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Old 05-20-2008, 07:29 AM   #1
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Insurance company knows more than the doctor??

Hi Everyone,

I had surgery at the end of March and then was admitted again a few weeks ago for an infection and blood clot. This has been a stressful time, in and of itself. However, much of the stress has been from my insurance company!

This all started as early as 8 days after my intial release from the hospital. I had a great surgeon, with the exception of no knowledge of dealing with pain management in chronic pain patients. Luckily my GP agreed to take over my pain management after surgery.

I was prescribed 1 to 2 percocet 10mg every 6 hours. After a few days of this, I was not getting enough pain relief. I called the doc a few days in, and he told me to increase it to 1 to 2 every 4 hours. This made my refill early, but I explained it to my pharmacist and they called the doc to confirm. My doctor gave the approval, then my insurance company denied it! The pharmacist called and explained, but was denied. I called and was on the phone for over an hour. The insurance stated that they would not pay for a refill until 60% of the med was taken. I figured it up, and even if I had stayed with the initial directions, I had taken over 70% of the medication.

Then they changed their excuse. After many calls they told me that they would pay for the script the next day. I explained that I was only a week out of surgery, and had an 8 inch abdominal incision. I was completely out of my pain meds, and I could not go 24 hours in excrutiating pain.

Long story short, I had to pay $116.00 for 70 generic percocet.

I thought this was a singular incident, but boy was I wrong! My doc and I were trying to treat my pain without having to go back on oxycontin. (I had sucessfully tapered off of it before my surgery, and wanted to stay off of it if possible). In order to control my pain, I was taking 1 to 2 percocet 10mg every 4 hours.

I go to get my script filled (168 qty) and the insurance denied it. This time they were saying it was too early again. Turns out the pharamcy had put 30 days supply on my last script, which was actually a 10 day supply. I started calling the insurance company at 9:00 am. They kept telling me and the pharmacist different instructions. (Call here, fax this, change that, ect.) It was never enough. After every hoop we jumped through, they came up with something else!

This all happened on a Friday, and my doc closes at noon on Fridays. It took 10 people and 5 hours to finally get someone to tell me what needed to happen! Turns out my insurance compay has a limit on how many pain pills you can take in a day. They needed a letter from my doctor explaining why I needed more than 6 per day. Of course by this time, his office was closed and would not re-open until Monday! The last person I talked to at the insurance company stated that due to the max 6 per day, I could not get my refill for 15 more days!

I was told that once they received the letter from my doctor, I would be reimbursed. So here we go again. We are so broke, as I have been on leave without pay. We had to use the emergency credit card........It was $276.00 for 168 generic percocet!

That following Monday, my doc got the letter out. I thought, okay, this is over and I will get my money. I go last Friday for a refill, and the pharmacy had to tweak the days supply to get it to go through. I called the insurance company. The response I got? "Oh yes, I see your doctor's letter here. It has just been floating around and has not been processed, we'll find out why and take care of it." I was so mad! It has been over 3 weeks since he sent that letter!

They call yesterday and tell me that my docs letter was approved and processed, so I said "Great, when do I get my refund?" After having to explain all of this over again, they tell me that the pharmacy has to re-run the script, then I will get my $$$. I call the pharmacy and they say that they cannot re-run because they cannot change anything or re-do anything after 7 days! So I call the insurance back, and they say because I have a co-pay plan, they cannot reimburse me. What does that have to do with it???? They then insinuated that the pharmacy just didn't want to do it for me. I call the pharamcy back, and last I heard, they were calling the corporate office to see how they could help. God knows if, or when I will get my money!

In all of this, I had so many people from the insurance company questioning why I needed more that 6 pills per day. Even if I stayed with the initial dosage (1 to 2 every 6 hours), if you needed to take the max allowed, you would be over the "limit." Since when were they my doctor?? How are they qualified to say I only need six pills for my pain??

So sorry for the length of this, but I needed to get it out! If you haven't watched the movie (Sicko) I highly recommend it! On top of all of this, I received a letter from the insurance company stating that they were not going to cover a dime of my surgery and hospital stay. Their excuse? They say they did not get a pre-cert for my surgery. Therefore, "Benefits are not available for this date service". I wonder how many phone calls I will have to make to clear this up!

