Nannygrams from my health insurance company

The BBQ Pit
21

Sometimes a prescription is just the doctor’s best guess about what drug/dosage will end up working the best. My doctor has certainly been known to prescribe, say, a steroid inhaler that normally lasts 2 months at typical adult dosage, but just tell me to use it for a week or two until my flare-up calms down. Or another example: I was prescribed anticoagulants (Coumadin) when I developed a blood clot after surgery. My doc had my blood tested every couple of days until the dosage could be adjusted properly, which meant I was taking anywhere from 1 mg/day to 10 mg/day, an amount that could vary depending on my level of physical activity or even depending on how many green vegetables I ate.

So no, the pharmacy isn’t the best judge of how much and what kind of medicine I should be taking; tehy simply don’t have all the necessary information to determine that. That’s why I have a doctor. I listen to my doctor first and foremost unless the pharmacist can give me some reason to believe that my doctor made a mistake.

22

Exactly. Confuse the shit out of them.

23

Oh bullshit. My health insurer has a stake in its profitability. If this conflicts with my situation, I lose.

Case in point: I had a hernia a few months ago. It was a serious problem: the hernia was incarcerated, necessitating immediate surgical repair. I handed over my insurance information and went into surgery.

Two months later, everything seemed to be fine. The site of the surgery was healing nicely and the surgeon cleared me for all activities.

And then I got a seventeen thousand dollar bill from the hospital.

Several frantic phone calls later, it turned out that my insurer had simply flatly denied the claim the hospital submitted on my behalf. No review, no question, no explanation, just, No we’re not paying this. Why? The idea is that they need to differentiate between different types of claims, so they aren’t paying for workplace mishaps or auto accidents or anything else for which somebody else, in their view, should be on the hook. They used to send out questionnaires to validate claims, but they had such a poor response rate that they’ve started to put the onus back on the patient. Denying the claim causes the hospital to shrug and turn the expense back to the [del]victim[/del] patient; whereas the individual might regard the bureaucratic questionnaire with only casual interest, the receipt of a huge bill really gets one’s attention. The patient calls the hospital in a panic, is told the claim was denied, calls the insurer, and then is presented with the opportunity to go through the scripted questionnaire on the phone. Then, and only then, is the claim approved, and the money released.

The vague part was, I couldn’t figure out if they were doing this routinely, for everybody, or if they were doing it only for a small subset of their claims, as a pilot type program to see how well it would work.

Regardless, as cynical as I already am, I got even more cynical that day, let me tell you.

So fuck you with the “they have an interest in your health” business, because it’s a Giza Pyramid size pile of steaming horseshit.

24

No, it isn’t their business. It is their business to make sure that they turn a profit. Health insurers don’t give a damn about their customers’ health: just whether or not they pay their premiums on time and whether or not they’re using their health insurance (and the health insurer hopes that you aren’t because that’s money they don’t have to spend).

I say this with love, having been one of those temps, but it is not some temporary employee’s business, nor the business of some RN who’s never seen me, to diagnose me or tell me what will be best for my health.

My health is no one’s business at the health insurer’s. It is my business and my doctor’s business. No one else’s.

25

Now, this is a bit funny to me, because I grew up in one of those awful socialized-medicine nanny states (Denmark, for those keeping track at home), and I’ve never, ever heard of anything even resembling this.

Doctor-patient privilege - do you speak it?

26

You don’t think your government knows what you’re taking?

27

Meanwhile I tried to refill a prescription today at a different location of the same chain and was told that the insurance company requires “prior authorization” before they’ll pay. My doctor needs to call them and tell them why I need it.

Ummm…same reason as last month? And every month prior to that for the past several years? Same pills, same dosage - I just switched my prescription to a store closer to where I work so I could pick them up on my way home.

28

That’s normal if your medical facility had to authorize refills. Not so normal if you were transferring a prescription that still had refills.

29

“You know, if one person, just one person does it they may think he’s really sick and they won’t take him. And if two people, two people do it, in harmony, they may think they’re both faggots and they won’t take either of them. And three people do it, three, can you imagine, three people walking in singin’ a bar of Alice’s Restaurant and walking out. They may think it’s an organization. And can you, can you imagine fifty people a day, I said fifty people a day walking in singin’ a bar of Alice’s Restaurant and walking out. And friends they may thinks it’s a movement.”

Sorry about the language. I wasted a lot of time in my adolescence memorizing Alice’s Restaurant.

30

The current meme among health insurers is that EVERYONE with asthma MUST TAKE INHALED STEROIDS. No exceptions. Based on a couple clinical trials that, by the way, never addressed people with mild intermittent asthma as opposed to chronic moderate to server types.

(Since I’ve been laid off I don’t have access to cites, unfortunately).

Me, I have a dreadful fear of being overmedicated. It happened several times when I was a kid. I go months without asthma symptoms, I have had doctors question if I even have asthma (I do - it can be triggered) - why the fuck should I take daily medication?

Same thing with the quesiton “When was the last time you were hospitalized with asthma?” Uh… NEVER. I have never had an asthma attack that required me to be admitted to the hospital. This makes the drones unhappy because, apparently, their little matrix has no option for “never”. Got news for the drones - not everyone with asthma is a sickly invalid!

