Brand New Day HMO: 2022

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Drug Plan pays nothing towards consumer’s monthly CloZAPine

Simple Solution – Resume Medication Delivery Every 28 Days

Briefer than the Brief

The “Insurance” needs to tell the pharmacy, Gilbert Drug, that they are re-approved to deliver the “Consumer’s” Medically Necessary medication CloZAPine which is the generic for Clozaril. This medication was approved for delivery every twenty-eight (28) days. The “Insurance” had it right for over nine (9) years. In 2022 the pharmacy indicated that the “Insurance” is interfering.

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Brand New Day Desolation

Now - They have added 1 chair

Was before the COVID Sickness

We had tables on which to work our treatment plans and eat

Now

Notable Comment – Fall out of eliminating unnecessary services and supports

Before the COVID sickness we had a friend that relied on Brand New Day BND) and its clubhouse to keep on top of his systems. In 2020 BND pretty much dropped their clubhouse and member in-person supports. Our friend would be considered young. Without the program helping him with self care and support he gradually deteriorated. About one month ago he lost the bed that served him well for quite a few years. He is in poor condition and needs that help that BND used to be known for. For now we will identify him as NRP.

Brand New Day’s form asks for these items in this order
Brand New Day Complaint Criteria
“Please tell us about your complaint”

BND Complaint Criteria – Additional Information
Complaint Selections – Appendices

[Link to this full report]
Brand New Day HMO

https://brandnewdayhmo.blogspot.com/2022/07/medication-problems-with-brand-new-day.html

About the Complaint - Narrative Text

20220616-TH @ 945am

New and Improved Medication GAP(s)

Basically the consumer Keith “Buster” Torkelson’s health insurance changed a routine that has been working and effective since 2012. The change has created and will continue to create GAPs in his most important medication CloZAPine (generic for Clozaril). We request that you connect with the offending party to go back to letting the pharmacy fill and deliver his CloZAPine every 28 - Days. Ever since 2012 the Consumer along with his medication partners have for the most part achieved good orderly progress with his CloZAPine (generic for Clozaril) Management. In this paper we demonstrate the nature of said GAPs.

Bright Health Complication (Vindicated)

Keith the Consumer is served by Brand New Day (BND) as his health insurance provider. Recently it would appear his account with BND was sold to another agency doing business as Bright Health. On the cusp of May-June 2022 Keith faced his first insurance generated CloZAPine GAP. The first GAP lasted for three nights. During this time he relied on his CloZAPine “For” Emergency Purposes Only (FEPO).

Routine 28-day CloZAPine Maintenance Cycle (28DCMC)

In this study the consumer is Keith “Buster” Torkelson MS. On the cusp of May-June 2022 the pharmacy, Gilbert Drugs, was told by “the insurance” to hold with filling of the consumer’s CloZAPine for a few days. It is within Keith’s power to reduce his nightly CloZAPine down from 200mgs per night to 175mgs. Some say it is better to have something each night rather than nothing. Slight reduction for a few days per month will permit him to maintain continuity while we work things out. For the purposes of this paper “We” are Mentalation Solutions Group or MSG. In keeping with our tried and tested routine that we call the 28-day CloZAPine Maintenance Cycle (28DCMC) Buster’s psychiatrist prescribes 30-days’ worth each time. Buster’s psychiatrist has been adhering to his regimen ever since Buster linked with him back in 2018. With the 28DCMC Buster had enough to cover all months including those 31 days.

Brand New Day Not Demonstrating Resilience Since COVID – GAP is Sustained

His insurance again indicates to the pharmacy that they will withhold his CloZAPine at the cusp of June-July. We have no information in writing of who is accountable for disassembling the 28DCMC. Keith will again face a GAP in his essential and medically necessary nightly before bed medication: CloZAPine generic for Clozaril. We would normally submit an appeal to BND yet we already have two outstanding concerns (complaints) with them. Much of business as usual before the COVID Sickness has not been revived. One complaint addresses an outstanding Reward that BND promised for his Annual Wellness Visit (AWV). If BND is not going to keep their promises they should inform their consumers in writing. The other broken promise is that BND’s Healthy Food Benefit has not been deposited since January of 2022. We hope to have this issue resolved before the next GAP at the beginning of July 2022. See what you can do – Thank you for your time and consideration. Avey C Asus for Keith “Buster” Torkelson MS.

20220604-SAT: Greetings,

Note to …Error Reporting…

We solicited for help the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). This part of what we said via MERPs website.

