Group Health Coop (argh!) HELP!

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realkarl

realkarl

Radiation survivor
Supporting Member
Joined
Jun 3, 2009
Messages
187
Location
Seattle, WA, US
Group Health (GHC) is supposed to cover home INR monitoring after 3 months, so I tried to start the process. The anti-coag clinic referred me to Coaguchek, so I called them (Roche). My PCP received a prescription which she filled out and returned to them. Now Roche calls me and tells me they have no contract with GHC. I call the anti-coag clinic back, and they hardly know anything - saying so few patients have such a machine, but she is sure Coaguchek is the company. I call Roche back, she calls Group Health, then me, to inform me it is possible Group Health has a contract with another distributor. So far no one that I have been able to reach knows this information.

This is so frustrating! Are they any other Group Health members with home INR testing equipment?

Karl.

EDIT: I will try QAS next - on hold waiting for a representative for 1/2 hour after navigating 7 or 8 levels in their phone system. Yay. Got through to them, finally. They don't know either, if they have a contract with GHC, but I started the process there as well. He said it could take anywhere from 4-6 weeks once they get the prescription.

EDIT2: I finally received the proper Group Health Procedure from a nurse from GHC's anti-coag management services. See this post.
 
The misinformation...

The misinformation...

I finally received instructions for how to obtain home testing equipment, but it contains the usual misinformation:

"AMS has very few patients who have their own INR home monitoring equipment. It is quite expensive, and not as reliable as venipuncture INRs. It is only covered by insurance in special circumstances."

The last item is not correct according the Group Health's own policy documents. Then she mentions accuracy vs venipuncture INRs, which GHC uses.

The accuracy is even included in Mr. Lodwick's Outrageous Advice : " Fingerstick INR machines are new and are not as accurate as hospital or commercial laboratory testers. This came from a physician who supervises doctors in training. I mention this because these doctors have an obligation to stay up to date on the latest developments and teach these things to the young doctors. There were some inaccurate machines in the early days of fingerstick testing. These have been removed from the market more than five years ago. There has not been a medical journal article in the past five years that showed that the currently used testers are anything but comparable to the larger models. It is a shame that this "leader" has chosen to retire his/her brain, and stay in a position of responsibility."

Argh!
 
Can you believe this?

Can you believe this?

I just re-read the document, and caught something I did not notice upon first readthrough:

"Every time the patient does a home blood test he would then call the QAS people. QAS will fax the results to AMS, and then AMS can manage the warfarin dosing. If fingerstick results are too low or too high, the patient will be asked to come into the lab for a venipuncture INR."

I hope they don't mean that if the result is as little as 1/10th out of range I also have to come in to their lab and draw blood, but who knows...

I am re-thinking my insurance options. My job also offers Regence Blue Cross, but I will have to investigate how I will be covered there, and their INR home testing policy. I am also no longer happy with my GHC cardiologist, who does not answer my questions in any timely matter, if at all.
 
Karl, i hope you get what you want...it sounds confusing..lol. Its amazing how companies and insurnaces, make it so hard for the patient to get what they need. Good luck.
 
Karl:

The only time I involved my insurance carrier recently was when I bought my machine out-of-pocket and filed for reimbursement 18 months ago. I buy my own test strips and file a claim for reimbursement out of my flex plan at work.

What is AMS? Is that your employer or an insurance carrier?

BTW, my doctor's practice (a large one, part of the Baylor Health Care System that's part of the Baylor hospital system in North Texas) uses Coagucheks. He had them in 2003 when I had my surgery. No one ever gets a lab draw, I've been told.

I'd suggest you going through a vendor rather than to the manufacturer. Have you considered the INRatio?
 
Thanks, but the only way my insurance will cover anything at all, is if I follow their instructions to the point. Group Health is an HMO, and AMS is their anti-coag clinic office.

I received a reply to my note where I tried to correct the misinformation I mentioned above:

"Successful INR home monitoring relies on the patient calibrating and maintaining the machine per manufacturer instructions, and also performing the test accurately. These are all variables that AMS cannot control, so when we are advising patients on their warfarin dosing, we rely on patients with home machines to be able to do the home testing exactly as specified by the manufacturer.

Group Health visiting nurses have some home INR machines that they use for patients who cannot come into the clinic lab for testing. Although the fingerstick result seems to be pretty accurate if the INR is in range, we continue to find it can be unreliable, especially for high INR results. The Group Health machines are maintained and calibrated frequently, and the visiting nurses have much experience doing fingerstick INRs. Still, the results are not always accurate. For this reason, AMS requires a venipuncture to verify all fingerstick results that are higher than 4.0. Similarly, if a patient has a low INR, or the INR is out of range for no discernable reason, we recommend a venipuncture for verification.

