Healthcare vs Health Insurance #4 w/Poll

You'll find prior installments HERE.  

See dKos diarist nyceve for the big picture on the Healthcare battlefield.

This series is designed to give you a bird's eye view of healthcare, from the trenches.  

As always, I loathe the insurance companies.  

Let me count the ways, below the fold.

If you haven't read any of those nyceve diaries, well, first off, shame on you, and get your sorry butt over there and dig in to some of the most poignant words every strung together to tell a story.  The heartbreaker?  The stories she tells are true.

So, of course, we need to kick the insurance companies, and their exhorbitantly paid executives and CEOs to the curb.

They are a luxury we, as a nation, can no longer afford.  

Last week, one of our patients received a notice from their Medicare Part D Prescription Drug Insurance company, explaining that a drug that they had been receiving was no longer going to be covered, and advised the patient to contact their physician to determine if another medication which is covered on their formulary (the list of medicines the insurance company will pay for) can be substituted for this medication.

The name of the medication was Triamterene, this is the generic form of the medication.  The Brand name is Dyrenium®.

Because our clinic is being flooded with paperwork required by Medicare and Medicaid and the State of Washington from managed care facilities housing aged and infirm patients, every new form takes more and more time out of the day.  Every form requires the doctor's signature.

Since the turn of the year, I've noticed that we are getting more and more pharmacy requests to contact the patient's insurance company and get a medicine pre-authorized as it is no longer covered by the insurance company on the patient's formulary (covered medicine list), like this one.

This entails filling out a form like one of these.  Now these forms are created by the insurance company, and in the case of a Medicare patient there is often a special version of this special form.  Medicare, apparently, has created a list of medications which the Part D Drug Insurance companies are required to cover on a Part D drug plan.  

Try and get the insurance company to acknowledge that this list exists, or that you should be allowed to get a copy of it.  They won't.

I know, I asked one of them for it, here's how that went.

Our patient gets a notice from the insurance company.  The patient calls our office, frantic, because they were just at the pharmacy, and the pharmacy told them their insurance won't pay for the drug.  They can't afford to pay cash for the drug.  The pharmacy told the patient, don't worry, we'll fax your doctor and the doctor can get the medicine pre-authorized, then the insurance company will cover it, hopefully, and sends the patient on their way to call the doctor's office, right away.

So the patient calls, scared, and the pharmacy also, helpfully, faxes an 'Rx request' form, usually with hand-written notation, to the effect: The patient's insurance won't cover this Rx, can you call them at this phone number and get a pre-authorization for the patient?  What the pharmacy means is

We don't want the patient to have to pay for this drug, and I'm sure you, the doctor, don't want the patient to have to pay for the drug, so doctor, please fill out the forms the insurance asks for so the patient can get the drug and not have to pay for it?

The doctor is being asked to spend time (work) on something that he cannot bill anyone for (for free), to save the patient money.  Not to sound like someone with a stick up my ass, but this isn't the doctor's job, to save the patient money.  The doctor's job is to treat the patient.

Do you work for free at your job?  I'll bet you don't.

But hey, it's just a bit of paperwork, right, how long can that take?

This seems rather simple, until you start the clock.

Doctor writes Rx and hands to patient, or clinic staff faxes or calls Rx to pharmacy: 5 minutes doctor's time, up to 10 minutes my time (if I call it in, to fax, only one minute).

Clinic receives fax back from pharmacy, with medication pre-authorization request: 1 minute of my time to read it and put in the doctor's 'before lunch Rx request pile'.

Doctor reads request, asks me 'what do they want from me', and hands the request back to me: 1 minute of Doctor's time.

I call the insurance company: at least 10 minutes spent on 'terminal hold™' while manouvering through the voicemail address system (VAS), to get to a customer service representative, who can either fax me a form or tell me where on their oh-so-user-unfriendly website I can find one to download.

Some companies offer physician-restricted areas of their website.  You have to request a login name and password.  They ask for things like your DEA number and IRS Taxpayer Identification Number (TIN) to qualify you to get access to this part of their site.  Last week, one of these insurance company sites denied our clinic a login ID and password.  Their reason?  Our doctor is not one of their Preferred Provider Office (PPO) contracted providers, meaning he refuses to contract with them, and then allow the insurance company to dictate how he can practice medicine.

