Health care providers v. insurance (kinda long)

Miscellaneous and Personal Stuff I Must Share
1

I’m having catatract surgery soon. Because money is tight for me right now, I’ve been very careful to talk with my insurance company to clarify my co-pays for the doctor, the surgery center, the anesthesiologist, and the very expensive eye drops.

Insurance company says that my cost for doctor, anesthesiologist and surgery center will be $5 each. Yes! I think: I have very good insurance.

Because two of the eye drops are some specialsupercool formula, my co-pay for each of those will be $30. Co-pay for the third bottle of eye drops will be $10. Again I think: it’s good to have good insurance.

So I go the pharmacy yesterday to pick up the eye drops and am told that one bottle will cost me $178!! My insurance has declined to pay for it. What?! I leave the pharmacy without the drops and call the insurance company. Turns out my doctor needs to send in a pre-authorization form. I called the doctor’s office. They don’t send those in because – get this! – Medicare always denies them. But, but, but I’m not on Medicare! I have private insurance. Same thing, she says, the insurance company always denies them. WTF!! She says, I can give you a manufacturer’s coupon to take $50 off. Not enough, I say. I still can’t afford it. Oh, in that case, she says, I can just give you a sample bottle. **WHAT?!! ** If I hadn’t said anything, you’d let me pay $128, when I could get it for free from you? :mad:

I’m still reeling from this when later in the day I get a call from the billing department of the surgery center, wanting to be sure I know that I will have a $165 co-pay due for my surgery. No, I say sternly, my insurance company has assured me that my co-pay is $5. Oh, please hold, the girl says. She then comes back to say, yes, you’re right, indeed, your co-pay is only $5, so sorry, we must have miscalculated. What if I hadn’t spoken up? They would have happily collected $160 more than I owed. Would I have gotten it back at some point? I rather doubt it.

The idea of the surgery itself doesn’t faze me but the twisty, mysterious, winding road between insurance and billing offices has freaked me out.

2

Oh yeah. I have officially given up on preventative medical care. At my one year followup for my heart attack/catheterization/stent, my copay was $145. :eek:

For that $145.00 copay I got my cardiologist asking if I’ve had any chest pain. I replied, “no” and he said good. He did an EKG and sent me on my way.

Yesterday I got a $35 bill from my cardiologist. The EKG cost $85 and my insurance only paid $50. So I’m done. I will continue to pay my insurance premiums, but will consider it a disaster policy.

3

Just make sure you keep taking your Plavix!

4

Heh. I am! He actually suggested stopping Plavix but continuing 81 mg aspirin, but I told him that I just bought 300 tabs of Plavix (three 100 tab bottles cost less than my copay on a 30 day supply from my pharmacy, although the legality is questionable) so he said stop the aspirin and continue the plavix.

5

Just wait till you’re on Medicare. Your experience will seem commonplace . . . especially (Part D) prescription copays.

6

Here’s my newest related rant. The patient needs a new diabetes medication. I give them a list of the options and ask them to check the formulary to see which are available and covered. The patient reports back that the insurance states that drug X needs preauthorization to be covered. We contact the insurance and procure a pre-authorization form. We document that the patient has already tried drugs Q, R and S and they are not proving effective and drugs Y and Z caused intolerable side effects. We search our records and photocopy our notes documenting these side effects and the dates each was started and stopped. My office manager spends 30 minutes on the telephone explaining to the insurance company that the patient has not tried drug Y in the past 180 days since when she took it 3 years ago she had an allergic reaction so I am not going to have her try it again to be within the 180 day window they arbitrarily set. We finally get approval for drug X with a nice note that it is now covered for the next year. We send in the prescription and get a telephone call from the patient. It appears that while the insurance company has authorized the medication, that does not mean that they actually are going to pay for it. The medication is over $400 a month so that the patient cannot afford it anyway.

(The only benefit I can see to getting it “preauthorized” is that it would then count toward the patient’s out of pocket maximum).

7

**Bolding **mine.

I think that the problem is one of definitions. “Available and covered,” in insurance-speak, clearly doesn’t have the plain and ordinary meaning the rest of us mere mortals think it does. To us, it means that the drug is available for purchase and, having gotten the coveted preauthorization, is covered, at least to some extent, by one’s insurance policy. To the insurance company, it apparently means that they’ve heard of the drug before, suspect that some people somewhere might be taking it, and regardless of what hoops you jump through, actaully have no intention whatsoever of paying any portion of the cost so you can be one too.

