Perjeta: Life Threatening Denial of Service

William writes:

“I spoke earlier about a major hiccup in her treatment. She is being denied a miracle drug her doctor prescribed which is called Perjeta (brand name). Dawne’s medical provider knowing this drug has never been paid for by AETNA in spite of AETNA not requiring pre-certification or pre-authorization chose to hide this reality from us while allowing the doctor to use it as the key selling point for doing pre-op chemo therapy and thus delaying surgery for 5 months. That was one heck of a sales pitch because Dawne was predisposed not to do chemo at all (which I mention at the risk of beating a dead horse) and more importantly Dawne’s version of breast cancer is Advanced Stage HER2 Positive, as it has broken through the milk ducts and is in her breast tissue and working over the lymph nodes. Your gut instinct is naturally to do surgery now which more than explains why we are on the floor after discovering the above news. To be clear, this fraud was conducted by the business office, not the doctor as the later had no such knowledge. Apparently, their business model is to let the doctor prescribe and then the business office goes into the blame the insurance company mode.

You know me. Never say it can’t be done or hasn’t been done. Give me a business hurdle, I’ll jump it. Don’t use blame the other guy as a rationale for failure. The medical provider’s office director quite frankly is the typical downer persona. She says, “We know what we are doing. This is our business.” (…Like go away idiot and stop bothering me I’m the professional.) “If you get Pejeta paid for you will be the first person in our extensive practice to accomplish this. No insurance company pays for this drug.” Talk about feeding the beast.

By the way, did you catch this idiot (sorry name calling is something I usually stay away from, but really) admitting to knowing all along that the key drug in Dawne’s plan was known all along not to be a viable alternative as far as her organization was concerned. Talk about Bad Faith. What a callous jerk. No doubt as the dusts settles that is a piece of unfinished business. Great doctors, lousy business model.

I can’t put a nice spin on this. My response wasn’t pretty. Stern, eye focused, bass-driven, low volume demands can come across like your pushing a 6 year old kid around – although it beats screaming at the top of your lungs at, or chocking the crap out of an obstructionist. In your face, give me all of your correspondence with AETNA and get out of my way for 48 hours while I’ll get your needed administrative approval thankfully worked. I now had the road map I needed to work through AETNA, as any thinking and motivated person with average intelligence could do if they really cared and were more concerned about getting their hands dirty than cruising the office in New York’s latest business costume.

Good news! Five phone calls, guided by outstanding AETNA employees all moving me constructively through the proper departments, about 3 hours of work, and we have the proper billing code, a public accessible web link to the AETNA policy standard for Perjeta, a fax from AETNA (as well as several unanswered messages from AETNA to our medical provider’s office director), and a verbal statement from the case manager that assures us Dawne is covered, the drug is authorized, and the provider will be paid. Even, better an AETNA case manager who compassionately and professionally said I don’t stop until the job is done. Dawne will get her Perjeta starting her next course of Chemo. God I hope so and I hope this unnecessary drama is done.



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