The advice from the CSR on how to locate the company Formulary so that I can try and save the doctor time and read through it, so that I can point out a medication he's prescribing for a patient, that I now know the company will deny coverage for, and suggest he consider one of the two to six alternatives they will pay for?  I should sign up on their website for a login ID.  The looped logic of this makes my head hurt, every time I think of it.  Aaaaaaarrrrrrggggghhhh, in the word of one of my favorite people, Howard Dean.

Sometimes, I've done this before with this particular insurance company and already have an electronic version of the company's required Pre-Authorization or Exemption Form stored locally.  This takes, total, a minimum of 2 minutes and a maximum of 30 minutes (it all depends on the volume of calls to the insurance company and the number of CSR's they have available).

The form gets filled out (minimum of 5 and maximum of 20 minutes of my time) and signed off on by the doctor (minimum of 1 minute and maximum of 5 minutes) and faxed back to the insurance company.

Now we wait for an approval or denial.  Neither decision comes with any details of how the answer was formulated.  If it's a denial, that's it, they won't cover the medicine.  Hopefully, the doctor can choose another medication in the same drug class, suitable to treat the patient's condition, write a prescription for it, and hope this new drug doesn't get denied, or the whole thing starts all over again.

Now, most, if not all, of the drug insurance companies publish their plan formulary for viewing by patients and doctors.  Look at just this one (it's 40 pages long), now imagine one of those for every patient in your practice (for us this number is close to 850).  There are not enough months in the year to read all of them.  Besides, truthfully, it's not the doctor's responsibility to ensure that every drug he prescribes is on your formulary. It's his responsibility to prescribe a drug you need.  As the patient, you want him to prescribe one on your list so that you don't have to pay out-of-pocket for the medicine.

Now, this particular episode of Healthcare Insurance Crazytown™ followed the preceeding event path pretty much just as stated, until we get to the part where I fax the required (two page) form, complete with doctor signature, medication name, dosage, frequency of use, length of course of treatment, justification for prescription, has the patient used any other medication already to treat this condition, and if so, were there and adverse effects, and if so, what were they, and how many doses was the patient given, and possibly three to ten more such or related details.  

As I mentioned waaaay back at the top of this story, the medication (Triamterene) was prescribed by the doctor.  
The pharmacy tried to bill the medical claim electronically to the insurance company, the claim was rejected, as not covered on the patient formulary.  
The pharmacy faxed us the pre-authorization request.  
I downloaded the form, filled it out, asked the doctor to refer to the patient's chart and consider authorizing one of these alternatives suggested by the insurance company (that they have already agreed they will pay for, so long as the doctor can justify the pre-authorization request), and sign the authorization.  
The doctor does so, the drug requested to be pre-authorized for payment is Triamterene (Which was also the drug originally prescribed by the doctor, and listed as an alternative to itself, go figure.)
I fax the request to the drug insurance company.  
The drug insurance company, the very next day (oh, they are soooo prompt) faxes us back a denial for Dyrenium the Brand name version of this medication AND suggests that the doctor consider prescribing Triamterene (the drug we requested that they pre-authorize) instead.

It made my blood boil.  All of that time wasted.  Some data processor at the drug insurance company obviously elected to process a request for the Brand name instead of for the generic name of the drug (as we requested), so it was summarily denied by their system.

You do the math.  Multiply this time wasted by a percentage of the number of patients seen, on the average, by each primary care doctor in the country each day.  It's got to be in the millions of staff-hours on a daily basis.

What do you think is really causing the rise in the cost of medical treatment?

I say the bulk of the costs come from time wasted on trying to work within the US Health Insurance conventions and meet patient needs and concerns about rising out-of-pocket costs.

We simply can't afford to keep paying billions of dollars to the insurance industry, every single year, so that they can bury our doctors in paperwork to justify every medical decision the doctor makes.  

We need those dollars to pay for Healthcare for our neighbors and relatives and fellow Americans instead of for luxury yachts for Heath Insurance CEOs (can you believe Google returned this: Results 1 - 10 of about 123,000 for health insurance CEO buys luxury yacht).