31

I’m going to stick a toe in the water here and admit I’m an RN working for a large disease management company providing some of the services described. No, I don’t work for any health insurance company directly - most of them contract the services out to a specialist company like mine. This is allowable under the language in HIPAA allowing some disclosures for ‘the purpose of providing healthcare operations’. Technically, we are a ‘business associate’ of the companys we provide services too.

Part of the problem is, the info we get from Great Big Health Insurance Company is so minimal all we really know is ‘we think person X probably has condition Y. Send them a mailing, give them a call, and see if they want the program’.

I talk to a lot of folks every day that are pleased to talk to me and interested in the info we have; we also hear from folks who are already well educated about their health and absolutely don’t need us, don’t want us, don’t want calls, mailings or any info whatsoever - and that’s fine; the way we’re set up, we’ll politely and cheerfully note that down and never bother you again. We have a lot of people to reach who need so much from us that it is a waste of our time, too, to send anyone mailings and try to keep calling if they don’t want or need the services.

I spent almost an hour on the phone this morning with the mother of a 3 year old who had just been diagnosed with asthma. The doctor basically gave her the diagnosis, some prescriptions, and that was it. She was almost frantic. I was able to provide her with some information that she really found helpful and we’ll follow up with her for a while.

Different companies manage these programs differently, and some are better than others. I’ve heard horror stories from friends working elsewhere. The company I work for, if your asthma is under control for a year (no asthma-related claims but meds) you drop out of our program automatically. A call every month for a controlled asthmatic is wasteful of time and resources.

BTW, the number of doctors actually prescribing inhaled steroids for asthma? About 3% from the latest info. It’s an outdated standard and most doctors know it. We don’t push that issue where I work.

In short, I enjoy my work and I feel there are people I help, but I know these types of programs aren’t for everyone and no one should be forced in to one.

32

The relationship between a service provider and customer is a complex one. They have to balance keeping their customers happy (so they continue to have customers) with keeping the overall business profitable (so they continue to have a business).

If their profitability coincides with your situation, you win. In this case, the company has an interest in making sure Vunderbob’s diabetes and cholesterol issues don’t get out of control. Vunderbob has the exact same interest, but he’s complaining about the company’s interest in it, as though there is something wrong with them wanting him to be healthy.

This is not the normal complaint about a service provider. Usually, it’s on the other side, like your complaint, refusal to pay, or refusal to cover certain procedures, etc. When a provider is actually taking steps to help people stay healthy, shut the fuck up and take it as one of the few situations that work in your favor.
BTW, I find Risha’s article just a bit more than bizarre. We have doctors prescribing “unnecessary” medication, which costs the insurance company money. They do this in order to get kickbacks from… the insurance company. I don’t get it, the company pays out with both hands and gets bupkus in return, how exactly is this supposed to work to their benefit?

33

Define “government” and “knows”.

There is in fact a central database that tracks medicine prescriptions to compute co-pays etc., but access is under strict control by law. Doctors are the only ones who can get specific information on their patients, pharmacies just get the co-pay percentage. Access can be granted for research and statistics, but then data is anonymized. If a well-meaning bureaucrat were to think up a scheme like the one described, it’d be a clear breach of the privacy and public register law.

34

Amen.

After my father died, we learned from the autopsy that he had died of an inherited heart condition. I was immediately referred to a cardiologist; testing ran upwards of $3000 or so. The damn insurance company would not even consider paying for it at first; somehow, the head of human resources at my father’s workplace (I was still covered by his insurance at the time) was able to intervene and get them to cover an appropriate amount. This was vital information to have for managing my health; why didn’t they want to chip in at first? Did they think I would be dead so quickly that I wouldn’t be profitable?

(I’m fine, by the way.)

35

Man, you need to learn to let things go…don’t you realize the effect getting so worked up has on your blood pressure!

:slight_smile:

36

Don’t you know the therapeutic value of a string of profanity?
:wink: :smiley:

37

Whiskey Tango Foxtrot??? Only 3% prescribe inhaled steroids despite knowing they’re the standard of care for all but the most minor cases of asthma??? Stunning. Though I shouldn’t be surprised, given the anecdote I told above. (it’s a damn good thing, in our case, that I a) know a fair bit about asthma so recognized the issue, b) had meds on-hand for my own kids so was able to, with parental permission, institute at least some treatment immediately, and c) was able to find decent medical care promptly).

My own ire with these programs was related to the annoyance level and near-perfect bad timing of the call. I can well believe they’re a lifeline for folks who don’t know much about them. My own experience with finding that book on the topic of asthma, when it hadn’t occurred to me that such information existed, was quite literally life-changing.

I do still concur with the pitting of the fact that these companies are so closely monitoring prescription refills.

38

Well, here in the States, there are many who have a deep deep distrust of centralized databases of any kind, especially those maintained by the government. They have the default assumption that it can and will be abused - if not by the government as a whole, then by authorized persons looking for profit or with axes to grind. This is why, for example, there’s so much resistance to a national ID program.

ETA: This doesn’t even count the large number of highly publicized, accidental breaches of security (e.g. lost laptops) or hackings.