Thanks for listening!

Your Friend,

Amanda

Last edited by butrfligirl28; 05-20-2008 at 08:31 AM.

 
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Old 05-20-2008, 07:51 AM   #2
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Re: Insurance company knows more than the doctor??

What a nightmare! Sorry to hear about everything. Unfortunately, you are the victim of this system we have now and I don't see any end in sight. The drug companies control medicine today....No more than this amount, won't pay for this, but will that.....It's all a bunch of bunk!

At this point, I would go as high as I could with your pharmacy. It sounds as if you used one of the chains....I would go see the Store Manager immediately and tell him your story. This all stems from the pharmacy putting the script in the computer for a 30 day supply, which was an error on their part. That's why your insurance isn't paying...From their standpoint, they see something entirely different. In cases like this when things really go sideways, it's about finding someone with the authority to fix things....The Store Manager has lots of power and equally important, knows the right people @ corporate to get things fixed. They may just have to reimburse you, if needed.

Good luck.

Ex

 
Old 05-20-2008, 08:11 AM   #3
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Re: Insurance company knows more than the doctor??

Amanda,

After reading the title to this thread I was going to write something funny like "of course the insurance company's make treatment decisions - where have you been?"

But after reading the entire post I couldn't bring myself to do that without adding the explanation.

Why? Because it isn't funny. At all. Far from it.

Amanda - I really do think this insurance company has flagged your file and is out to "get you," so to speak. There is just no way they could come up with so many excuses to deny coverage during these intense phone campaigns without a concerted effort. While it wasn't well orchestrated, they are succeeding in making your life miserable, probably in order to ultimately cancel your policy, coverage, or get you to switch coverage.

I urge you to get legal counsel. Now. Even with your finances, there are assistance plans out there. Maybe someone on the board knows how to go about getting legal representation when strapped for funds? I think a few letters from a lawyer would do you a world of good. Without it, I think you will continue to be on the receiving end of this campaign of denial.

I've never felt the need to recommend legal assistance so urgently as I do in this case. If no one comes in with concrete ideas for you soon I will try to research it myself. Don't be scared off by insurance policy text requiring arbitration and all, thinking you are beyond assistance. Let's see who knows what to do.

steve

 
Old 05-20-2008, 08:30 AM   #4
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Re: Insurance company knows more than the doctor??

Amanda,

I'm sorry you have to deal with the insurance company on top of everything else. It really does add so much undue stress. Although I've had my share of bad policies and no policies, I guess I'm just extremely grateful of my current insurance and case manager. If you don't have a case manager through your insurance already, I highly recommend getting one. Sometimes, they can smooth things over. They really have helped me.

I also wanted to say Bless You and all of You that must work to make ends meet. I can't even imagine!! Obviously, I don't work anymore (haven't worked in years). I'm so blessed to be 100% financially supported by my husband and his insurance through his work. I got married at age 30, now 37, and before that, my parents supported me 100%. I really don't know how all of you get up each day and work. I hope things all work out for you, Amanda.

Bye for now! Shay

Last edited by friendly_one; 05-20-2008 at 09:40 AM. Reason: spelling

 
Old 05-20-2008, 08:54 AM   #5
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butrfligirl28 HB Userbutrfligirl28 HB User
Re: Insurance company knows more than the doctor??

Hey Guys!

Thanks for your posts! I need all the help I can get right now, so thanks so much for your ideas and support. This has gotten completely out of hand. I am so furious with these people right now! I was on the phone at least two hours yesterday trying to get the initial $116.00. It is amazing the amount of excusing and bull they come up with. They finally stated that I should have bought one to two days worth of my script until they would pay for it.

I told the woman I talked to that the pharmacy could not partial fill a schedule II med. She argued with me, and actually stated that "she had worked there for 13 years and had NEVER heard that." She also listened to the phone calls I made that day. She stated that she listened to the recording and she thought that the representative gave me some options, such as asking my doctor for an override. (By the way, the day of, the rep stated than an override could not be done due the script being a narcotic).