It's time for a real change in healthcare.  

UPDATE: It's 60% on those voting at least one medication required a doctor pre-approval.  Think of all that wasted time.... sigh....

2nd UPDATE: After about a day, it's now at 50% on those voting at least one medication required a doctor pre-approval.  No wonder I loathe the insurance companies.

•  You know the drill - tips, flames, comments

  gladly accepted.

  by Angie in WA State on Sun Mar 23, 2008 at 06:14:31 AM PDT

•  Tipped and recc'ed

  It's good to get the POV of a medical proffessional on this topic.  Insurance forms are designed to frustrate!!!

  by minerva1157 on Sun Mar 23, 2008 at 06:27:45 AM PDT

  •  Exactly right!

    Deny and delay are the insurance company business model.  Each additional hour a patient waits for the insurance company to cover something is another chance the patient will give up waiting and just pay cash-out-of-pocket for the medication.  

    You know the old saying, "a dollar saved is a dollar earned" - and the insurance companies take that saying right to the bank every single day.

    by Angie in WA State on Sun Mar 23, 2008 at 06:39:03 AM PDT

    •  Deny and delay = profit$

      Don't forget that insurance companies make money by taking the premiums they are paid by costumers and investing that money on Wall St. Even if they know they have to pay, every minute they delay payment means more interest they earn with your money.

      by drewfromct on Sun Mar 23, 2008 at 07:14:06 AM PDT

•  I went through the delay/deny model a while ago..

  when a physical turned up a heart murmur and I was referred to a cardiologist due to a family history of heart disease.  Blue Shield of California initially denied the claims -- then they saw the results of my stress test indicating a probable blockage.  Once they saw that, they revisited and approved the previous claims and approved a cardiac catheterization to confirm the blockage.

  Something about the possibility of my dropping dead from a heart attack got their attention. I'm sure the negative publicity around the industry in recent months, thanks in no small part to nyceve and other Kossacks, played a part, too.

  I had the cath & subsequent angioplasty/stent placement on Friday, was released from hospital last night, and plan on being back at work Tuesday.  I managed to get lucky in that the insurance company was willing to revisit the claims, and that I was able to get the blockage resolved before I had a heart attack.  Lots of people aren't so fortunate -- we as a nation desperately need to reform or rebuild the health care system.

  by 3waygeek on Sun Mar 23, 2008 at 06:50:29 AM PDT

  •  And it continues...

    when I was released from the hospital Saturday evening, I was given a prescription for Plavix & Lipitor.  When I tried to fill them this morning, I found out that Lipitor isn't on the approved list.  Zocor & Vytorin are, so I should be able to get my cardiologist to prescribe one of those instead.

    Not a big deal, since my cholesterol is normal, but it's a headache I could do without.

    by 3waygeek on Sun Mar 23, 2008 at 10:06:16 AM PDT

    •  If you are a diabetic

      they stick you on Lipitor whether your cholesterol is high or not.

      by Kitsap River on Sun Mar 23, 2008 at 09:06:52 PM PDT

      •  Though I also found my

        insurance company would only pay for Zocor and not Lipitor.

        by Justanothernyer on Sun Mar 23, 2008 at 09:19:43 PM PDT

      •  And should do so

        Lipitor seems to help the generalized inflammation that comes with diabetes--it doesn't just lower cholesterol.

        by barbwires on Mon Mar 24, 2008 at 07:30:50 AM PDT

•  Keep up the fight Angie

  Save this diary. Please get some help documenting instances like this. We'll need them for testimony before Congress and our state legislatures. Thanks.

  by Ivan on Sun Mar 23, 2008 at 06:55:32 AM PDT

  •  Using modern data technology, I don't have to

    make a special effort to save this types of stories, they are archived for me here dkos.  

    Our medical office scans everything that comes in the door, or through the fax machine.  We document every piece of paper.

    If there were ever a need to show documentation, the only thing that could cause a problem is the patient failing to authorize the release of their private, HIPAA protected healthcare information.

    by Angie in WA State on Sun Mar 23, 2008 at 06:58:41 AM PDT

•  "For profit" health insurers..

