insurance argh
May. 16th, 2014 12:15 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
boxofdelightsSo, I have a new doctor, which is a good thing. But Monday, when I went to pick up my blood pressure pills, the pharmacist asked, "Did anyone talk to you about preauthorization?"
No. Why would anyone talk to me about preauthorization.
The insurance company doesn't want to pay for the dosage I'm taking, which is 60 pills. They only want to pay for a normal dosage, which is 30 pills, unless I have a preauthorization. The fact that the doctor wrote the prescription isn't enough; he also has to give the insurance company a preauthorization. The fact that this is the same dosage I have been taking for years, that the insurance company -- the same insurance I have had for years -- has been paying for for years is irrelevant. It was no-one's responsibility to warn me about this before I ran out of pills. The fact that it will cost the insurance company more in the long run if I have a stroke? Well, maybe I will be on some other insurance company's books by then.
Probably, 60 pills of the high dosage ACE-inhibitor and diuretic combo is not the best way to manage my high blood pressure. My old doctor started with the diuretic, added the ACE inhibitor, and then kept upping the dosage until it worked. She never tried beta-blockers, which, according to my reading, are more likely to be effective on high blood pressure in someone who has as much anxiety as I do. But, as my old doctor liked to remind me, I do not have an M.D. But neither does the nickel-and-dimer in the insurance company!
So, Monday, I called the doctor's office and explained the problem to the person who answered the phone, who said she would leave a message for the medical assistant, who would arrange the preauthorization and call me back when that was done. What should I do in the meantime? I had accepted from the pharmacist the 30 pills that was all my insurance company would pay for. Should I take a half-dose this month, because the preauthorization can't move back in time to preauthorize the 60 pills I need this month? Is there any way around this? (My trip to Wiscon is not going to be low-stress.) I did not think the person who answered the phone would know. I thought I could ask the medical assistant, who deals with insurance companies, when she called me back. Unfortunately, she didn't call me back. I have called the doctor's office again. This time the person who answered the phone transferred me to the medical assistant's answering machine, so I left her a message myself. So I am waiting again. But what should I do in the meantime?
No. Why would anyone talk to me about preauthorization.
The insurance company doesn't want to pay for the dosage I'm taking, which is 60 pills. They only want to pay for a normal dosage, which is 30 pills, unless I have a preauthorization. The fact that the doctor wrote the prescription isn't enough; he also has to give the insurance company a preauthorization. The fact that this is the same dosage I have been taking for years, that the insurance company -- the same insurance I have had for years -- has been paying for for years is irrelevant. It was no-one's responsibility to warn me about this before I ran out of pills. The fact that it will cost the insurance company more in the long run if I have a stroke? Well, maybe I will be on some other insurance company's books by then.
Probably, 60 pills of the high dosage ACE-inhibitor and diuretic combo is not the best way to manage my high blood pressure. My old doctor started with the diuretic, added the ACE inhibitor, and then kept upping the dosage until it worked. She never tried beta-blockers, which, according to my reading, are more likely to be effective on high blood pressure in someone who has as much anxiety as I do. But, as my old doctor liked to remind me, I do not have an M.D. But neither does the nickel-and-dimer in the insurance company!
So, Monday, I called the doctor's office and explained the problem to the person who answered the phone, who said she would leave a message for the medical assistant, who would arrange the preauthorization and call me back when that was done. What should I do in the meantime? I had accepted from the pharmacist the 30 pills that was all my insurance company would pay for. Should I take a half-dose this month, because the preauthorization can't move back in time to preauthorize the 60 pills I need this month? Is there any way around this? (My trip to Wiscon is not going to be low-stress.) I did not think the person who answered the phone would know. I thought I could ask the medical assistant, who deals with insurance companies, when she called me back. Unfortunately, she didn't call me back. I have called the doctor's office again. This time the person who answered the phone transferred me to the medical assistant's answering machine, so I left her a message myself. So I am waiting again. But what should I do in the meantime?
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Date: 2014-05-16 07:15 pm (UTC)Insurance companies suck.
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Date: 2014-05-16 11:58 pm (UTC)We'll just pretend not to notice that the people with the least power to pay unexpected medical bills out of pocket are often also the ones with the least power to argue insurance companies into meeting their obligations.
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Date: 2014-05-16 09:10 pm (UTC)You have my deepest sympathies.
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Date: 2014-05-16 11:54 pm (UTC)no subject
Date: 2014-05-16 10:31 pm (UTC)I'm glad you're shut of the former doctor.
I so hope the people you employ to render you service make this easier. :(
And that the various stresses let up.
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Date: 2014-05-16 11:46 pm (UTC)no subject
Date: 2014-05-16 11:00 pm (UTC)Your doctor's office should be able to triumph over the insurance company. The problem is that sometimes this requires you being persistent with the doctor's office, the insurance company, and/or the pharmacy if they're not getting back to you and getting it fixed-- I've seen my transplant patient partner have to do this song and dance a couple of times to get stuff worked out. Which is no fun no matter what, but especially no fun if you're prone to anxiety.
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Date: 2014-05-16 11:46 pm (UTC)no subject
Date: 2014-05-16 11:09 pm (UTC)no subject
Date: 2014-05-16 11:41 pm (UTC)Not intrusive at all! If it isn't screened, it's public. Thanks for the suggestion!
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Date: 2014-05-17 03:44 am (UTC)(Experience with this: my fiance takes the latter)...so maybe, if your doctor thinks it's safe and you feel ok doing so, you could switch from one to the other until the pre-auth is straightened out? Because $4 is yeah, great. Also, my fiance gets lisinopril for $4 or else for free at Winn-Dixie (depends if it's call-in-the-refill time once every three months, which is $4, or between call-in-the-refill times, in which case it's free).
Also hope I'm not intruding. I had a case in the past where despite the public nature of the post (made by another poster not tied to you at all that I know of) I got my butt chewed out for commenting at all.
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Date: 2014-05-17 04:24 pm (UTC)Another possible bureaucratic snaggle is that your health insurance company has enlisted the services of a "pharmacy benefits manager." This can be a new department inside the insurer, or a separate company that does nothing but juggle drugs. "Prior authorization" is their bread & butter. In theory it means they can get better prices on meds, which are passed along to end-users. In practice it means they stomp their way into established doctor-patient relationships.
PBMs can't say, "everyone with this diagnosis only gets this much medicine" because that's practicing medicine without a license. They can require prior auths, and oh! they're a pain in the butt. Lots of my meds require prior auth, and I've become accustomed to eye-rolling from doctors and medical assistants who have to fill out the forms (at least they're electronic now). I sigh back and say, "Yes, I want that med!" I reflexively ask now whenever I get a new Rx, "will that require a prior auth?" and sometimes the docs don't even know. (Thousands of meds! The "formulary" (OK to dispense) changes monthly!)
Once you're back home and things have settled a little, you may be able to head off a repeat of this misery. List out all your meds w dosages, contact the insurer, find customer service people in charge of prior authorizations. Hand them the sheet and say: any of these require prior auths?
MyGuy spent twenty years wrestling in one of the largest health-insurance companies in Wisconsin, and could provide copious details if you're interested. But as you put it so well:
We'll just pretend not to notice that the people with the least power to pay unexpected medical bills out of pocket are often also the ones with the least power to argue insurance companies into meeting their obligations.
It's infuriating that the people with the least understanding of the medical impact of your prescription are also the ones with the greatest power to prevent you getting it.
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Date: 2014-05-18 07:34 am (UTC)