Although the fingerstick machines have become more reliable over the years, they are by no means perfect.
Venipuncture remains the gold standard for INR testing."
 
Again Karl, sorry. It sounds like a runaround! Keep being persistant, and im sure youll come out on top with the machine.
 
Thanks, Danny. At this point I am pretty hopeful I can manage to convince them to sponsor 80% for both the machine and test strips. It depends on whether the office responsible for durable medical equipment (DME - also part of GHC) approves the referral. According the the policy document I have found, they should, but who knows. I have until Nov 16th to decide on changing my insurance plan at work. Hopefully I will have an answer by then.
 
QUOTE

The Group Health machines are maintained and calibrated frequently, and the visiting nurses have much experience doing fingerstick INRs. Still, the results are not always accurate. For this reason, AMS requires a venipuncture to verify all fingerstick results that are higher than 4.0. Similarly, if a patient has a low INR, or the INR is out of range for no discernable reason, we recommend a venipuncture for verification.

END QUOTE

The Finger Stick instruments used at my local Anti-Coagulation Clinic (1500 patients) are known to read "high" when INR's are above 'normal'. I have been told this is a known problem with several different types of instruments. Note there are Several Manufacturers of Finger Stick instruments for Professional Use in addition to HemoSense and Coaguchek.

It is not uncommon for Clinics to require a Venous Draw for High INR's. Different Labs use different cut-off's, ranging from 4.0 to 5.0. My lab changed from 5.0 to 4.5 some time ago.
 
Karl:

See

http://www.valvereplacement.com/forums/showthread.php?t=24104

Don't understand the references to the patient calibrating and maintaining the machine per the mfr's instructions and doing the test accurately.
Instructions for my INRatio say nothing about me having to calibrate the machine -- those are built in for POC machines -- and as far as maintaining, that's keep it clean, the battery in good juice and keeping the machine at an optimum temperature (don't leave it lying out in the Sahara Desert).
Doing the test accurately? It doesn't take rocket science to do that.

Do read the thread above and watch the clips from Discovery Health about anticoagulation monitoring. I would love to find a way to download or save the clips, but I'm not a tekkie. If someone knows how, please post it here or PM or e-mail me.
 
Thanks, I have seen them, that's not the problem. I was quoting my HMO's anti-coag clinic's response/policies. I doubt they have seen the videos, but I am not going to start an education campaign for them ;)
 
realkarl said:
AMS requires a venipuncture to verify all fingerstick results that are higher than 4.0. Similarly, if a patient has a low INR, or the INR is out of range for no discernable reason, we recommend a venipuncture for verification.
Click to expand...

not as bad as it looks. if you're over 4.0 you have to get a vein draw.
that's required. how often do people go over that level, and what are
the dangers? (i'm obviously not an expert...) what would normally
happen if your fingerstick was over 4? would you do a second finger
stick to verify the high reading before you called in?

but read the next half: if low or out of range for no discernable reason,
they recommend a vein draw.

recommend is not the same as require. can you refuse? do you have
some latitude? is it dependent on how far out of range?

but you're saved with the "no discernible reason" clause. you just need
to supply a reason --- ate too much salad, had a few beers, increased
your exercise level, had diarrhea, etc.
 
I have Kaiser HMO, they have very few patients that use their own monitor. I was the first to fight for it in my area. Now all goes smoothly, I test and call QAS, QAS sends and fax to Kaiser. My range is 2.5 - 3.5, if my INR is 4.0 or more or 2.0 or less I must go to the lab to have it checked. Every ten weeks I have to go for a check no matter what readings I have. It is very rare that I have to go more than every l0 weeks. Works for me.
 
And I have a Humana Medicare Advantage HMO. I had to educate my insurance company for about 4 months until I finally got approval. Don't you just love it when insurance dictates our health..:mad::rolleyes:

Hang in there Karl and get the machine....and please do "educate" your insurance company for the folks following in your footsteps when you feel up to it. It takes a lot of energy to go up against the big folks..:eek:
 
Karl,
Keep posting please. I know it helps to vent and your information may save a life.
I have been on Grouphealth and with Aetna now. Both are just as confusing.
God help this country find a way to give health care to the sick.
 
There's no news to report since my PCP sent a referral to my HMO's Durable Medical Equipment office. I am waiting for them to contact me now, but if I don't hear anything mid next week, I will see if I can figure out how to contact them.

