Fixing problems w/o intimate knowledge

I have no idea how someone who doesn’t understand the internal working of the healthcare system gets things done.  I have trouble when I understand it.

A few months ago, I had an issue with a prior authorization for an Rx for my son.  I paid cash and then knew to send it in via a paper claim.  It was still rejected.  Fortunately, I know you can appeal twice and then formally a third time.  It took two appeals and several “discussions” with the call center staff, but I got it fixed.

Today, it happened again.  I had changed something on our plan and eligibility got mixed up so my Rx rejected.  When I called, the managed care company said my family was all eligible.  When I explained what happened, they informed me that prescriptions were a different eligibility file that they weren’t looking at.  (Like I should know to ask this.)

They then explained that my employer must have submitted the wrong paperwork.  I said that was impossible since I did the paperwork myself.  I also explained to the agent that since the managed care eligibility was right then it was a data entry issue on the pharmacy side for them.  She tried three times to tell me to talk with my employer.  (Only because I understand the process did I refuse.)

She finally went away for 20 minutes.  (I was sure she was just sitting there laughing at me.)  When she came back, she admitted that they had made an error and needed to fix the eligibility data.  Of course, it couldn’t be done tonight, but it could be done in the morning.

If I didn’t know how data was sent and the processes, I would have been chasing my tale with my employer and TPA for days.  I feel for all of you that don’t know these things.

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