  That is where we went wrong.  It is time to cut out the middle man who is draining the system of healthcare vs profit.

  Sorry to hear that it is as hard for you to understand as the rest of us....thanks for your hard work in the trenches.

  by gdwtch52 on Sun Mar 23, 2008 at 07:02:21 AM PDT

•  Co$t of paperwork

  An anecdote from my job: A few months ago, I went to do a job at a small private airport in Western CT--I do environmental drilling. I was a little nervous, as my client wanted me to set up my drill rig within ten feet of a corporate jet which one of the airport personnel informed was worth $38 million. Curious, I asked about which company owned the jet and what kind of work they did, only to be informed that the jet is owned by a company which does nothing but process paperwork for insurance and pharmaceutical companies.

  So now you know where some of that money goes.

  I was also told that at least one of the corporate jets at this airport (don't know if it is the same one) is often used by the wife of the CEO for shopping trips.

  by drewfromct on Sun Mar 23, 2008 at 07:06:28 AM PDT

  •  why am I not surprised

    that the money (sometimes pennies per prescription) that the insurance 'saves' from not providing healthcare to their insured patients is spent on frivolous or completely, unbelievably-expensive 'perks' for insurance company executives (or their wives or girlfriends)?

    by Angie in WA State on Sun Mar 23, 2008 at 07:16:42 AM PDT

•  I use Metrogel...

  and about a year ago, when going for a refill, my insurance company suddenly refused to pay for it.  When I called, it turned out that they used to pay for the .5% and would still pay for the .5% in a cream base but now that the company had come out with a 1% in the gel base (for more money), they would no longer cover the .5% gel.  Since I didn't want the cream base, I had to call my doctor's office to change the prescription and OK it with the insurance company before they would throw in their pittance towards the cost.  As it turned out, my doctor was out of town but the insurance company got whatever they wanted faxed from her office staff and they went ahead (even though that was a significant change in my prescription).  Even the people in the prescription division thought the whole thing was idiotic.

  by Design the Future on Sun Mar 23, 2008 at 07:45:23 AM PDT

  •  Even trickier if you're a dual medicare-medicaid

    patient.

    For Part D plans patients, for whom, generally, their Medicaid (State funded) insurance kicks in whenever their Medicare doesn't cover the cost of something -

    Except now, with Part D drug coverage, Medicaid is NOT eligible to cover a medication for dual coverage patients, unless it's originally covered by Medicare (in which case, if Medicare doesn't cover the entire cost, then and only then, will Medicaid pick up the balance.

    So, crazily enough, patients with JUST medicaid are now better off - they will pay for any necessary medications, the doctor might be required to sign a WA State form stating a generic or less expensive medication is, in this instance, not suitable to treat this patient at this time, for this condition.  It's still a hoop, but at least when the doctor jumps through it, the patient is assured to receive the medication the doctors prescribed for the patient.

    With Medicare, even with Part D drug insurance, now, some patients will have to pay out of pocket, even if they have dual insurance coverage because of the Part D drug plan legislation.

    Are you surprised to learn the Denny Hastert sponsored the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, or that only one democrat co-sponsored this piece-of-crap legislation that really only cares for the drug insurance companies?

    I'm not.

    by Angie in WA State on Sun Mar 23, 2008 at 08:09:07 AM PDT

•  Huh?

  I take Triamterene/HCTZ (a slight variant) and I pay $4.00 per prescription.

  Couldn't the pharmacist have checked the price, probably $4, sold it to the patient?

  by JG in MD on Sun Mar 23, 2008 at 07:50:18 AM PDT

  •  The pharmacy, to put it bluntly

    will do anything, it appears, to not have to make the patient pay a penny.

    They will fax us interminably until they get an answer, even if we have already contacted them three times in the past month, telling them that the patient has a new primary care physician and to contact them directly, and ask that new doctor to authorize the medication.

    I understand, in a lot of cases, these are older patients on fixed incomes, who cannot afford to pay anything more than they are already paying for prescription drugs, not even what seems a pittance to you or even to I.

    A number of the pharmacy staff's have told me that they routinely persue these pre-approvals so that they won't have to be the one to tell the patient it's not being paid for by the insurance, and that the patient is going to end up responsible for the cost of the medicine.

