Big Crooks, LIttle Crooks

One of the many topics that is omitted from the discussion about health care reform is participation by providers. It is not required and there are many providers who choose not to be in network in any insurance plans. Recently I was prescribed a medication that requires compounding. Unfortunately, my two favorite pharmacies, Stamford Pharmacy and Hope Street Pharmacy, which usually do compounding, do not offer this particular medication, which is medically necessary for my condition. My doctor's office gave me a choice of four pharmacies to use, but because of logistics, I chose Wedgewood Pharmacy in Swedesboro, New Jersey. When I found out that they do not handle insurance, I wasn't concerned. The "customer service specialist" claimed I would get the paperwork necessary to file for reimbursement. No problem, I thought.

To make a long story short, I had to spend almost two hours of my time (so far) trying to determine why the claim was rejected. It boiled down to the fact that Wedgewood would not give my insurer a complete breakdown of the ingredients and costs,something to which I believe is required under HIPAA regulations. At least I know I would be entitled to it. And why not? Shouldn't I, as a patient, know what's in the medication I'm taking? It's only my health. Of course, sometimes it's my money or other issue that I must know about. I argued with Dan Bitler, the "QA" and regulatory person at Wedgewood that I am entitled to know this. He denied it. The fact is that I have received thorough breakdowns from doctors and hospitals' billing departments and even found a serious error in the bill for the delivery of my first child. Someone entered the wrong code and claimed I had a bone marrow transplant. Another time I received a statement that billed my health insurance company for ambulance service after I slipped on ice in a shopping center. I made the calls to straighten it out. It was an accident, not a health issue. Therefore, the insurance company of the strip mall was responsible for the claim. To those who believe that health care costs can be contained if only consumers knew what things cost and would not abuse the system, hey, I'm on top of things. I protected my health insurance company from bearing the costs of the bone marrow transplant I did not have and that ambulance ride.

Fortunately, I am working with someone at my insurance company who acknowledges that I am entitled to reimbursement and that Mr. Bitler is being stubborn, evasive and outright misleading. She's taking action on her end and I am taking action on mine. Woe to Wedgewood Pharmacy! Furthermore, I am going to recommend to my doctor's office that they find an alternative provider because no patient should have to have to go through what we're going through for a claim of $146.00.