Insurance company knows more than the doctor?? - Pain Management Message Board

butrfligirl28 · 05-20-2008, 08:29 AM

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 (*****) 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

Executor · 05-20-2008, 08:51 AM

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

forginon · 05-20-2008, 09:11 AM

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

friendly_one · 05-20-2008, 09:30 AM

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

butrfligirl28 · 05-20-2008, 09:54 AM

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