Even if you get an approval for an expensive specialty drug, good luck.
I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug.
So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval.
During the complaint process I learn:
- Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive.
- The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error.
They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings.
Regulator closed it as resolved.
I'd class action their butts if I wasn't still exhausted by the experience two years later.
dolphin3.0-llama3.1-8b Q4_K_S [4.69 GB on disk]: correct in <2 seconds
deepseek-r1-0528-qwen3-8b Q6_K [6.73 GB]: correct in 10 seconds
gpt-oss-20b MXFP4 [12.11 GB] low reasoning: wrong after 6 seconds
gpt-oss-20b MXFP4 [12.11 GB] high reasoning: wrong after 3 minutes !
Yea yea it's only one question of nonsense trivia. I'm sure it was billions well spent.
It's possible I'm using a poor temperature setting or something but since they weren't bothered enough to put it in the model card I'm not bothered to fuss with it.
I've had BCBS reject prescriptions they've already pre-approved multiple times. First time, they denied all knowledge of the REQUEST (when my doctor has their APPROVAL fax in hand). Second time they acknowledged they had approved it but had to contact their pharmacy group to put in an "override".
I've submitted a complaint with the state insurance regulator though I doubt it goes anywhere.
Anyone for a class action lawsuit on the grounds of bad faith breach of contract and medical malpractice for obstructing access to care they already admit is medically necessary (by denying something already pre-approved)? I don't even want money. I want a Consent Decree enforced by the court that strikes fear across their whole industry.
Audio record every interaction you have with insurance and tell 'em you're on a recorded line.
I had the insurance written approval in my hand while the pharmacist told me it was being rejected for needing prior approval. The insurance phone rep said they could find no record of any REQUEST, let alone approval, for the drug.
So I go to the state insurance regulator. That does at least light a fire under their arse. They can't claim it's not medically necessary when I already have their approval.
During the complaint process I learn: - Front line reps don't have any access to any pre-auths. You need to talk to a supervisor. They ADMITTED the system is by design obstructive. - The person who entered my approval did it wrong and did not follow the SOP to run a test transaction that would have caught the error.
They then submit their reply to the regulator leaving out all of the above and blaming the pharmacy instead. I follow up with the regulator pointing this out. I have voice recordings.
Regulator closed it as resolved.
I'd class action their butts if I wasn't still exhausted by the experience two years later.