Lorraine?

[Perrster]

Hey Lorraine,

I was just wondering where you are at in the process of getting insurance to help with a Protime (or other brand) machine?

My e-mail has been weird lately and I'm getting messages bounced back.

I'm in the phase 2 part whereby more paperwork needs to be submitted as an appeal. What a pain!

Have you decided where you are staying in Vegas ? I presume you are still going? We haven't made final arrnagements.

 

[Jeffrey A]

Hi Perry,

I'm not Lorraine, but I have gone through the process for the machine with my health care provider, Prefered Plus of Kansas, and it was not very pretty. My primary care Dr put in the request, and I was denied. I appealedna d was denied again. I appealed the appeal and got to go pitch my case in front of an independant board of Prefered Plus of Kansas employees, who were not involved in the first denial or appeal. I took 15 minutes, I worked up a cost justification along with the anticipated payback (Current PT test at DR vs the cost of the cuvette) for the machine, based on my current testing requirements, which were at the time about every 2-3 weeks because I was starting on Amioderone, which has a high loading dose and also thins the blood. DENIED. Bottom line per documentation that I have from Prefered Plus of Kansas is that PT should be monitored by a Dr, and if I was to get one of these machines, the Dr would not be as involved. I focused on a working together relationship with my DR, and that I would still go to see the DR to get tests done, possibly even letting the nurses preform the test with the machine, and also taking blood out of my arm. I stressed veina scarring etc. but none of this worked for me. My PT levels are very stable, as long as we are not messing with any additions/subtractions to my meds, and I get checked every 4-6 weeks--always 2.5-3.1.

It was a very frustrating chain of events. I contacted the Kansas office of the Insurance commisoner, and I realized what a beauracy I was fighting, and I gave up. I have been hounding my DR to buy one of the machines, but they have not, and in my area only 1 Dr's office has a machine, but he is a quack, and I like my current DR. I now switch arms, and every visit I get a poke in different places, including butterflys in the tops of my hands-ouch those hurt. Best of luck to you, and if you do succeed let me know how you did it, maybe I can use you as a precedent/case history type angle

 

[Perrster]

Thanks, Jeff

Thanks, Jeff

Jeff,

Thanks much for your response. It's amazing how much IMBALANCE there is in the Insurance business! I don't understand why the hell they all can't be on the same page as it appears so many people can get Protime units in a blink and others (like us) have to go across hell's coals to probably get denied again.

My carrier's "excuse" (I refuse to say reason-ing) is that I can be tested at an outpatient facility. Duh...that's exactly what I'm trying to avoid. Yours is the first I have heard that says you MUST see a Dr. to get PT tests.

I hope to get my first appeal into the works later this week. If I get denied again, I guess I will just continue my contribution to the high cost of health care.

I'll let you know what happens. Yes, we're having some fun now...!

Take care.

Yeah, them hand pricks do hurt!

 

[Blanche]

Jeffrey:
So sorry you had to deal with insurance people who do not understand home testing. If you are still interested, you might contact QAS. They have helped so many people with insurance problems.

I do have some concerns with some of your statements.
You said:"...documentation that I have from PPofK is thatPT should be monitored by a DR, and if I was to get one of these machines, the DR would not be involved."

That is not a correct statement. The doctors are involved in the same way they would be if you went to a lab for the test. The doctor still monitors the patient, follows the tests, and issues the orders for medication to maintain appropriate INR. Actually, your doctor would have to attest to your ability to properly use the machine. This is required by the FDA, as well as other forms for the doctor that show that the doctor is monitoring your home testing. My husband tests once a week. We email the results to the doctor. A short time later, the doctor calls or emails his instructions regarding dosage to my husband. Everyone here who has a monitor must have a doctor involved. It is evident that your insurance company does not understand the stringent procedures that are required.

You also said that you would still go to the doctor to get the test done and the nurse would take the blood out of your arm. Why?
Wouldn't that defeat the convenience of home testing? You are required to demonstrated that you can use machine, then you may do so wherever you wish. Also, there is no "blood out of the arm." The home testing machines require drops of blood from a finger stick.