The problem is, the rep told me that it could take days for it to go through. I explained that I couldn't wait that long, and they said that this was my only option. So yesterday she tells me that I should have gotten that letter and then they could have reimbursed me! I asked why no one told me that.......and her respone was that all they could do is give me options and didn't know that I needed that information because I didn't ask??!! Geez! I told her that it was THEIR job to educate me and to act as advocates for me! Of course, she had so many excuses, I had to get off the phone before I said some very nasty things! What a nightmare!

Your Friend,

Amanda

Last edited by butrfligirl28; 05-20-2008 at 09:01 AM.

 
Old 05-20-2008, 09:34 AM   #6
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Re: Insurance company knows more than the doctor??

Amanda, honey, don't throw darts at me but I think you are being to nice to them. Sometimes you have to yell and scream to get a response. I have found when dealing with insurance companies you can't always be nice.

I want to share something with you and hope you get a chuckle out of it. I had a back fusion with hardware. My insurance paid everything except for the hardware and billed me $14k. I called them very upset and said, you preapproved my surgery what is the deal?? They told me I had to file a letter of dispute which I did. In closing of my letter, I said that I felt they preapproved my surgery and therefore preapproved the hardware and if they wanted to they could come reposses it out of my back. Needless to say I never heard from them again. Could you imagine?

Good luck and I hope this is resolved quickly for you.

 
Old 05-20-2008, 10:59 AM   #7
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Re: Insurance company knows more than the doctor??

Amanda, you have to have the same insurance as mine. My story is almost exactly like your except mine happened the day I got out of the hospital. Since I was admitted(had emergency surgery) I had missed my PM appointment, so I leave the hospital, go get my scripts the off to pharmacy, denied. Went through same crap as you except mine said I neede a pre-auth which I already had so call doctor, insurance like you giving everyone all different info on what to fax, where to call, blah blah. I had to pay out of pocket at first 5000.00 for mine. Then like you had to go back to pharmacy and heard the 7 day rule, ARGH! I did get reembersed eventually thank goodness.

I'm so sorry you are dealing with this, it about drove me crazy.

Melissa

I forgot to add that I am in the middle of a nightmare between my insurance company and medicare, Back when I got disability my insurance company said they were my primary coverage and medicare was my secondary. This has been for three years. All of a sudden I start getting bills from doctors and HUGE bills from hospital(10's of thousands) that my insurance took back because they say medicare is my primary. Apparantly my insurance has been giving me the wrong info all these years. And I have kept checking with them on it and in fact they have on their records of my conversations with them where they have told me they were my primary. Both my insurance and medicare each say the other has to fix it and medicare will not pay anything over one year old. Now get this, my insurance is still paying primary on some of my claims. I GIVE UP! I told them I am not paying anything until they all get it figured out. I have not heard a thing in 4 months and my claims are being paid so ...

Last edited by Boxerluver; 05-20-2008 at 11:21 AM. Reason: forgot to add

 
Old 05-20-2008, 05:21 PM   #8
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Re: Insurance company knows more than the doctor??

Wow. That is just unbelievable and a disgrace. Having had insurance problems myself, I empathize but what you have been put through really makes me angry for you.

 
Old 05-20-2008, 05:31 PM   #9
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Re: Insurance company knows more than the doctor??

Do insurance plans issue a formulary/list of drugs/qtys they will subsidise?

Can you ask your doctor to refer to this before issuing a prescription.... if limited to six tablets a day for examply, maybe he can prexcribe higher strength tablets in lower numbers? (instead on 1-2 10mg tabs every 4 hours, 1/2 - 1 20mg tab etc)

Last edited by aussiejono; 05-20-2008 at 05:34 PM.

 
Old 05-21-2008, 12:00 AM   #10
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Re: Insurance company knows more than the doctor??

Aussiejono...Between the size of the formularies and the fact that each insurance company has their own and can change it on a whim, makes it almost impossible for docs to keep track of which ins, co.'s formulary covers what.

