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Old 01-17-2011, 01:28 PM   #1
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Exclamation Pain Meds and New Insurance worries

Hello folks,

I needed some advise on what to do about the following.

I was under corporate insurance for 2 yrs and lately due to divorce had to go on cobra. I could not afford 400 pero month on cobra so I had to apply for private insurance and was accepted by AETNA. They have a clause where If I had continuous coverage I don't have the 12 month pre existing period wait. I had been on pain management for the past 2 yrs and my previous insurance always covered the meds and the PM doc visits. That's in a nutshell.
Now, I have to admit that I did not mention to my new insurance that I was on Pain management. Doctors have never given me a consice diagnosis as to why I am in pain, but my rheumatologist was the one who referred me to my pm doctor 2 yrs ago. I have back pain and joint pain though and my PM doc has been happy to prescribe for me. Im a good patient.
I visited my PM doc last month when I had no insurance coverage so I will have to pay him cash/no coverage which is fine, but I wonder what will my current (started this month) insurance company do if I fill my Hydro and Oxy prescription with them. Will they make no problem or will they start asking for doctor's notes, etc?
I am afraid that they may cancel my insurance policy if I fill my prescription and there is no doctor's visit in their record covered by them or because they will say I did not inform them i was under PM.
Should I just absorb the cost of the PM doc's visits and prescriptions and not charge it to my insurance? will that get me out of their scope?
Or I should go with the flow and fill my prescription and charge my next PM visit to my insurance since I can provide credible coverage by my previous insurance?
Any Suggestions are welcome, but please spare me the lecture I know I know

 
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Old 01-18-2011, 09:57 AM   #2
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Re: Pain Meds and New Insurance worries

unles you need prior authorization for any of the meds file your insurance. Shouldn't be a problem at all

 
Old 01-18-2011, 10:32 AM   #3
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Re: Pain Meds and New Insurance worries

Quote:
Originally Posted by katlovesdogs View Post
unles you need prior authorization for any of the meds file your insurance. Shouldn't be a problem at all
Thanks for your reply! You mean I should call my insurance to ask if I need authorization to fill Percocet and Norco? Never had to provide that for my last insurance BCBS unless they requested it directly from my doctor and I never knew they did?

I may be able to fill this prescription, nut what about next month's and the PM doc's visit.? Should I use the insurance for those as well you think?

Thanks again

 
Old 01-18-2011, 03:17 PM   #4
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Re: Pain Meds and New Insurance worries

hi i have worked in the medical field for many years so i think i can help you-the problem wont be you filling the presciptions, they will be filled no problem-what will happen is when your pm sends in the bill for your visit since you are an established patient he is going to use a code that indicates you were there for a follow up visit and not a new patient-that is when the ins co will ask for notes and find out you did not disclose this pm to them and then the have the right to caancel your coverage. you have 2 options- 1) pay for the ov's yourself and dont use your ins, or 2) start over with a new pm and as a new pt, but you would not be able to tell the new pm you have been treated before because, again the new ins will find out because it will get docmented in your med rec by the new dr, and usually for a new pt visit your ins will ask for the notes. if it were me i would continue with same pm dr and just pay him-you can still get your rx's fileed thru your ins-just DONT use ins for the visits-------good luck
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Old 01-18-2011, 09:02 PM   #5
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Re: Pain Meds and New Insurance worries

Quote:
Originally Posted by BB07 View Post
hi i have worked in the medical field for many years so i think i can help you-the problem wont be you filling the presciptions, they will be filled no problem-what will happen is when your pm sends in the bill for your visit since you are an established patient he is going to use a code that indicates you were there for a follow up visit and not a new patient-that is when the ins co will ask for notes and find out you did not disclose this pm to them and then the have the right to caancel your coverage. you have 2 options- 1) pay for the ov's yourself and dont use your ins, or 2) start over with a new pm and as a new pt, but you would not be able to tell the new pm you have been treated before because, again the new ins will find out because it will get docmented in your med rec by the new dr, and usually for a new pt visit your ins will ask for the notes. if it were me i would continue with same pm dr and just pay him-you can still get your rx's fileed thru your ins-just DONT use ins for the visits-------good luck
Thank you for this information. It makes a lot of sense. If I fill my monthly prescription with my insurance but not the doc's appointment, won't they be suspicious as to how I get these prescriptions for controlled substances and there is no doctor's visits?
I'm afraid they might catch up after a few months since they won't be office visits and monthly prescriptions. Thoughts?

This also brings me to the following question. I called my primary physician care to have him fax my medical records and refer me to a known rheumatologist I'd like to see. When the new rheumatologist files with my insurance as new patient then he will be sending along my medical record from my primary care and they will find out about my chronic pain. Is this correct? This rheumatologist has experience with fibromyalgia hence why I want to see him, but he requires referral. Even if he didn't require this referral and medical records I would still have to say that I have chronic pain and tell my story, which will be documented in the notes as well and the insurance company will know about my cronic pain. Do I have to find a new primary care doctor and don't disclose my previous history and make him think I just started having pain and start fresh? What do you suggest?
Thanks again for your insightful information.

 
Old 01-19-2011, 06:40 PM   #6
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Re: Pain Meds and New Insurance worries

one thing to think of is that if you don't tell the new doc any history, it will be hard to explain any tolerance you may have built up.

I'm not advocating either way....

 
Old 01-19-2011, 09:23 PM   #7
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Re: Pain Meds and New Insurance worries

Not sure how to proceed about that .. The goal is to get care and not kicked out of my insurance.

 
Old 01-20-2011, 03:03 AM   #8
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Re: Pain Meds and New Insurance worries

So, in America, if you tell an insurance company you have an illness, then can refuse you cover?