“We have a potential medication error on hand that we would like you to be aware of. Keith Torkelson, MS is a consumer receiving services from Brand New Day HMO. Rather recently Keith’s account has been picked up by Bright Health Group. With Brand New Day since 2012: Keith has never had a sustained medication GAP with respect to his nightly medically necessary CloZAPine. We would like you to help return to the way it was from 2012-2017 (Dr. Lee) and 2018-2021 (Dr. Bera). The way it was is that 30 days’ supply is delivered roughly every 28 - days. Among several reasons the 28-Day routine provided for a prudent reserve of this essential medication CloZAPine.”

Perfect Attendance Based on Time Tested Routines

Keith “Buster” Torkelson’s doctors have agreed to sustain what we call the twenty-eight (28) day cycle more formally the 28-Day CloZAPine Maintenance Cycle (28DCMC). CloZAPine requires monthly lab testing after the consumer graduates from the titration stage to the maintenance stage. Lab work performed every 4 weeks or 28-Days permits Keith to have his monthly blood draw on the same day of the week. This has worked out nicely for Buster as indicated by the fact that he has never missed a scheduled blood draw (CBC) since 2012. We coordinate by aligning the monthly blood draw with receiving Keith’s monthly prescriptions of CloZAPine. Prescriptions filled every 28-Days makes common sense. Keith DBA as Buster’s psychiatrist writes the prescription for 30 day supply.

About the Complaint

20220719-TU: Complaint Brief – New and Improved Inappropriate Service

This appeal or complaint regards the following with regards to Brand New Day (BND). BND’s new and improved drug plan is failing to serve. BND is failing about the prescription CloZAPine. So far since their improvement the plan refuses to serve the consumer appropriately. In the process of serving inappropriately BND has generated a medication GAP. Next month at the beginning of August 2022 we expect a two (2) day GAP in Keith’s CloZAPine. Before we submit this we are going to call National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP to see where we stand from their angle.

BND Complaint Criteria – Share times, people, and places

28-Day CloZAPine Maintenance Cycle (28DCMC) – No Head’s Up!

We didn’t find out that we were facing an insurance generated issue with the consumer’s routine medication until May 31, 2022 (TU). Before this day we received no correspondence from the insurer to expect any changes. Therefore we don’t know who within our consumers insurance pushed through said change. The change resulted in Medication GAP. We designate May 31, 2022 (TU) as the date this medication error began. May 31, 2022 is the day that the consumer’s pharmacy said they could not deliver the CloZAPine as they had since 2012.

Break in CloZAPine Pattern – Interrupted (STR)
Issue Begins Roughly May 31, 2022 (TU)

BND Complaint Criteria – Share times, people, and places

28-Day CloZAPine Maintenance Cycle (28DCMC) – Pattern Senselessly Interrupted

Just before we send and or publish this report (complaint) we are going to look online for anything about prescribing CloZAPine in a good orderly fashion. At this point we have to assume the consumer’s health insurer Brand New Day doesn’t understand the 28DCMC. Our study is driven by the fact that: Brand New Day (BND) mediated the current interruption with the consumer’s most important medication CloZAPine. This interruption generated a Medication GAP. If not corrected there with be more GAPs in the consumer’s Medication down the line. The CloZAPine pattern of delivery (dispensing) every 28 Days has served all involved well since the consumer signed on with BND in 2012.

Break in CloZAPine Pattern – Interrupted (STR)
Research – Motive and Effort

MSGBase > Metadata

Even though we have entertained the 28-Day Clozapine Maintenance Cycle (28DCMC) since 2007 the concept only appears formally in our records on March 4, 2017. The motive for our efforts here is that we have yet to find anything along the lines of the 28DCMC in research. We think we have something promising to share. Whenever you look online about information on CloZAPine you more often than not find something new. In addition the material is continuously evolving. Here are two concepts we came across with this episode of research. Years ago Keith “Buster” Torkelson discussed the benefits of moving CloZAPine related CBCs to every other month from every month. It is nice to find that others are interested it the savings that fewer CBC would bring.

Can a 90 day supply of clozapine be dispensed?

“In a recent international consensus statement, recommendations were made to consider a reduced hematologic monitoring frequency of every 3 months with the dispensing of a 90 day clozapine supply (if safe).” May 14, 2020

Can you dispense 30 days of clozapine?
“Dispensing clozapine”

“If an RDA is rejected there will be an option to request a Dispense Rationale through the website or contact center. To obtain a Dispense Rationale, the pharmacist must have an ANC [Part of a CBC] that was obtained in the last 30 days within the acceptable range.” Nov 15, 2021

In Practice Dispense Within 15-Days

The paragraph above most likely applies to a different county. In practice our pharmacy Gilbert Drugs prefers the CBC testing to be within 15-Days of dispensing our monthly CloZAPine.

