Friday, September 4, 2009


The medical office for Dr. Wonderful called yesterday and delivered the great news that they had prevailed over the insurance company. I was surprised it had gone through so quickly and easily, and Dr. Wonderful's medical front office person chuckled and said she had found a lovely loophole. The medication was approved not because our doctor thought it was the best medication for Nolan, but because of some quick thinking on the part of our doctor's medical office personnel.

The story, as related to me, went something like this:

I dropped off the prescription, and our pharmacist called to get insurance approval. The insurance denied the claim, and forwarded the information to Dr. Wonderful's office. Dr. Wonderful's office then sent the information back that the medication was urgent and the child in question needed approval quickly due to the severity of the case. Again, a big red DENIAL. So Dr. Wonderful's office decided to save the big battle for Wednesday, when there would be no one around. Just in case things started to get a little "loud."

She called and restated the information, that this child needed this medication. And he needed it quickly. The insurance company's response?

"Absolutely not."

She lobbied again and again, to no avail. They insisted Nolan take the cheaper drug, even though it was not recommended by our doctor. They would not approve Nolan to take Nexium until he had tried Prilosec and it had failed to work.

Then Dr. Wonderful's office noticed something. The Prilosec the insurance was willing to pay for was not only less effective for our little guy, it was also a PILL. Giddy with her plan, the office called the insurance person back.

"The medication you will approve for this child is a pill. He can't take a pill."

"He can take a pill. We are approving the pill."

"He's two. He can't swallow a pill."

"Why can't he swallow a pill?"


"And how does that make him unable to swallow a pill?"

"It's a choking hazard!"


More silence.

"The Nexium is approved."

So, on the basis that Nolan might choke to death on the cheaper drug and therefore cost the insurance company even more money than the cost of the Nexium, we have approval.

The kicker is the phone call I received about 10 minutes after I hung up with Dr. Wonderful's office.



"This is XXX Insurance Company, and I'm happy to let you know your son's medication has been approved without delay!"

Yeah, right, buster! I know the whole story. And I also notice that you never call when you're denying things, only when you have finally succumbed to approving something after a fight.

At least we have Nolan's medication approved for the next year, no matter what hassles we have to go through to get it!


Lucas'Mommy said...

So glad to hear it!!!

Anonymous said...

I'm glad it worked out but boy does this stuff make my blood BOIL! But nope, we don't need to reform healthcare in this country, everything is just FINE. Freaks me right out.

Julia said...

Great outcome, and a great story, too! But why does it sound so frustratingly familiar? Why does it sound so much like the battles we've fought, and battles I hear about all the time on cicircle ... where some stuffed shirts try to put off using *our* premium dollars for *our* medical care for as long as they possibly can, hoping that we'll walk away in defeat or that at least they'll get another week's worth of interest on it, and then jump over themselves to take credit for it when we finally beat the money out of them?!? (No bitterness here, no.)

Bill and Shelly said...

So glad that you finally found out what was going on. Hopefully you are on the road to good health.
Don't you just love insurance companies?

tammy said...

Great news! Another battle fought, another battle won ... truly thought, why does there need to be so many battles to just do the right thing for our children? Glad this one's behind you!

tammy said...

Great news! Another battle fought, another battle won ... truly thought, why does there need to be so many battles to just do the right thing for our children? Glad this one's behind you!

Ericka said...

So happy that you found the cause of Nolans eating issues!!! I hope the medicine works and Nolan will feel better!

Herding Grasshoppers said...

Way to go Dr. Wonderful... very quick thinking!


leah said...

We are so happy it was approved- it is really making a difference! He's obviously still refluxing (coughing and grabbing his throat a lot), but he has also started eating! Some days are better than others, but often he eats THREE FULL MEALS. At this rate, we'll be able to break out the size 18 month jeans SOON!

rouchi said...

Great news. Hope he eats well and fits into those jeans. I am glad another milestone crossed and another path found.All the best.

xraevision said...

This is such good news (except for the insurance company battle)! I will be curious to hear about how Nolan's eating habits improve as his symptoms decrease. Big boy pants, here he comes!