If you are not familiar with the materials from QAS, there is a link at the top of the page. You might want to call them, or check out their information on the net. Lance or Brian are really good with insurance companies and with providing accurate information on their product and the rules and regulations for proper us. If all else fails, you might want to consider paying for your own machine. We did and it was a very important decision that I'm glad we made.

Best of luck to you.

 

[Jeffrey A]

Blanche,

I had contacted QAS. I distributed copies of the literature QAS supplied to me to the panel, my primary care DR, and my Cardio guy. I had the prescription from my Dr for the machine, with a memo from him stressing the benefits.

Regarding your concerns:
ITEM 1--That is a correct statement as far as PPK is concerned. They wrote it. They used this as their denial justification. I do not have the time or the resources to battle a case with an insurance provider.

ITEM 2--I have used the machine. The sales rep from Colorado was in Kansas and came to Wichita, and actually tested me after he meet with some hospital labs. The slant that I used in my defense, is based on CURRENT MEDICAL PROFESSIONALS NOT TRUSTING A MACHINE VS THE CURRENT PT TESTING METHOD. i KNOW THAT YOU HAVE TO KEEP THE DR INVOLVED, THEY KNOW THAT TOO, i MEAN i'M NOT BUYING COUMADIN ON THE BLACK MARKET FOR PETES SAKE. (oops caps came on)

I was forced to follow a process set in place by Preferred Plus of Kansas. I had to play by their rules. If I had unlimited resources and cash, I could have fought this decision through the Kansas State insurance commisioner, but I don't. If I had an extra $1,000 lying around I would by this thing with my own money, but I don't. What I do have is a 5 year old daughter, a 3 month old son and a wife that need my attention, and money too! So I have to get poked every 4-6 weeks, no big deal, and it is free. The only drag would be is if I have to test more frequently (like weekly) and I'm just not there.

Thanks for your comments, and I hope that I was able to clarify your concerns.

Jeff

 

[Blanche]

Jeff:
Sorry if I added to your burden by posing possibilities that you have already tried and options that you have already explored. It does appear that your insurer will not approve home testing for any of their insured. It's obvious that you did all that you could to pursuade them. Now that Medicare is going to approve payment for certain patients for home testing, we may see changes in the near future. Acceptance by Medicare is sometimes seen as implied validity by the insurance carriers. Let's hope that this will help people in future who desire home testing.
Kind regards,
Blanche

 

[EVELYN]

HOME TESTING KIT

HOME TESTING KIT

HI PERRY, BLANCH, JEFF, ET. AL.:

WE JUST RECEIVED A CALL FROM THE FIELD REP. FOR MY HUSBAND'S INSURANCE THAT MIGHT BE A HELP TO YOU. THEY WERE REVIEWING TYCE'S PROTIME APPLICATION AND HAD A FEW QUESTIONS. ONE OF THE QUESTIONS THEY ASKED WAS, "WILL THIS KIT PRECLUDE VISITS TO THE CARDIO?" I SAID NO, THAT WE WOULD FAX OUR WEEKLY RESULTS TO THE CARDIO AND THEN STILL GO IN FOR A MONTHLY EVALUATION. THEY SEEMED TO BE QUITE CONCERNED THAT WE WOULDN'T BE IN TOUCH WITH THE CARDIO FOR HIS EVALUATION. I'M NOT SURE WHY YOUR INSURANCES ARE GIVING YOU SUCH A DIFFICULT TIME, (WELL, WE ALL KNOW IT BOILS DOWN TO $$$$) BUT MAYBE IF THEY'RE REASSURED THAT YOU WILL CONTINUE CARDIO/LAB TESTING USEAGE THEY'LL LOOK AT IT IN A DIFFERENT LIGHT.

OUR CARDIO ALSO CHECKED FREQUENT TRAVEL AND UNSTABLE INR'S ON THE FORM FROM QAS.....I THINK THAT HELPED, TOO, BECAUSE THE FIELD REP MENTIONED THAT HE TRAVELED FREQUENTLY ON COMPANY BUSINESS.