Issue Began Roughly May 31, 2022 (TU)

(*) See Calendar Graphic Organizer
Concentrate about July 4, 2022 the GAP Day

Aside - Define Impinge
Impinge might be defined as having an effect or impact, especially a negative one.

Brand New Day Criteria - Dates and times (Part of Chronology)
Quantity 60 = 30 day supply per month as prescribed by Dr. Rimal B Bera
Demonstrates 1-Day CloZAPine GAP (July 4, 2022)

Figure – Marked Up Calendar - Calendar GO

Brand New Day seems to be the agency initiating the change with established and normative CloZAPine coordination processes.

Appendix

28-Day CloZAPine Maintenance Cycle (28DCMC)
With held in favor of keeping simple for the time being.
Further development needed before we share the 28DCMC notion online.

Appendix

Coordination

These CloZAPine GAP issues are centered about the consumer’s insurer for health care Brand New Day HMO - H0838. Recently it appears that BND sold Buster’s account to Bright Health - H4853. Yet, BND Member Services indicate that BND still manages the Medicare accounts. The consumer Keith “Buster” Torkelson is a Medicare account. Here we discuss a bit about coordination and coordinated care in health care. Some of the tools used in coordinated care are: Phone calls, letters, emails, treatment planning, invoices, patient portals, electronic health records, Zoom virtual meetings, and face-to-face meetings. As time progressed since 2012 the consumer has been asked by BND to coordinate more and more of their care.

Associated Items
Matrix - Appendix – Additional Information
Coordination in Context of the 28DCMC

Appendix - Additional Information

GAP Demonstration using Photographs

Below we include some photos that are in context for our request to resume the 28-Day CloZAPine Maintenance Cycle (28DCMC). The photos below demonstrate the new and emerging CloZAPine GAPs. We call pill bottle evidence. The prescribing doctor is Rimal B Bera MD. He has performed business as usual this year 2022. He will be brought into the discussion at the consumers next September 14, 2022 Medication Management Appointment (MMA). In reaction to the GAP we considered making an emergency appointment with Dr. Bera. Since 2012 the consumer has never had to make an emergency appointment with his Brand New Day associated Behavioral Health Doctor (BHD). Gilbert Drugs has been the consumer’s pharmacy since 2012. They eagerly wait for the return of the 28DCMC.

CloZAPine dates Filled by Gilbert Drugs

CloZAPine 05/03/2022 & CloZAPine 06/03/2022 & CloZAPine 07/05/2022

Appendix - Additional Information - Coordination

[MERP HELD BACK]
Asking for Help – NCC MERP Method
NCC MERP
https://www.nccmerp.org/
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
Associated with:
08_Clozapine_Error_NCC_MERP_Route_22070501_Notes

Appendix

Brand New Day’s Methods

Over the years since 2012 we have corresponded with Brand New Day (BND) regarding various Quality of Care (QOC) issues. These included complaints, grievances, and appeals. We have been using some old BND related forms. Therefore, we felt it would be a good time to update our BND form set. Member services indicated that the following web address would provide what we were looking for in the name of forms.

BNDLink > “Filing a Complaint, Grievance or Appeal”

https://bndhmo.com/Members/Plan-Resources

Brand New Day Soliciting Feedback

BND aspects of “speaking up and or asking for help”

FYI – Links to Brand New Day Forms
Appeal Form
(English)

https://bndhmo.com/BrandNewDay/media/BND-Media/2021_Appeal-Form_EN.pdf
Grievance Form
(English)

https://bndhmo.com/BrandNewDay/media/BND-Media/2021_Grievances-Form_EN.pdf

Appendix

Itemizing Resources

Ever since signing on with Brand New Day back in 2012 the consumer has jumped over many hurdles set by BND. In the process we have identified many resources. Some are helpful and some are not. We place BND itself right in the middle. BND’s CMS Stars scores place them above the middle at 3.5 CMS Stars out of 5.0 CMS Stars. The theme for this study (complaint) is a Medication Error that resulted and will sustain a Medication GAP. Again, without the “Insurance’s” intervention the Medication GAP will be sustained. In the table below we list some of the consumer’s BND centered resources.

Other Routes - Theme – Medication Error
Brand New Day Centered Resources
Some in-network and some out of network

Appendix

20220706-W: Phone Notes – Medical Board of California A Dead End

We now believe that Brand New Day’s (BND) compliant and appeal processes are now for service year 2022 compromised. On behalf of Keith “Buster” Torkelson (The Consumer) we have two outstanding complaints about 2022 with BND. In the past we would get timely responses. Not so is now the case! We looked into alternative methods before we involve CMS Medicare. On July 6, 2022 (W) we called the Medical Board of California (MBC) to test out a resource new to us. We told them that doctor had no part with our BND issue for he is behaving the same as usual since the consumer signed on with him back in 2018. The MBC phone rep referred us to the CA Dept. of Managed Healthcare (DMHC).

