Don't count on your doctor to know your insurance situation

[Marc1955]

HCV treatment teaches you many things. One unpleasant lesson I've learned that I want to share with folks who are contemplating starting treatment is that you can't count on your doctor to understand or help with your insurance situation. This is a huge hole in our medical system: the very people who are prescribing medications and directing treatment don't understand costs or insurance. Some doctors aren't timely about handling appeals with insurance companies. Some won't handle them at all. It's going to be up to you to make sure this is all squared away. Do not count on your doctor.

When you are starting treatment, one topic you should discuss with our doctor is how they handle insurance issues as they arise over the course of treatment. Do they handle appeals? quickly? What is their track record at getting treatment and rescue drugs covered? Try to be as reassured as possible that your doctor is up on these issues since  dealing with them yourself down the road when your faculties are compromised is challenging. But be aware that whatever reassurances you get from your doctor may not be worth very much. Doctors know so little about insurance and many are so arrogant that whatever they say cannot be relied upon.

[FlGuy]

You should expect your doctor to provide medical service and 'assit' with insurance matters.  More accurately; the office staff.

Who is covered by insurance?  Who pays the premiums?  Who benefits from the coverage?  Who is the consumer?  It's you.  And the sooner that you make yourself more responsible and knowledgeable about a product (insurance) you are buying the more effective it will be and the more protected you will become.

"Do not count on your doctor."  Absolutely correct.  Do not abdicate your own responsibility

[jmjm530]

Some very good points. The majority of drugs I took on treatment  (and there were many of them) were turned down at one time or another by the insurance company.

The remedy was always for someone in the doctor's office to call or fax them more information. And that was not always easy because these offices can be very busy and whoever does the insurance work (it ain't the doc usually) tend to give after two or three shots, especially if there's a lot of on hold time involved.

So unless you've very lucky with your medical team's insurance folks, that pretty much leaves it on you, the patient, to shepherd the entire process.

The first thing I would do when something was turned down (and this could be a drug,or a procedure like an MRI) was to find out why. Sort of obvious but not as easy as you think, and for some reason you never get a clear answer from the doc's office as to whay, because again they're real busy and often don't take very good notes.

So, the way to do it -- or at least the way I did it -- is to first call the insurance company yourself, but not the  "customer service" number, because they are usually useless in these situations. What you need to do is call the "Provider" number. That's the number for the docs and their offices. Only problem is that they're not supposed to talk to you so sometimes it takes several calls before you get an agent who is nice enough (or one you can wear down) to work with you. The others basically tell you to get lost.

What you want to find out are two things. First, why it was turned down. And most importantly, what are the requirements the insurance company needs for a particular drug or procedure. Sometimes the requirements are simply a call or fax from the doctor saying "this or that". What you want to do is copy down exactly what "this and that" is supposed to say and then give those words to the insurance person in the doc's office. Believe me, they will appreciate the help because all the want is to finish off your appeal as quickly as possible. And if time is of the essence, there's nothing better than doing a conference call between you, the insurance rep and doc's insurance person.

Sometimes it's something else like a note from the doc saying you tried another drug first for a certain period of time. But in any event, the trick is to find out exactly what the insurance company needs to change their mind and overturn the denial, and there is always SOMETHING.  

So the next time the doc's office tells you that you were turned down for this and  that, take that as a starting point not as an end point and be prepared for some legwork which is just loads of fun when you're all shot full of Peg and Riba.

Some doctors offices make this process easier than others,  so the discussion "Marc" suggests is an excellent one. I think you'll also find that the more experienced offices -- the hepatologists -- tend to have more experience and will get more of the stuff approved from the get-go. Not all, but more.

Lastly, I remember that horrid conversation with the insurance company around week 12. Basically they told me that they can't deliver any more Pegasys. The reason turned out that some requistite paperwork(viral load test results I believe) from the nurse was never turned in. To do it over again, I'd find this all out in advance from the insurance company so that there would be no surprises.

-- Jim

[joannatsf]

There are pharmacies and there are Pharmacies.  They are on the front line of handling your insurance problems and can make all the difference in the world.  Find one that is familiar with insurance problems and they will serve your interests.

As far as I can tell the best pharmacy in San Francisco is the Walgreens at 18th and Castro streets.  They were at ground zero when the AIDS crises hit and quickly adapted to the fact that insurance delays could be a matter of life or death.  It's not especially conveniant for me but I go there because I know that problems will be handled quickly and correctly.  Find one where you live that is used to handling problems.

Doctors and pharmacies are partners in your health care.  You need to be involved in the process and plan on doing needed leg work when problems arise.  WHen Xifaxan became available for hepatic encephalopathy I had to fight tooth and nail with my insurance carrier to get them to pay for it.  My doctor provided the science and my pharmacy FAXed the supporting documents over to the carrier.  Eventually they relented and my life improved dramatically.

[Marc1955]

jmjm530 - Thanks for your typically informed and helpful comments. I wish I had read something like that before I started. I wonder how many people realize how much can be involved in staying on these medications.

joannatsf – You make an extremely valuable point. I also use a great "Pharmacy" that is skilled at working on approval issues. This is such important advice for people starting out. Although insurance companies often steer you to a particular pharmacy, in most cases you are not obligated to take their choice. It's important to find the kind of pharmacy that works with complex pharmaceuticals and insurance issues. Mine has been extremely valuable to me as I've worked through my approval issues. They have experience and skill that I don't have.

[jdwithhcv]

I thought your response to this thread was excellent and to the point.  Since Marc1955 pointedly omitted to thank you, allow me to do so.  Thanks for an excellent and accurate comment.

jd

[lalapple]

actually, i wouldn't count of my doc to know anything since the only time i've seen her was before i started tx.  since then, they have a PA to play doc for every single one of my clinic visits.  i'm wk 37 finally.  

[YuK]

I also had the many of the same issues.  I'm on an HMO, authorized to see a specialist.  I'm so paranoid about my perscription authorizations not being in place I call 3 weeks prior to every delivery.  Several times I have stayed on the phone for hours trying to get the right folks to fax the proper paperwork to the correct place.  Not to mention, my medical group's protocol (and office staff) does not seem to be up to date on SOC.

If or I should say when, I become cured, I am going to contact a lot of organizations, medical groups, and people about this situation.  It is bad enough a person has to take these medications with all the sx, but then have to deal with all the red tape also.  It scares me to think of people that are invalids with no one to help them.

[bandman54]

make sure your lab is in your insurance network.... mine wasn't , doc was.      showed card to everyone.... got new doc! ridiculous... send my blood to memphis when they could have sent it almost across the street.  
bandman