BASED ON THE ANSWERS TO SOME OTHER QUESTIONS, THEY ARE GOING TO APPROVE IT AS DURABLE MEDICAL EQUIPMENT AND WILL COVER IT 75%!!!! YAY!!!! MY INSURANCE, WHICH IS TYCE'S SECONDARY CARRIER, HAD ALREADY APPROVED IT 100%, WITH ABSOLUTELY NO QUESTIONS ASKED, BUT QAS HAS TO GO THROUGH THE PRIMARY FIRST.

BELIEVE ME, WE WERE PREPARED TO FIGHT TO THE DEATH IF THEY HADN'T APPROVED IT, BUT SOMEHOW WITH THE GRACE OF GOD THEY DID.

I HOPE YOU ALL GET BETTER RESULTS.....DON'T GIVE UP, KEEP UP WITH THE APPEALS, ETC, EVEN IF YOU HAVE TO GO DOWN THERE AN PRESENT YOUR CASE YOURSELF.....$2,000 IS WORTH IT.

GOOD LUCK.

EVELYN

 

[Lorraine]

Morning Perry,

I guess I'm still in the first stages of the process. I submitted my paperwork about a month ago and haven't heard a thing yet. I sent about three emails to QAS and they haven't responded back yet. I think I'm going to write them daily this week until they give me an answer of what is going on. By weeks end, I start calling them. I realize it appears to be a slow process, but I want to be kept informed of what is going on. Like the rest have said. Do I need more documentation or what? I'll keep you posted. I'll brace myself for the denial phase! Yeah it's easy for the insurance to say you can just go to a clinic. They aren't the ones taking off work to do so. Like my doctor had put down. I live in a remote area and my job is in the city. To go for a teat I ended up taking the day off work. He stated (which is true) that interveinous blood draws are hard on me. I have awful veins and the pin prick to me is a breeze! Pain? What pain? It's just a little jab and withing a few seconds you don't even feel it or at least I don't. Anyway, I'll keep you posted as to what happens. Sounds like your on the Merry-go-Round!

Yes, I'm still going to Vegas. Haven't made arrangements yet but I'm going to call Lady Luck today to see if there are any rooms available. Didn't someone write there was only five rooms left as of Friday. That appears to be one of the lower priced ones to stay at. Hopefully the five of us can co-ordinate getting the same flight out of Ohare with a good rate. I enjoyed myself so much last year in Nashville (in spite of sister and friend) that I don't want to miss being there. We'll keep in touch on that issue. Take care!

 

[Woody]

qas

qas

Lorraine, sorry you sent 3 emails to us. I have been on vacation to the center of the earth( Mamouth Cave) Cave City, KY. Anyway emails to QAS go to an IT person who gets plenty of them, she then sorts them to different depts. If you email me direct, I would get it in a shorter time period & response would be quicker. When we spoke last month I said that it was in your Insurance company's hands & they will look at it for 30 to 45 days . This is where you can help you pay them so you can bug them if you wish & I encourage it. But if we bug them them always lose the file & say to refax it & we start over.So at this time we have to wait for them to review and wait for the findings. Thanks for your patience.

 

[Lorraine]

Hi Woody,

I thought I did email you direct. Maybe I didn't! I do get forgetful! Anyway, you must have pulled some strings because a girl name Sheree from QAS called me at work yesterday. She said it takes 30-45 days for my insurance to process the paperwork and review it, from the day they receive it, which was July 23rd. She said she would bug them on August 23rd to see where it stands. I will in the meantime get in touch with my insurance and see what they have to say. Would love to have it before I go to Lost Wages! I appreciate your help and yes, believe me I have plenty of patience. Thabks again! Take care and God Bless!

 

[Lorraine]

Hi Perry & Anyone Who Has, or Is Trying To Get a Protime through their Iinsurance.

Help! I guess I'm in stage two. My request for a Protime was denied by Blue Cross/Blue Shield. Now, I know I need to write a letter of appeal. I started working on it. I'm looking for some supportive arguement for my cause.
I'll be brief but in a nutshell so far I wrote:

*Extensive Bruising- I'm always afraid everytime I bruise it could form a clot.

*Interveinous Draws are rough on me because of rolling veins. Many attempts later they get the draw and I have a arm full of bruises again.

*Bleeding Gums when I brush teeth. Would feel better if I could occasionally test and know my INR wasn't too high from too thin of blood.

