by Toby Smithson, MS, RDN, LD, CDCES, PWD
I am a diabetes care and education specialist and a person with type 1 diabetes (PWD). My work setting is coaching people with diabetes via telehealth. For those of you that do work in a clinic setting, you may have mastered the process of guiding your patients on how to order all their diabetes supplies. For me, this was an eye-opening adventure.
A couple months ago I decided to get a newer model continuous glucose monitoring (CGM) system for myself. I had already discussed the various options with my endocrinologist and fellow certified diabetes care and education specialist at the their office, and they told me to just let them know if I was interested in getting a prescription for a different CGM system. The very next day, I said yes. Having diabetes for over 50 years and being a very organized person (directly related to managing my diabetes), I thought this would be smooth sailing. Hey, I know what to do, right?
Unfortunately, this process has not gone smoothly. As soon as I had the prescription, I contacted my medical insurance provider to ask whether it should go to the pharmacy or to the insurance company. They told me it should go to the pharmacy. Simple enough – I sent the prescription to the pharmacy.
A week later I was notified that my endo had not provided prior authorization for the CGM. What? That didn’t make logical sense. Wouldn’t a prescription signed by my endocrinologist be the approval that I am a patient who is warranted to use a CGM? Plus, I was already using a CGM and just switching brands. I continued to go along with what they were asking by calling my MD’s office to relay the message and encourage them to send the documentation the pharmacy was requiring.
After another week, I was told that preauthorization was not approved. What? I proceeded to call my insurance company, which took a couple calls because I was abruptly disconnected after a long wait on the first try. Accidental? Maybe, but it did add to my aggravation level to make a second call and start all over with my questions.
Be patient with your clients. There certainly is frustration involved in all these processes, and your clients may vent about it.
At last, I got some clarity. My insurance company said, this time, that a CGM is not covered through my pharmacy benefit, but my medical will cover 90% of the cost after my deductible and I need to order through a medical durable supply company (MDS). The coverage was, of course, contingent on the order being through an in-network supplier, but the representative was nice enough to give me contact information for two in-network MDS companies. Simple enough – I called both places. Neither company carried the CGM.
Ok, back to calling my insurance company. This time I asked specifically about the in-network status of an MDS company I had worked with in the past for my pump supplies – jackpot! I proceeded to call the MDS company and they were very nice, adding my request into their system. The very next day, I received a call from the MDS along with the quote and a promise to reach out to my endocrinologist to get the required paperwork and then to my insurance for approval. The wait time is expected to be 2.5 weeks. One week allotted for my doctor to send in the paperwork; one week for insurance to approve; and 2-3 days for the CGM to be shipped to my front door.
Many lessons were learned over the past 5 weeks of pursuing to get a CGM. Here are my top, hard-won lessons to share with fellow diabetes care and education specialists:
- It is estimated that diabetes management takes at least an extra 2.5 hours a day. I’m now thinking this estimate does not include the quest to get supplies.
- Be patient with your clients. There certainly is frustration involved in all these processes, and your clients may vent about it. Running low on supplies or having financial limitations would multiply the stress level a great deal.
- Prepare your clients for the process and share some best practices. Remind them especially to be their own advocate.
My favorite line of thought that I share with my clients as well as myself daily is…every day there will be problem solving as a part of diabetes management. This is just one more thing.
ADCES Perspectives on Diabetes Care
The Association of Diabetes Care & Education Specialists Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the Association of Diabetes Care & Education Specialists.
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