    It seems unrealistic to not expect a patient to pay for a $4.00 precription, but the patient's as a whole (like my own Medicare covered patient, my mom) don't want to pay anything.  They expect their medicines, like all their medical care, to be compeletely covered.

    by Angie in WA State on Sun Mar 23, 2008 at 08:40:04 AM PDT

•  we don't need insurance we need healthcare

  http://www.guaranteedhealthcare.org/

  by pollwatch on Sun Mar 23, 2008 at 08:08:06 AM PDT

  •  That IS the point, in a nutshell

    asdf

    by Angie in WA State on Sun Mar 23, 2008 at 08:09:42 AM PDT

    •  this organization leads CA

      in coalition with other public interest groups to bring universal single payers health care to Ca; bill for it was passed in  assembly and Arnold vetoed it;

      thereafter Arnold brought up his own health care bill which was total give away for de-regulated health care insurance industry; it failed to get enough support to make it out of committee;

      the coalition of public interest groups lead by state Senator Sheila Kuehl (who wrote and sponsored the universal health care single payer bill that the legislature passe) will be brought up again fall 2008 with expanded support;

      by pollwatch on Sun Mar 23, 2008 at 09:14:56 AM PDT

      •  I think CA reform is dead in the water

        until this budget hole is plugged. Our school system is looking at cuts of $800 per student. Tens of thousands of teachers are getting layoff notices.

        by elfling on Sun Mar 23, 2008 at 09:58:35 PM PDT

•  My doctor has to fill out a form once a year

  to tell CIGNA (referred to as "Say No" by him) to inform them that, yes, I still have type 1 diabetes.

  He keeps threatening to write on the form, "STILL no cure!  BUT she's not dead YET!"

  by arielle on Sun Mar 23, 2008 at 08:39:52 AM PDT

  •  He should definitely

    write that.  This is idiotic.

    by Justanothernyer on Sun Mar 23, 2008 at 09:22:24 PM PDT

  •  Sigh....

    I'm a family doctor in Michigan, and I've lost count of how many yearly forms I fill out to say that John or Jane Doe still has severe heart disease, or quadriplegia, or legal blindness, or.....

    It's encouraging to see that people, both professionals and patients, are starting to not only wistfully hope for, but actively work toward a functioning health care program.

    by UPDoc on Sun Mar 23, 2008 at 11:33:20 PM PDT

    •  Usually

      then again there are bright spots.  I know one person who was pre-approved for a certain psychiatric drug until 2058.

      by ohwilleke on Mon Mar 24, 2008 at 05:17:33 PM PDT

•  The problem is ...

  The government isn't more efficient than the private sector. It's LESS efficient. Much less. And knowing seeing the bad things the government does documented on DailyKos, are you sure you want to put it in charge of your health care?

  I don't have a solution to the problem, but I know government-run health care isn't it.

  by hippykicker on Sun Mar 23, 2008 at 09:02:09 PM PDT

  •  In this particular instance

    there would be a significant increase in efficiency from trying to deal with one insurer.

    However, these problems will still exist in a single payer health care world.  

    by Justanothernyer on Sun Mar 23, 2008 at 09:23:34 PM PDT

  •  efficiency

    What is your source for that?

    I ask, not to be snide, but because although it's a classic assertion, I'm not sure it's correct.

    For some things, the government is more efficient. Fire protection, for example.

    The private sector in health insurance doesn't have a particular motivation to be efficient. Indeed, their motivation is to train doctors and patients to expect less and to accept their denials. If you give up, they keep the money. They have no motivation to provide streamlined, efficient, helpful service, because even if they do, the people who pay the premiums (whether patient or employer) don't experience that service directly.

    Having to understand and accomodate hundreds of different payment plans and drug formularies is not efficient.

    by elfling on Sun Mar 23, 2008 at 09:53:42 PM PDT

    •  re: efficiency

      Government waste is well documented. The treasury/IRS is spending millions just to send out completely unnecessary letters to people telling them they will get an "economic stimulus" check in the mail in a couple months.

      It's far from a perfect system, but private insurers at least have competition as a motivation to be efficient and effective. The government doesn't any motivation. It's solution to every challenge is to pass another law granting itself more authority and/or raise taxes.