Is there any system of appeal, to guarantee people with serious illness cover?
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Old 01-20-2011, 05:19 AM   #9
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Re: Pain Meds and New Insurance worries

I think you are going to have to suck it up and pay cash for your PM visits for the next year. You can still use your insurance for the prescriptions, but attempting to use it for PM visits will very likely get you cancelled.

Tigg.

 
Old 01-20-2011, 06:27 AM   #10
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Re: Pain Meds and New Insurance worries

Did you EVER have a lapse at all in coverage even for a month or two ? This is a classic example of why people go on COBRA so that they can be overlooked for the pre-existing condition clause. I think Obama and te health care reform is trying to do away with this problem.

 
Old 01-20-2011, 07:24 AM   #11
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Re: Pain Meds and New Insurance worries

Quote:
Originally Posted by tiggertoo2174 View Post
I think you are going to have to suck it up and pay cash for your PM visits for the next year. You can still use your insurance for the prescriptions, but attempting to use it for PM visits will very likely get you cancelled.

Tigg.
Tigg,
But what about the rheumatologist? If u go to a new rheumatologist and tell him my history won't that be scrutinized by Aetna and they might say it was preexisting? Even though Aetna covers preexisting conditions right away if I have continuous creditable coverage, which I can prove I had, the thing is that I didn't tell them about these on te application to avoid then not approving me. Or at this point I should just risk it and go ti the rheumatologist and hope for the best? After all I am paying 200 a month and can't be for nothing.

 
Old 01-20-2011, 08:16 AM   #12
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Re: Pain Meds and New Insurance worries

I'm no expert on insurance, but I would think that being referred to a new doctor by your primary for something that you don't have a specific diagnosis for probably won't raise any flags. I don't know enough about it to know if the insurance company will get much more than the codes from forms. I'm thinking that would show a "new paitient consult" from the new Dr. plus whatever they put as a diagnosis. Have you seen your primary for this since you started the new ins. and if so do you have any idea what your primary put as a diagnosis for this? For example did he/she put something specific like Degenrative Disk Disease, or just something like back/joint pain without a specific diagnosis? I think that it's likely to be OK since it's a new referral to a new Dr. Good Luck.

Tigg.

 
Old 01-20-2011, 12:41 PM   #13
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Re: Pain Meds and New Insurance worries

brighter, it might be a better idea to ask these questions on the Health Insurance forum here on the HealthBoards. There are many people there who are very qualified to answer your question...just a thought...janiee

 
Old 01-20-2011, 01:47 PM   #14
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Re: Pain Meds and New Insurance worries

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brighter, it might be a better idea to ask these questions on the Health Insurance forum here on the HealthBoards. There are many people there who are very qualified to answer your question...just a thought...janiee
you are right! will do. Thank you all for your contributions.

 
Old 01-20-2011, 05:13 PM   #15
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Re: Pain Meds and New Insurance worries

Jonnstar: Here in the US there are a few types of medical insurance. This is a basic review, but we don't have national health care so our system can be hard to understand:

(1) Group Insurance: group insurance is obtained thru an employer or the employer of your spouse, partner, or parent. Under Group insurance new entrants aren't evaluated for medical conditions. Only if they have no prior coverage they can prove int he last 63 days. The cost of coverage is based on past experience (claim costs) of the specific employer. You can go from Group Ins to Group Ins with no pre-ex and no question as long as there is no gap of more than 63 days between policies. The cost is split between the employer and the employee and has been going up due to cost of health care increasing. When employment ends we have COBRA which is continuation of group coverage. Usually 18 months and more than the cost of group coverage since the employer is not paying it's portion.

(2) Individual Insurance: You purchase a policy that covers only one person or perhaps that persons direct family. To price it right they ask medical questions about doctors, conditions and medications. Coverage can be far less generous than Group plans (such as limiting hospital coverage to $1000 total if people don't check the policy provisions carefully) Diabetes is one condition that will lead to denial of coverage under individual insurance. If you go from Group to Indiv with a gap of no more than 63 days then pre-exising conditions can't be excluded BUT there are conditions such as diabetes that result in no policy being issued and denial of coverage. The risk of potential problems is too great. If you develop diabetes or cancer while on a policy they can easily raise your rate as your medical expenses go up. In applying for this the application includes a provision that you have given FULL DISCLOSURE. Failure to do so can lead to policy termination. Indiv coverage is much more expensive in most cases as it's based on you or your family alone and doesn't have a huge risk pool and employer based group plan would have AND there is no employer to pay part of the premium

(3) Medicare is for people on Social Security Disability or Social Security Retirement. There is no questionnaire about past conditions and no pre-existing exclusion. The person pays part of the cost and the government pays the rest.

(4) Medicaid is for the poor. It doesn't cover all who have no insurance as it requires you have limited income and limited financial resources.

Other than that our hospitals are required to treat the uninsured, but that of course doesn't help with preventive care. Here in the US some emergency rooms can be quite full of people who don't need emergency care, but who have a cold, minor infection, ankle sprain, etc.

Our government has changed some of the requirements under insurance and if the current plan in place is not overturned by the government in 2014 there will be no pre-ex exclusions. However it will still cost more to get insured if you a have a condition or history of a condition.

This past summer my husband's employer abruptly closed and his COBRA ended. We tried to get Indiv insurance to last him until his new employer's coverage started 60 days later. His Type II diabetes led to immediate denial. Unfortunately they don't even evaluate the person. His is so well controlled that tests would never show he had it, but that didn't matter. So I added him to my policy at $400/mo for 2 mo. I am on "retiree disability" under my employer and I'm lucky they keep me on insurance for as long as I am on disability. So I can add my spouse but it's expensive. I could be added to his coverage and drop mine, but since I have my coverage for life and have a plethora of problems we figured that's not a good idea unless we had some change in my coverage that resulted in coverage ending.
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