And they say no one should stand between a patient and their doctor

September 7, 2009 6:51 AM

I need to argue with my insurance company, but my case is such a convoluted mess that I'm not sure how to make my point to them. Help!

Long Story: I have Rheumatoid arthritis, diagnosed in 2005. I began taking a weekly medication, Methotrexate at that time. Because my arthritis is very aggressive, I've also taken Enbrel, Humira and now Rituxin, while also taking Methotrexate. The Rituxin is given by IV every 5-6 months. As part of my blood work for the Rituxin in May of 2008, the doctor found that I had dangerously low levels of white blood cells. Although there could have been other cause, he felt there was a risk that I had developed "Methotrexate Toxicity", and took me off that drug. I did I dance of joy, because I hated the foggy feeling the MTX gave me, and was looking forward to being able to drink occasionally without worrying about total liver destruction.

But then...
It was time for my next dose of Rituxin and the insurance company threw a fit. Rituxin was FDA approved with MTX, so they would only approve it for me if I went back on the MTX. My doc, who has a lot of influence with them, having served as a consultant for Auto-immune treatments, was not able to get them to change their guidelines. He put me back on it, at a lower dosage, with another drug to counter the side-effects. I admit that I considered just chucking the MTX as soon as I got it, and pretending that I was taking it. But it does honestly help my arthritis, especially as the Rituxin begins to wear off. So I went back on it last October.

When my next approval for Rituxin was being processed, we hit another snag. They wanted my refill records to prove that I was getting the MTX. But because I'd formerly been taking a higher dose, and had a 3 month script filled right before stopping it, I had a ton of pills at home and didn't need a refill. I dug out all the dates and records and wrote up the reason why I hadn't needed any refills, ending by saying I had enough pills to get me to early June. I even took out all my pills to count, to prove to myself that my math was right. But, it wasn't. There were still about 30 extra pills. I considered dumping them, because I knew if I didn't order a refill in June, they would suspect that I hadn't been taking the Metrotrexate again.

And here's where I'm stupid. I didn't order a refill in June. I was busy, and broke, and used up all the pills I had before ordering a refill in August. My doctor put in for an approval for the Rituxin for this month, and I got the letter on Saturday that I was not approved because I hadn't been taking Methotrexate. Ugh. My doc is on vacation, and he's already argued with them so many times on my behalf, that I hate wasting his time after my stupidity. So I'm going to call them on my own tomorrow to file an appeal an my own.

What can I say? How do I assert that I've been on the MTX like a good little girl, when I can't prove it? It's not like this whole story fits into an easy soundbite. I really need the Rituxin, but the insurance company is not just going to give in and give me a $10,000 treatment because I asked nicely.

posted by saffry to health & fitness (2 comments total)

Resubmit the maths. You said you had records for the amount purchased on the old scrip. Or you could demand a (hopefully expensive for them) blood test to determine MTX levels. That oughta make their heads spin.
posted by Gungho at 7:32 AM on September 7

Since your doctor put you on a lower dosage of MTX and you still had the balance of the higher dosage MTX, couldn't a case be made that you are using a pill splitter and are still taking the MTX?

There's a couple things to remember about insurance companies. First, I like to liken them to Jumbo Jet Airplane hangars used for storing money. The money comes in through the giant doors up front and flows out through a little mouse hole way in the back. In actuality, they are hugely inefficient banks, losing about 18 per cent on every dollar deposited, leaving about 82 cents left to pay claims. A couple decades ago, when I knew the numbers better, there were more people employed by the insurance industry in the US than were employed by the Post Office.

The good news in this is that the decision makers that you deal with are all bureaucrats with no skin in the game. Just as man or woman, over time, can outrun and capture a cheetah that can run 60mph in short bursts, you can easily conquer any bureaucrat with extreme persistence. They will eventually cave in when they realize that *their* life will get easier when you go away. Call them every day and take copious notes, getting the first and last names of everyone you talk to. Give each of them the long story, including the names and decisions of everyone you've talked to so far. Be friendly and inquisitive and do your best to find out how their system works and who the decision makers are. There is also the high likelihood, if you're friendly enough, that one of them will slip up and tell you something you shouldn't know about denial of claims. Sometimes this is the appropriate point to stop and let them know you are writing down "Susan Smith says that they look for this reason to deny claims..." and then ask them if they think it would help if you contacted a local news reporter to do a story on your situation. I have gotten *immediate* action in the past when I caught someone giving up privelaged information.
posted by Rafaelloello at 7:43 AM on September 7