Dear “Brad” from ATC Medicaid, (changing names to protect the innocent)
I just wanted to let you know how I spent much of my day “off” today. I had been on vacation, and stopped by the office to catch up on things since I’d been away.
One of the “things” was a denial for a medication which I feel very strongly would be helpful for one of my patients (and for his entire kindergarten class next year). The denial said he wasn’t old enough. We sent an appeal to US Scripts and it was denied. It said I could call for a peer to peer review if I wanted to appeal this. Here’s how that has gone so far:
1) Called number and picked “pharmacy” option for appeal.
2) Spoke with someone who sent me to pharmacy, I guess someone at US Scripts.
3) After being on hold 10 mins (9 min and 56 seconds, according to the phone I was on), a pharmacy tech answered the phone.
4) I described the situation to the pharm tech. She said she could not help and sent me to pharmacist.
5) I waited until the phone said 25 mins and 45 seconds had passed and a pharmacist picked up.
6) The pharmacist listened to my reasons for wanting to change this child to the long acting form of his medication and proceeded to read me the exact thing that was on the denial form. I am able to read, have been for quite some time, so I was aware of the reason for denial (child too young). Said he either needed to get older or try a medication with more side effects first, which I strongly feel is not in the child’s best interest at this time.
7) Pharmacist told me I had to call the original number I had called back and pick another option, she wasn’t sure which one though. She mentioned nothing about filling out any more forms.
8) I called back and picked something to do with management and appeals.
9) I explained the situation to the operator. She put me through to someone, who I assumed might be a physician.
10) I left a message.
11) While I was grocery shopping (remember, I am “not working” today, and if I were, I would not have time to do any of this), I got a call from Sharon, who sounded very nice, but I was in line at Aldi and due to HIPAA issues, decided it was best if she call me back, which she did.
12) After I described the issue to Sharon at some length, she said she could not help me. She was an administrative assistant.
13) She connected me to Ed, who listened briefly to my issue and said I would have to fill out an appeal. I am not sure what Ed’s job is.
14) I told Ed we had filled out an appeal and I had already done a “peer to peer” and that the “peer” person said that I would not have to fill out anymore paperwork: I need only make it clear to him that I had already done the “peer to peer” and they would help me at Absolute Total Carolina Care (Sharon and the pharmacist both said several times that I would be connected to someone who could actually help) .
15) Ed said he could not help me and connected me with Tammy.
16) After I asked multiple times whether she was the right person to listen to my story about the good reasons I had for wanting this child on the medication I had prescribed and Tammy said yes, Tammy listened to my whole clinical story about this boy. It took awhile.
17) Tammy said she could not help me. I would need to fill out an appeal. I asked to speak with someone else.
18) Teresa was called in.
19) Teresa and Tammy informed me that I would have to fill out an appeal.
20) I explained that I had filled out an appeal which was denied and had done a “peer to peer” and was told that the next step was to call and speak with a physician or a director in the appeals department and make sure that they understood that I had already done a “peer to peer”.
21) Tammy said that I had appealed through “US Scripts”, but not through ATC. So I should complete another appeal.
22) I explained that the child had already been waiting a month since medication was originally prescribed. She was told she couldn’t get the medicine and didn’t understand that she should call us to get medication authorized, but we did start the appeal process a week ago, and at this point, I was kind of ready to speak with the medical director.
23) Tammy and Ed both made sure I knew that that was really not the process. I made sure that Tammy and Ed knew that at this point, I really did not want to hear them say that. I asked Tammy whether the questions on the ATC appeal were exactly like the ones on the US Scripts appeal which they were very likely looking at while as we spoke. There was silence for a little while on the other end, and then they offered to have the Medical Director call me back.
24) I am waiting to hear back from the medical director.
25) I am counting the minutes until my yoga class this evening.
Just wanted to let you know how I have spent my day “off.”
Hope your Monday was good.
Martha Edwards, MD
PS: I still would love to have more local options for pediatric psychiatrists to help with medical management. I certainly can understand why there aren’t more after spending my afternoon “off” on the phone with your staff.
PPS: The medical director was knowledgeable and reasonable and gave me his direct number for when things like this happen in the future and assures me he answers his phone. I will be tattooing it on my left forearm sometime in the near future. Clearly Sharon, Ed, Tammy, and Teresa are earning their pay by preventing any human contact with their medical director. They protect him fiercely–to the point that he told me he rarely gets calls because things are so “easily taken care of.”
over, under, in between 