      We're at serious risk of going from a near monopoly held by the insurance companies to an absolute monopoly and in the process give the government even more control of our lives.

      by hippykicker on Sun Mar 23, 2008 at 11:20:49 PM PDT

      •  You, my friend, are uninformed on this issue

        Private health insurance companies are not more efficient than government health insurance, evidenced by average administrative costs, for private insurers of around 20-30%.  

        For Medicare it's about 3%, and for most states Medicaid, it's about 4%.

        Government, in this area is over five times more efficient than private insurers.

        Fraud and waste are also, sadly, not merely found in government administration systems, but are also rampant in the private sector.

        This is one of those 'Ronald Reagan' myths that just won't die.

        Why do you assume that a government run system will cost more, and provide less?  

        by Angie in WA State on Mon Mar 24, 2008 at 03:26:51 PM PDT

        •  Actually, I am informed

          My understanding is Medicare's administrative costs are 5-6 percent, including "hidden costs" of bureaucracy. The private sector reports an average "administrative cost" of about 17 percent, but without profit and taxes it would be about 9 percent. So, you may be right that the government is more efficient in at least one area. But not enough to justify handing over control.

          by hippykicker on Mon Mar 24, 2008 at 07:02:35 PM PDT

  •  Single payer. Not single provider.

    (Sigh.)  

    We're not talking about the government running health care.  

    We're talking about the government PAYING for health care.

    by therealdrlaura on Sun Mar 23, 2008 at 10:09:25 PM PDT

    •  Same thing

      You are too trusting of election-year promises. The government isn't going to pay the bills without having a whole lot of control over what it is paying for. You will have even less choice in health care and we may even see rationing of health care. This is a another power grab. One party does it in the name of national security, the other under the guise of the "the public good."

      by hippykicker on Sun Mar 23, 2008 at 10:58:10 PM PDT

      •  We already have rationing of health care

        it's just by luck (who has insurance, money, etc.) instead of by need or even by some rational formula of cost vs benefit.

        by terran on Mon Mar 24, 2008 at 11:36:01 AM PDT

        •  Not luck

          I have health care through my employer's group plan. Luck doesn't have anything to do with that.

          In most cases, bad "luck" should only leave you unemployed and uninsured for a temporary amount of time.

          I am not against finding a way to make health care affordable and of high quality, but I don't think the federal government is part of the solution. Remember, that's who created the HMO system.

          by hippykicker on Mon Mar 24, 2008 at 03:36:32 PM PDT

          •  I worked for years without insurance

            full-time, part-time, temp jobs, all without any kind of affordable health plan.  My family members and many other people I know have done the same. We know people who work, but who lied and jumped through hoops to get on welfare, just to get the health card.

            You may not be able to get enough hours to qualify for the benefit plan. Your employer may offer a plan that you can't afford and still make the rent. Or the deductable is so high that you can't afford to see the doctor for anything less than something life-threatening. You may be a full time worker, but are a "contractor" without any benefits.

            I had strep throat for several weeks, using otc stuff until I could not stand the pain, then I went to a McMedicine center and put everything on my sister's credit card. That was our "health plan". I don't know what I would have done if I had come down with a serious illness like cancer. I am grateful that I did not have kids at that time.

            We did that for years, and eventually, my sister ended up declaring bankrupcty. Of course, that was back when regular folks were allowed to do that....

            The US still the only holdout who think this private piecemeal health crap is a good idea. It seems that if Australia, France, Germany, Japan and friggin Cuba can figure this out, we can.

            by terran on Tue Mar 25, 2008 at 12:00:14 PM PDT

    •  Medicare Part D is single payer

      with multiple providers.

      by ohwilleke on Mon Mar 24, 2008 at 05:01:32 PM PDT

•  It sure is messed up.

  To get around all of those problems, I recently gave in and got Kaiser.  They cover everything their doctors prescribe, so I don't have those problems, but they do have a co-pay, and for some presciptions that is up to $90.  I don't know if this is the best way, but it prevents certain problems.  I don't know what problems I might have if I have different medical conditions.

  by karpinsky on Sun Mar 23, 2008 at 09:02:48 PM PDT

•  It happens all the time!