20220706-W: DMHC Independent Medical Review (IMR)

The contact information for the DMHC given us is California Dept. of Managed Healthcare (DMHC) @ 888.466.2219. When we called the DMHC the call rotary said there we 28 callers ahead of us. They picked “Buster’s” call up at about the one hour point. Because they told us the initial number of callers we could project ahead and do other tasks while we wait. We told them “I need help with a complaint” and “A complaint that my health insurance fails to recognize”. They indicated that we might benefit with an IMG or Independent Medical Review. We are putting the IMG option on the back burner for a bit.

20220707-TH – Phone Notes – Member Services Resource falls through

We decided that on behalf of the consumer we were not using an up-to-date Brand New Day (BND) form or method. Thus we opted to call BND Member Services. We tried three different dialing routes. First we used the dial pad and put in BND # 1-866-225-4795. This redirected us elsewhere to something not related to BND. Then we put in the number in our phone for BND’s Isabel. The first time using Isabel our call went through and we connected with “Rassy”. Rassy put us on hold for 12 minutes and 46 seconds. We said we have a “Medication Issue” for our consumer. She said she would email the form(s). The forms didn’t arrive. Later we dialed a call using the Google Route and their number comes up as that for Isabel. We are puzzled that the same number could yield difference results.

FYI Brand New Day's Number as offered by CMS Medicare = H0838
Brand New Day’s current CMS Stars Rating is 3.5 of 5.0.

Notes

20220708-F@11am – Phone Notes – BND’s John is a good guy

On behalf of the consumer we have tried to work with Brand New Day’s (BND) Member Service many times. In general Member Services is not very helpful. This changed when we reached “John”. We have two outstanding complaints with Brand New Day this service year 2022. We thought that maybe the old form we were using didn’t contain the up-to-date mailing information. We asked John about it and he gave us a method to find both complaint and appeal forms. Marginally this is not an appeal. We asked John about interference by Bright Health. He indicated that BND still serves the Medicare clients.

20220708-F – Expiring Resources

We also asked John about two of our corporate contacts Ali Khalkhali and Constance J “Connie” Snyder. He says Ali is in high administration and the Constance may have retired. Maybe the reason behind this problem is that the new hires or those appointed or promoted really don’t know what they are doing. In the end John said “Call back anytime”.

Figure - From Letter from Constance Snyder (CJS)
Losing those in the know

Professor Gary Zager’s Quote (2011)

“It is hard to get good help for the non-profits”

Appendix - Share of Cost Aspect

About the complaint – Who is the culprit?

We can’t be certain who exactly altered the way Keith “Buster” Torkelson’s most important medication is delivered. We received no advanced notice by mail or email indicating who is responsible. If we knew who was responsible they might be more accountable. The GAP promoting change in “Buster’s” CloZApine delivery cycle is something new yet not improved. Bright Health has been added to Brand New Day’s letterhhead header. Again, we called BND Member Services and the phone Rep indicated that BND is still managing the Medicare accounts. “Buster” is what is called Medi-Medi. For the most part Bight is vindicated. Then we are back to BND making a change after getting it right for just over ten years. The table below demonstrates that BND has no share of cost with the consumer’s CloZAPine. Overall CloZAPine is less than $1.00 per tablet. All of this is to not save anything across six (6) or less tablets per month.

Associated Study

MSGBase >

From: 10_BMB_Clozapine_Gap_Intervention_22061101_Brief

Figure – CloZAPine Share of Cost Breakdown
May 20, 2022 Statement as provided by mail from Brand New Day.
BND’s Part D Drug Plan appears to be challenged

Appendix

Share of Cost Table

The table below is just another way to demonstrate that Brand New Day (BND) shares no cost with CloZAPine. The consumer “Buster” has come to rely on his medically necessary medication CloZAPine. For more than eight years and up and until this year 2022 the consumer was prescribed a thirty day supply of CloZAPine delivered every twenty-eight (28) days. Since the plan, BND, shares no-share-of cost the decision to alter processes associated with CloZAPine more likely not driven by BND’s financial concerns.

28 days V 30 days

2 night count = 4 MAX – Note Plan Pays Nothing towards CloZAPine which is the generic for Clozaril. Note: CloZAPine is not to be confused with any Benzodiazepine such as Clonazepam generic for Klonopin. We reviewed some medical records finding that in the records they use CloZAPine rather than Clozapine to reduce ambiguity.