This has me completely flummoxed. I have received one bottle of eye drops for free from the physician and the pharmacy significantly reduced the cost of the second by using my “loyalty” points. That’s all well and good but how am I supposed to pay for these same drops when needed for the surgery on the other eye? I don’t have any more “loyalty” points and that tiny bottle of eye drops retails at $264.

I’m tempted to contact the insurance company and try to get someone to explain this issue to me, especially how to work around it, if possible. But frankly, I’m not sure I’d believe a single word they said.

8

That and the patient will pay whatever the negotiated rate the insurance company has instead of the pharmacy’s retail price.

9

It might get you the negotiated rate, but it would probably NOT count toward out of pocket.

Insurance doesn’t make sense, and they seem to make decisions on a whim or a toss of a coin. A couple of examples:
I take a wakefulness medication, because without it, I’m a zombie even on 9 hours of sleep. Provigil is the older version, Nuvigil is the right-handed (left-handed?) isomer of that, and is therefore newer and shinier and more profitable.

Provigil went generic a couple years back. My insurance at the time said “OK, Nuvigil isn’t covered any more, gotta go for generic Provigil”. Whatever. The dosage is slightly different (need to take two pills at different times of the way instead of one daily) but it worked acceptably. Then I switched insurance. THAT policy said “no Provigil, no way, no how, not even generic” - so I’m back on Nuvigil.

And my steroid inhaler - I vented about this a couple years back. The insurer said “no more Flovent” so I switched to Symbicort (one of the steroid + long-acting bronchodilator mixes). Ignoring my personal VERY strong dislike of combination medications (easier to take, but it’s a way of extending the patent on out-of-patent ingredients), the damn stuff trashed my blood sugar. 9 months later, as I’d just begun to figure out the connection and made 'em switch me to Advair (another combination, same steroid as Flovent), they re-added Flovent.

I’m on a proton pump inhibitor (think Prilosec and Nexium) called Dexilant. That’s another “left handed isomer” kind of thing, equivalent to one of the OTC PPIs. When I was “just” on Prilosec, the generic was cheaper by prescription, even counting the insurer’s portion than the OTC stuff - same dosing.

I wound up switching to the Dexilant because the Prilosec wasn’t doing it, and I was losing my voice from the acid. Worked like a charm. My insurance then decided it wasn’t paying for any PPIs any more. (and they were discontinuing coverage for my blood pressure medication). Fortunately (?) right about then I switched to being covered under my husband’s policy, which DOES still cover it.

10

jayrey, I’d be having a conversation with your doctor about the staff not filing prior auths. If they are truly “never” being authorized, they’re doing something wrong. That would make me find a new doc, as more and more meds and treatments now require a prior authorization.

My insurance ***still ***doesn’t want to cover Relpax, a migraine treatment med. And they REALLY don’t want to pay for the 18 per month my doctor prescribed.

So when I got the prior authorization for the “over-limit” amount, I went to fill my prescription. No go. Why not? Because my prescription insurance vendor, CAREMARK (CEO, Satan) has an agreement with my insurance company to only approve 12 tablets every 45 days.

I said, that’s not what my doctor ordered. “Oh, we have an agreement with Tufts.” That’s nice. What about doctors and what they order for their patients?

And why the hell isn’t this on any of the documents my doctor had to complete for the prior authorization for the medication or the over-limit issue? Oh, we don’t know.

Twits.

So the doc added Maxalt, which now that it’s a pill and not a gross mint-flavoured melting tablet, works pretty well. So the first half of the month, I use Relpax. The second half, I use Maxalt. It works.

11

Yeah, Tufts asks what preventatives you’ve tried in the past 3 years before Botox for migraines authorization occurs. I’ve been getting BOTOX for three years, so I haven’t taken and failed on any meds. We get around it by listing EVERY every preventative and EVERY side effect I had in the 7 previous years of attempted treatment.

And the insurance company ***still ***didn’t want to approve it. Last year, in addition to the normal paperwork, the following physicians had to call and talk to the medical director at the insurance company: 1) my neurologist, who teaches at Harvard, 2) the medical director of my company, and 3) the Chief Medical Officer of my company. The Medical Director and CMO basically got on the phone with the insurance company and said, not only have we seen Bunny have a week-long migraine, but also she’s in charge of two $500,000 projects, and Bunny really won’t be any good to us if she’s in constant pain and whacked out on opiates.

It took us weeks of back and forth to get the coverage approved.