  Several times a year, we get requests from the insurance company for a justification for something or other that we are already on and have been on for some time. Usually it is one of the diabetes drugs. Funny how one of them always seems to be Januvia, for which my doctor has to do a request at least once a year for each of us. It never seems to be our Byetta, which would cost about 20 times as much out of pocket as Januvia. (There is no generic for either one. I am on 4 diabetes drugs and there is no generic for any of them.)

  I had a prescription request for a drug for neuropathy pain get turned down several times. I am a diabetic. This is a drug for neuropathy pain. But because it wasn't diabetic neuropathy in my feet, they turned me down 3 times. We gave up. All these requests and re-requests and turn-downs are time that Dr. I. has to spend doing stuff other than treating his patients. It's terrible.

  He's an excellent doctor and we're sticking with him, but he gets treated by both his practice and the insurance companies pretty badly.

  by Kitsap River on Sun Mar 23, 2008 at 09:05:26 PM PDT

•  An excellent diary.

  It's good to see the view from inside the trenches.

  by Justanothernyer on Sun Mar 23, 2008 at 09:24:50 PM PDT

•  When denial is procedure!

  Great series that was bound to open many eyes.   I received a Living Donor Liver Transplant in June of 2005 when the incredibly strong selfless woman that was then my 18 year old daughter became my donor.  Hey what were you doing a month after you graduated from high school?  She flew through famously without any complications and was back home in a month.   I wasn't so lucky.  multiple complications sent me back to the O.R. four more times in the next two weeks culminated in the sixth and final surgery on July 27th.  All in all I was hospitalized an additional seven times that year including stuffing my crashing body into an air ambulance jet that rocketed my ass from Albuquerque to the Mayo Clinic on a successfull race against death.  The whole ordeal had a MAJOR impact on my over all health and well being and I now find myself collecting disability and covered by Medicare since November of last year, God help me.
  So much for background!  
  Begining in January of this year every REFILL was denied by the health plan, I have one of those enhanced Medicare Advantage Plans that I pay extra for.   The pharmacy attempted to  refill one of my meds through the plans approval system only to receive a  denial justified by the statement "Medication not on the approved Medicare List".  That was kinda frightening since I spent a solid month researching a Medicare plan that covered all of my needs.  The pharmacy tech told me I had to call the health plan.  The rep at the plan didn't understand since the medication was on the formulary and put me on hold to talk to the supervisor.  On return she told me I had to call my doctor to get an over ride authorization!  That was enough for me.  I'm fortunate in that I work in the health care industry in the late seventies through the mid eighties (when it truly was health care) as a respiratory therapists and knew how things work.  Unfortunatly, I  was infected with Hepatitis C in 1984 from a needle stick after drawing blood from a patient admitted into the ICU in final end stage liver faliure of unknown etymology. Sorry, another aside.  So I called the pharmacy back and requested to speak with the pharmacist who understood the bullshit that was going on and stated that he was having a lot of trouble with THAT health plan.  The medication was ultimately approved the next day.  One week later I went through the same foolish drill with another refill and similiar resolution by the next day.  Well you guessed it, the same thing happened a few days later but this time I asked the customer rep with the health plan if she could take care of the prior auth once she realized what a cluster fuck this had become.  Sure she said and put me on hold for about a minute or so then told me to call my pharmacy to run my prescription through the authorization system and it should be approved!!!!! WTF!!!  I asked why none of the other "Customer  Service Representatives" didn't do this for me in the last two cases?  She apologized and said to ask for the supervisor if I have any trouble next time. Next time happened two more times for two more refills.  However this time I was armed with my new knowledge and things went much more smoothly.
  So what's the moral of this terribly long post to the one person with the patience to get to this point?  1) Speak directly to the pharmacist when problems arise.   2) Know your health plan, especially the formulary.  Call the telephone number on the back of your health plan card and ask them to mail you a copy of the formulary.  Their web site will also have it posted often in a PFF file that you can save to your computer and use the find function if that's easer.  3)  Call your health plan back if the rep you spoke with didn't give you the answer you wanted to hear, you are bound to get a different person. They all have different knowledge bases, some better than others.  Ask for the supervisor if you run into a wall after a couple of tries with different reps.  4)  Request refills as soon as your health plan allows, usually seven days, to give time if problems arise so you don't run out!  
  5)  You are your BEST advocate for your own health.  Know your diagnosis and medications.  6)  Keep a written diary of all of your communications and doctor appointments.  The good old composition book works great.  Write  down every telephone number that you ever come across  with a brief explanation.  You have no idea what a time saving tool this can be.  
  Ya, this is all a pain in the ass but the chances of falling through the cracks are good if you don't become an active  participant in your own health care.   I have three different nurse  Clinical Coordinators - one from the Mayo, one from my local hepatologist, and one from the Hepatitis C Interferon clinic - and they all tell me the same thing, a great deal of their time is consumed with insurance company bullshit rather then with patient care.  Remember the job of the insurance company is to take in money and hold on to it.  These parasites spend almost as much money trying to deny claims as they do paying for claims.
  Stay strong and join a local support group that centers around your particular malady, you may find insights from those that went before you or better yet provide support for others.
   