The official Group Health procedure is as follows, in case anyone else in this forum needs them in the future:

Group Health (GHC) procedure to request home INR monitoring equipment
  1. The PCP sends a referral to DME for INR home monitoring equipment. This is something that the PCP has to do to start the process.
  2. The referral people decide if the patient has insurance coverage for this. If he does not have coverage, he will have to pay for the equipment out of pocket if he still wants it. The referral office will discuss this with the patient.
  3. If the patient decides to go ahead with this, then the referral office will send orders to the PCP to sign. On these orders, the "managing provider" should be listed as AMS. Once these orders are signed, the referral office will contact a company that they use called QAS.
  4. QAS will contact the patient for the equipment delivery and teaching.
  5. Every time the patient does a home blood test he would then call the QAS people. QAS will fax the results to AMS, and then AMS can manage the warfarin dosing. If fingerstick results are too low or too high, the patient will be asked to come into the lab for a venipuncture INR.
Notes from the nurse: AMS has very few patients who have their own INR home monitoring equipment. It is quite expensive, and not as reliable as venipuncture INRs. It is only covered by insurance in special circumstances.

However, according to a public GHC policy document on the web, I can not find any special circumstances other than procedural, so we shall see.

AMS = Group Health's Anti-coag Management Services
DME = Group Health's Durable Medical Equipment office
 
Talk about red tape ..................

Talk about red tape ..................

realkarl said:
There's no news to report since my PCP sent a referral to my HMO's Durable Medical Equipment office. I am waiting for them to contact me now, but if I don't hear anything mid next week, I will see if I can figure out how to contact them.

The official Group Health procedure is as follows, in case anyone else in this forum needs them in the future:

Group Health (GHC) procedure to request home INR monitoring equipment
  1. The PCP sends a referral to DME for INR home monitoring equipment. This is something that the PCP has to do to start the process.
  2. The referral people decide if the patient has insurance coverage for this. If he does not have coverage, he will have to pay for the equipment out of pocket if he still wants it. The referral office will discuss this with the patient.
  3. If the patient decides to go ahead with this, then the referral office will send orders to the PCP to sign. On these orders, the "managing provider" should be listed as AMS. Once these orders are signed, the referral office will contact a company that they use called QAS.
  4. QAS will contact the patient for the equipment delivery and teaching.
  5. Every time the patient does a home blood test he would then call the QAS people. QAS will fax the results to AMS, and then AMS can manage the warfarin dosing. If fingerstick results are too low or too high, the patient will be asked to come into the lab for a venipuncture INR.
Notes from the nurse: AMS has very few patients who have their own INR home monitoring equipment. It is quite expensive, and not as reliable as venipuncture INRs. It is only covered by insurance in special circumstances.

However, according to a public GHC policy document on the web, I can not find any special circumstances other than procedural, so we shall see.

AMS = Group Health's Anti-coag Management Services
DME = Group Health's Durable Medical Equipment office
Click to expand...

Karl your post profiles the disadvantages some Americans and some Canadians encounter when seeking POC monitors.
I had a difficult time convincing my PCP of the value of home monitoring. Several others on this board had similar experiences as well.
When my PCP learned I would be trained and monitored by medical personnel at the Toronto General Hospital he agreed and wrote the prescription.
Toronto General ordered the machine, taught me its use and manages my INR. I test Monday a.m., e-mail the result to TGH and they advise my dosing usually before noon. Health Canada approved the monitors prior to 2004 when I bought mine. All costs are occurred by the patient--monitor, strips, lancettes; however costs are 100% tax deductible--a little savings account.;)
Roche requires a venipuncture every six months--I think that's nonsense but comply. My manager has never requested a venipuncture because of a high or low reading. I seldom experience either.
Tell me please, how anyone is able to discredit the monitors as being less accurate than the vein draw. There is an acceptable difference of .8 between the two methods. None of my comparison tests have been out that much. The largest discrepancy was .2. Now my local lab sends the vein sample to another city and the results can take 2 days. Phooey, how accurate is that? Since my spouse received a stent and was put on warfarin last year my PCP suggested I monitor his INR. Thanks to this site I am able to do that. Seldom is he too high and he has never been low, ever. My Coaguchek XS is programmed with a high and a low setting adjusted by the user. So if a test result is lower or higher than the user programmed the monitor will display an upward or downward arrow depending--totally unnecessary in my opinion everyone knows their own range.
Perhaps years ago POC monitors were not accurate and if so those days are long past. Around the world these monitors have stood the test of time for about 10 years unlike a certain mechanical heart valve released worldwide without prior to clinical trails manufactured by a well-know manufacturer of mechanical heart valves and other medical devices.
So the well-tested, proven accurate POC monitor is regarded with suspicion and the use of the untested valve embraced by the medical fraternity. It's really hard to understand. Unlike the valve POC monitors have never been subjected to a recall.
I wish you well and look forward to learning you have successfully negotiated the red tape and have received your monitor--oh happy day.:D
Cheers
 
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