*I have two artificial valves and will be on Coumadin for life! I will have many INR tests in the course of my lifetime.

*Unstable INR a various times in the year, meaning testing every three or four days.

*My cardio feels the need for me to have one to monitor my INR due to fluctuation. He filled out a perscription. I'll show documentation.

*Protime Machines were approved for home use in Pennsylvania by Blue Cross/Blue Shield.

These are some justifications of what I jotted down on paper. Sounds like I should include everything I can download about QAS also in my appeal. I would appreciate any input. I can't afford to pay for one on my own. Thanks!

 

[ILoVeNY25]

Hi Lorraine and everyone,

I guess, I'm in step 3 of attempting to get the machine. I've been denied twice. And my third appeal they told me to mention...
-The keloids on my veins
-Frequent bruising
-Very unstable INR's, 3 weeks under 2.0
-My prolonged hospital stay (5 days) to get restabilized after wire removal
-Uneasy stick/Lack of efficient veins
-Also the fact I'm 19 years old, 2 mechanical valves and lifetime on Coumadin

Good Luck and sympathy to everyone trying to get this machine, I know how frustrating it is to get denied. Whoever said we should get a protime machine with the valves, Is absolutely correct!! I want to see how KEWL home testing is.

 

[KristyW]

Hit them in the wallet?

Hit them in the wallet?

Lorraine,

How about you present the cost effectiveness of the Pro-Time? A venous draw at $70/mo for life is a lot more money than the testing unit would be.

Many times the financial side is all they can see.

 

[EVELYN]

Hi Lorraine.....you can also add in your letter that Protime is approved completely in NY under BC/BS...we just got ours about 2 weeks ago, and it IS wonderful. We were extremely lucky. Both my husband's and my insurance approved the machine and supplies completely.....believe me, I was prepared to fight to the death!!! When the reviewer contacted us her main question was...."Will Mr. Beede stop being checked by the cardiologist?" To which my reply was "NO! He will continue to be monitored, we'll just fax his results in weekly and visit him monthly or whenever a problem arises." I do think $$$$ is the Number 1 issue, but they were concerned that he would not continue to check with the cardio where we have his tests done.

Hope that helps you in some way. Don't give up---even if you that to go through 2 appeal stages...the machine is worth every bit of aggravation. Even if they split the difference in cost with you and then just cover the supplies....it's still worth it.

Keep fighting!!

Evelyn

 

[Perrster]

Looks ok

Looks ok

Hey Lorraine,

I am awaiting my Cardio's nurse to fine tune my appeal with as much technical "nurse-speak" as she can muster. I'll be seeing her in a couple of weeks for another conventional protime test. Oh joy. She's jabbing my hands now! I'm giving her a vr.com t-shirt which may or may no tbe considered a bribe.

I wonder if the so-called professional nursing and doctor staff that insurance companies employ make more $$ than nurses/docs in the field? How could anyone be happy in such a job that does nothing but disappoints customers?

Will keep you posted.

 

[Lorraine]

Hi ILoVeNY25,KristyW,Evelyn and Perry,

Thanks for your responses! The more ammunition the better, Right!

ILoVeNY25 you made some very good points. The bruising I can relate to BIGTIME, because I always did bruise easily, even Post-Op! Don't have Keloids in my veins, don't even know what they are? Like I said, interveinous draws play havoc with me. Thats even using butterfly needles and warm compresses. Finger Pricks are so much easier and effecient. Yes, I would say being on Coumadin the rest of our lives, should be a strong argument.

KristyW I had thought about the cost effect too, and that will be a good thing to mention, which I will. The machine is nothing compared to the many times we go for an INR.

Evelyn,(my middle name by the way) I like the added argument I can use about that Blue Cross/Blue Shield approved it in New York. I am willing to fight for the Protime System and hopefully will presevere! I would be monitoring with my doctor, so it's not like I'm trying to control it all on my own. It does stand to reason that if my INR got too high, I'd eat more greens or avocados(which I miss). I won't give up! I will appeal and appeal and appeal!