  by djwebst on Sun Mar 23, 2008 at 11:43:30 PM PDT

  •  Wow, now that's Patient advocacy!

    asdf

    by Angie in WA State on Mon Mar 24, 2008 at 03:29:23 PM PDT

•  Poll

  doesn't include zero, because I submit my pharmacy bill AFTER I've been to the pharmacy (which isn't located in the US)

  I get to argue with the insurance company after the fact, but that's for such silly things as explaining why I would bother to fill a couple of months' prescriptions on the same day.

  What bothers me is something similar with my HSA. I have a prescription for supplments and nutrients. But a doctor's prescription isn't enough. I have to have my doctor fill out a form explaining why, the length of treatment, blah, blah.

  Now my doctor speaks French first, so it's not like I drop it off to him. What will happen is I fill out the form and track him down so he can sign it.

  argh

  by karlawithaK on Mon Mar 24, 2008 at 03:05:19 AM PDT

•  One of my clients...

  When I was helping people select a Medicare Part D plan, I had one client who was extremely concerned because she absolutely required a medication for pain and she also knew that her doctor would not take the time to deal with this sort of bs paperwork. So she wanted to be absolutely sure that the plan she picked covered the medication without requiring pre-authorization, even if that meant paying a higher monthly premium. But of course there was no guarantee that the plan wouldn't change their formulary at any time. And clients can only switch plans during a small window once each year. This lady was literally in tears over the phone with me. Bastards.

  Good for you for detailing exactly with this "pre-authorization" entails. What a waste.

  by lesliet on Mon Mar 24, 2008 at 04:05:19 AM PDT

•  Other more subtle sins

  One practice I've observed recently involved the multiple tiers of co-pays for some drugs.

  Typicially there is a cheap generic tier with a $10-$20 copay, a brand name drug tier with a $30-$40 copay, and a superexpensive brand name drug tier with a $50-$75 copay.

  But increasingly, generic or low cost brand name drugs are being placed in the superexpensive brand name drug tier, leaving only $5-$10 paid by the insurance company for the drug.

  Generally these are drugs for conditions that have somehow earned the disfavor of insurance companies, for example, because they have an off label use that could be considered cosmetic or optional.

  by ohwilleke on Mon Mar 24, 2008 at 05:13:34 PM PDT

•  I suspect this will be fairly short lived.

  The insurance companies are playing with fire here, against the specter of a class action bad faith suit and actions by state AG offices.

  Also, I suspect that they are not saving nearly the money that the promoters claimed that they would when this was first promoted by some consultant or conference that caused it to spread industry-wide.

  Sooner or later, some insurance company will miraculously offer to fill prescriptions without dicking around with you and voila other companies will have to follow suit.

  A similar thing happened a few years ago with primary care physician referals.  For a while, most insurance companies required them for ob/gyn care.  Then, insurance companies discovered that women generally do know when they do and do not need ob/gyn care without having a primary care physician tell them and dropped the requirement.  At first it was some wonderful freebie, but it soon became the industry standard.

  by ohwilleke on Mon Mar 24, 2008 at 05:22:21 PM PDT