Dealing with insurance

Most of the time I enjoy my job as a pediatric nurse practitioner working with chronic headache and pain patients. I enjoy the relationships with the families, figuring out what can help manage the headache and life issues best to allow optimal functioning. I enjoy doing certain procedures like Botox for chronic migraine or injection procedures for my patients which very often improve their headache profile. I can even enjoy the scheduling logistics.

What I REALLY do NOT enjoy is dealing with insurance companies. For any of the newer medications, you are always required to do a Prior Authorization, which means justifying why you have made the clinical decision to start a certain medication. For the most part, if someone is over 18 and meets the basic criteria, you can get one of the appropriate medications for them to try, whatever is on the insurance company’s formulary. It’s a process but usually works out OK. When the family changes insurance, you have to go through the process all over again. Time consuming but feels reasonable.

Even for Botox approvals, when they reach criteria to qualify for it (enough migraine days 15/month, tried enough medications and other strategies) and are old enough, over 18, the process is almost reasonable. For those under 18, we also try to get it approved, and are about 50% successful. The insurance companies are a bit more open to approving it for those under 18, if you can make a case. It will often include having to get a peer-to-peer interaction, an extra step for your fun and enjoyment.

For many years, we have been doing occipital nerve blockade and triggerpoint injections for those who are appropriate- those with cervicalgia, occipital neuralgia, chronic tension-type headache, and even chronic migraine. It was a procedure that was more available to younger patients and those who have been denied everything else. And very often quite helpful in reducing headache burden, especially with neuralgic pain. The medications we use- lidocaine, bupivacaine and sometimes triamcinolone- are older medications and not terribly expensive. Procedures if effective are done every 6 weeks or so. We rarely had trouble getting these procedures approved, not even on the radar of problematic procedures. Until now……..

For the past 2 months, the insurance companies have been denying the occipital nerve blocks as being ‘experimental and not medically necessary’, even when you have used the correct and appropriate diagnosis codes. They seem to still be approving the triggerpoint injections. Patients are now getting bills for these procedures often back dated to before the denials. When you call and try to appeal, doing a peer-to-peer or whatever is required, you are just denied, full stop. It is not even worth it to fight about it, never approved.

My opinion is that it started with one company (guessing Blue Cross Blue Shield) which led the way for all the other companies. They decided that, in their infinite wisdom, these procedures are now off the list of approved procedures for our patients. They have removed another tool from the headache clinician’s toolbox, which is well tolerated and usually effective.

So what to do now? Well, I have started to keep track of those patients I know are denied and when I see them, I explain the situation, unless they already know it. I also speak with other families, to let them know what is happening, and to let us know if it happens to them, just in case we do not have the information. If I know it is denied, I perform the procedure as always, including the ONB, but just bill for triggerpoint injections. It’s the same medication mix, just a location that seems to be getting rejected. It is less revenue for the clinic, but I cannot in good conscience have patients be billed for the ONB. I may soon just do it for all of them. I always document what I do in the clinical note.

What is not commonly known among the public is how much clinician time (especially nurses and NPs) is spent having to deal with these issues- writing letter of medical necessity, filling out CoverMyMeds forms, filing out other forms when you have been given the wrong form in the first place, writing letters of appeal, doing peer-to-peer reviews with the insurance people, and being on hold and transferred multiple times when having to call the insurance companies. Rinse and repeat….. This is on top of having a full clinical schedule. We are asking the administrative/management people to consider hiring someone to manage this job, doubtful it will be seriously considered.

This is a seriously flawed system and one of the reasons we need to be considering a Medicare-for-all system or something like it. You cannot imagine the time wasted and frustration that builds and it seems like every day it is getting worse. Clinicians only want the best care and options for their patient and families. Dealing with a pediatric population, we already have fewer options than other providers. There is already a shortage of headache-specific providers. I cannot imagine that dealing with these roadblocks to appropriate care is attractive to those we are trying to entice into the profession.

This is my rant about the subject and now it is over.