Perry-Good Point. I go for my test Tuesday. I just need to find one of my nurses that will agree with my cause. I will see if my cardio and/or nurse will put some stuff in medical lingo etc. I plan to get a copy of my chart of visits for testing and the readings. I have them in a chart but I'm sure it won't be as effective, as coming from the doctors office.

I Thank Everyone who gave me their input. I guess no one said it would be easy to convince an insurance of the necessity of a machine tha is marketed to help us Valvers, or anyone else on Coumadin. I look at it as preventive medicine! I'll get to the private message I received a little later, as I better get back to work. Coffee break is over! Wish me luck on my appeal!

 

[ALCapshaw]

OUCH ! Regular arm draws to check INR levels every week or so sounds like CRUEL and UNUSUAL Punishment !

Tell your Dr. to get either a ProTime or Coaguchek machine for his office ! I hear that Coaguchek will provide the machine FREE to Doctors if they buy the slides from them.

In that regard, I guess I'm fortunate that our Heart Doc's (group of 25+) have their own Lab / Coumadin Clinic (provided by the hospital) and they use a Coaguchek (finger stick) machine for the Coumadin Clinic.

Good Luck with your insurance company !

'AL'

 

[Lorraine]

Hi Al,

No! No ! No ! Thank God! I don't get interveinous draws. My cardios office does use the Coagucheck machine. That's how I knew the machines existed first. After my first time going to my local hospital as a outpatient to draw blood, I found out from my cardios office I didn't have to do that because they had a machine that all they have to do is just prick your finger. No painful needles. I guess I should explain. I've had many bloodtest in my lifetime, some routine yearly bloodworks, some because I have an underactive thyroid etc. Blood draws have always been a huge discomfort for me. First of all I don't care what nurse I've gotten for a blood draw, they all seem to think they have the "touch" and will be able to get my vein on the first shot. I tell them to use the butterfly needles. They usually don't until they fail. That was when I was less verbal. Now I throw a fit if they don't listen to me when I go for bloodwork. After all, I'm the patient and I should know what will work and what won't for me

I tried to find info on Coagucheck but I couldn't really find much documentation to present the insurance company, plus I didn't know if it was available to patients in the USA yet. I figured since the Protime machine is the same and Hank demonstrated it last October in Nashville, it would work just as well. Thanks for encouragement with my insurance. We'll see!

 

[Blanche]

Lorraine

Lorraine

I'm going to send some thoughts off the top of my head and hope some will fit for you. Have you talked to the folks at QAS and asked for some thoughts on the appeal? I've talked to a QAS nurse, Sue Barrett, in the past. She's a marvel. The sales people are wonderful and full of information. I rather like information from people in the medical area too. Sue Barrett helped us with other interpretations. Perhaps???

May I suggest that you scan the Proceedings from a roundtable discussion, "Anticoagulation-Use, Management and effect on Quality of Life." which was recently posted by Kristy on the Coumadin forum here? You have 10 distinguished cardiac surgeons and cardiologists all from prestigious hospitals and universities who seem to advocate (PST) Patient self testing. The information about home-monitoring begins around the middle of page 4.
From this article, you might want to somehow weave in the following: 1.) lower incidence of anticoagulation problems. 2) Less visits to the doctor for minor considerations due to INRs which are not in range. 3.) decreased incidence of stroke.
These are all cost effective arguments for home monitoring.
I base these on info in the article that includes that research shows that people who home monitor are 93%-95% of the time within their range---a state where less problems occur. More accurate monitoring = fewer complications which are expensive.

Finally, I'm thinking that you might want to include the fact that Medicare provides coverage for people who have prosthetic valves. Insurance companies tend to follow practices that begin with Medicare coverage. Medicare covers something, insurance companies follow...implied validity.

Best of luck to you.
Blanche

 

[Granbonny]

Lorraine, I see where you will soon be at 1 year and 6 months since your surgery. 18 months. Do you get a statement from your insurance company showing how much they paid your doctor to do your INR? Mine was $54.00 each time....Get a record of the number of times you have had a draw for INR from your doctor and multiply that towards the amount they charge. Bet it is already over the $2,000.00 machine cost. Nicole, you are so young..your insurance carrier must be nuts not to see how much money it would save them for not buying you a Protime. Bonnie