Amanda....The next time this comes up, or actually since you are still in the process of dealing with this ins. co., 1) Ask to speak to a supervisor 2) tell this supervisor that you are contacting the state insurance department in regard to the way you have been treated and 3) if they try to tell you that a supervisor is not available, tell them you will be happy to wait or to call back at 2 minute intervals, until the supervisor is available.

I worked in health insurance, mainly for HMO's, for 15 years as an administrator. There is nothing like the fear of a possible Insurance Department complaint, to get them quickly kissing your you know what. There are certain standards that they are required to maintain (NCQA), and they do not like to fall behind in those standards.

Good luck and let us know how it goes. CMP/MM

 
Old 05-21-2008, 04:42 AM   #11
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Re: Insurance company knows more than the doctor??

I am so sorry that this has happened to you. Hearing your story really makes me sad.

Insurance companies like to play doctor. They did the same thing with my father. They told him that they didn't think he needed to take a certain kind of medication when in reality it was the only way for him to open up his air ways and breathe.

I work in a pharmacy, so I see this all the time. Patients come in wanting to get their perscriptions filled, but the insurance company denies it until the doctor sends a letter or calls saying why the prescription is needed. I don't get that because if the doctor wrote the prescription is what the patient needs. The pharmacist I work with actually asked an insurance company to show him their medical license because they think they know as much as doctors.

You should not have had to gone through that huge fight just to get your prescriptions and I really hope that everything works out for you. It seems that insurance companies do not understand pain management like they should. It is a medical condition and therefore needs prescriptions to handle it. Again I am so sorry that this happened to you. Just know that you are not the only one who has ever gone through this problem. I know a lot of our patients have too.
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Old 05-21-2008, 06:32 AM   #12
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Re: Insurance company knows more than the doctor??

Excellent post KDD! You hit the nail right on the head!

It's all about cost control for the insurance company...Not care for the patient. The bottom line is that the insurance company loves to collect your premiums, but doesn't want to pay out any claims. I'm being crass here, but if one thinks prescriptions are tough, try to file a claim for disability or some other large payout. It's like an act of congress to get them to pay.

Unfortunately, nothing is going to change until the system gets fixed. As long as managed care is profit oriented and a traded stock on the NYSE, the patient will NEVER come first. .....When a company is a publicly traded one, the # 1 goal is stockholder return and profit maximization. Thus, the patient will lose over the long run.

Ex

 
Old 05-21-2008, 04:30 PM   #13
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Re: Insurance company knows more than the doctor??

Australia's national healthscheme has rescrictions on drugs covered, and some drugs can only be prescribed for certain conditions, but generaly, most bases are covered

 
Old 05-21-2008, 07:19 PM   #14
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Re: Insurance company knows more than the doctor??

Gosh Amanda I can feel your frustration just reading your post. You have been given some excellant advice. I went through something like this when trying to get an MRI. Twice I got lectured by doctors because of them having to deal with the insurance company. I will tell you it is strange first your meds, then denying coverage of your surgery. If it was me I would indeed be on the phone but I would also be sending a certified letter to who ever I had to, & I would get the name of every single person you speak to with the date & time you spoke to them. CMP sounds like she is giving you some excellant advice so perhaps a nice certified letter with cc at the bottem may get there attention. You could try it & if worse comes to worse Steve may be right, hate to think about lawyers but you are going through enough & all this just adds to the pain. By the way I have to call my insurance tommorrow to see if they will reimburse me for my scripts for my compound creams, I am not looking forward to it after reading this. Good luck, please let us know what happens. Sammy

 
Old 05-21-2008, 10:32 PM   #15
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Re: Insurance company knows more than the doctor??

I don't know what your financial situation is but you did mention that things are a little tight right now. I recently needed a lawyer for some disability issues at work (they were trying to fire me) and I also had no way to pay to hire a lawyer. If you do feel that you need a lawyer to help with your current situation you can go to the ABA website, they have a link you can click on to find pro bono lawyers in your state and also a list of lawyers who represent people with low incomes. Sometimes you can find one that is willing to just make a few phone calls without charging you. I hope this helps a little bit and I hope you can get things straightened out soon so you can rest and heal. I know very well how stressful things can get when you have to count pennies and I'm sorry for what you are going through.

 
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