviewer at the insurance company has things in black and white. Those policies are now available online at some insurers, others you might have to call and ask for it.

Once you have that, and assuming you have a contact at the doctor’s office…find out who to fax it to at the insurer, fax # and which dept., reference number for PA request. Tell the doctor’s office exactly what to send and exactly where to fax it. I once took the inconvenient step of dropping in at the doctor office and handing the staff a sheet of paper with all the details.

Then call the insurer and tell the PA dept. you have reviewed the medical policy and your doctor just faxed everything needed for approval. If the insurer is cooperative, stay on the line while they look for the fax and promise you it will be given to the reviewer promptly…,and cajole them into a quick review.

This takes a lot of time but is a good way to take control of these seemingly random faxes that go back and forth when a PA gets stuck.

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If you are treated at a hospital or clinic that handles a lot of diabetics, they have in-house staff that deal directly with Dexcom/Insurance companies and Medicare. It appears to me that the patients that waste the most amount of time are those that in effect have to do all the research and then train their “small doctor’s” office to properly fill the proper paperwork with the proper entity. I am treated at Joslin - Boston and whenever Dexcom tells me that they need additional doctor’s notes, insurance verification or other such nonsense it is cleared up within 24 hours between Dexcom and Joslin as Joslin has dedicated staff that know all the ins and outs and proper procedures up-front. Dexcom does not want to lose their relationship with large hospitals and clinics so they have dedicated staff that work with staff dedicated to making sure the paperwork is all done properly. So, although I could use an endo within a 15 minute drive of my home or work location, I invest the 2 hours in driving to Joslin and save a lot of headaches and frustrations.

I can tell where the pharmacy and doctor’s office are coming from but they are not 100% correct. You have no imput on the prior authorization itself. You cannot submit it yourself. Only the doctor can submit the prior authorization and give the clinical justification as to why you need the sensors. HOWEVER, you as the patient can most definitely call the insurance company. You can ask them if the prior authorization has been submit? You can ask them what the problem is and what is the hold up? If your insurance companies are anything like they are in my state, the carriers should be very good about it. You may be able to get them to call the doctor’s office too and tell them what they are missing. In our state, SOMETIMES, in some circumstances, a patient can even initial the prior authorization. (Basically, ask the plan to send the paperwork to the provider).
I had a prior authorization that I needed and my doctor’s office is not very good at it. I pushed the plan to push the doctor’s office and make sure it was done and correctly.

In all honesty, it is possible the office didn’t send it in when they said they did or they weren’t “careful” when they sent it and didn’t send everything that was needed. The beginning of the year is the WORST time to need a prior authorization because offices are inundated with requests. It’s also possible that with one plan it was covered under medical benefit and the next plan it was a pharmacy benefit. DexCom has been working very hard to get all the plans to do DexCom through pharmacy benefit because it often has less out of pocket for patient than DME benefit. A lot of the switches from medical to pharmacy were in the last six months or so. It is possible that the doctor’s office sent it to the wrong part of the plan.

One thing that can help is that a lot of plans put their “policies” online. The policy will typically tell you EXACTLY what the plan is looking for (if it is a commercial insurance) to get things approved. This can help.

I’m glad you got your sensors now but you can tuck this away for the future.

Uh? Do you live in USA? Sensor warranties are only good for a year. (Insulin pumps are longer). Medtronic it is a year. Dexcom I believe the receiver is good for a year and the transmitter warranty is 6 months. I am almost positive an insurance company can’t require a warranty longer than the device’s company offers. Depending on what state you live in (if it is USA) the state may have laws in place regarding diabetes coverage that can help you. State laws, however, do not apply for Medicare, military, or “self-insured” employers; those fall under federal law.

Be sure you check both prescription benefit and medical benefit. It may be covered under one and not the other (especially DexCom). If you work for a large employer or are part of a union, talk to human resources or a union rep sometimes they can help. Also, if you work for a large employer your prescription benefits and medical benefits may be handled “separately”. Large employer groups are usually self-funded so they contract with the insurance to provide medical and a pharmacy benefit manager to provide prescription benefits. Typically, in those situations medical can’t tell you what is covered under pharmacy and vice versa since they are separate.

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Let me clarify that I believe that the receiver is under warantee for three years…but let me re-check the paperwork to verify. Thanks, btw, for verifying how to spell ‘waranties.’

I ran into this last fall over pump supplies. Edgepark wouldn’t fill my regular 3-month reservoirs/infusion sets order for October because, they insisted, my autho had expired in July. Since my scripts are written on a yearly basis, February-February, this didn’t make any sense. They said they’d requested one from the insurer (Allways) and didn’t get anything. I tried contacting my Dr to send one to the insurer b/c normally talking to an insurance co is a nightmare, like calling the DMV or Social Security. But Allways had to request it for the Dr to send it, so I contacted them. And actually they were great.

But here was the thing: the reason they didn’t request an autho renewal was because they didn’t require one. When Edgepark had asked them for one at the expiration of the previous one, they told Edgepark they couldn’t send a new one because it wasn’t required. They would pay without one. They didn’t need it and didn’t want it. This was back in July. But Edgepark just had it sitting there as a request that hadn’t been complied with. Allways, to their credit, had very thorough documentation: tracking number of the interaction with Edgepark, even the name of the agent they’d spoken with, all of which they shared with me. And even with all of that it took me days to get Edgepark to acknowledge it.

Which they eventually did, but the part I hate about the whole process is that you can’t have any direct contact with the group that does the insurance verification. You have to do everything through a customer agent, and they hand it on to insurance verification to get the ok for the order to be processed. And insurance verification was exactly who Allways HAD contacted and told no autho was necessary in the first place. Meanwhile the clock is ticking on my supplies running out. Meanwhile it takes them several days to go through the processing even if everything is fine. You have absolutely no way to tell if silence means it’s all going through, or it has died in committee once again either through neglect, someone missing the note on the account, god knows what. And explaining to the agent “I need this stuff in order to stay alive” doesn’t get through to anyone who matters. Ugh.

In the US (at least) I can almost say for certainty that it is only 1 year. There may be some caveat though that I’m not thinking of that may make it longer.

The third party DME supplies drive me nuts.

My prior auth snafu with Edgepark in late '18 involved both my insurance company and Edgepark faxing and re-faxing documents back and forth to each other for a few weeks…to randomly wrong fax numbers. And this was just an annual renewal of a prior auth, one would think that is a routine event. It got to the point where I would call each and (after they checked their screen and told me “It has been faxed”, “will be reviewed pronto”, etc.) ask “What number did you fax it to?” and then call the other and ask “Was it received…What number should it be faxed to?”, call the other back with the correct faxing instructions, etc. Total clown show.

The silver lining was I documented the whole mess with good notes and used them to make the case that due to mis management of the vendor my insurer was unable to fulfill my orders for Dexcom supplies, stressing the word Continuous in CGM. I put my foot down with the insurer and told them they are obligated to find an alternate supplier for me. That triggered a call from the pharmacy benefits dept. offering to handle re-orders for me. With Edgepark out of the picture I saved a boatload of money on my 20% co-pays (because Edgepark prices were so high). A good result but it took hours of phone calls over many weeks to resolve.