I couldn’t figure out what thread to post this in, but I thought “healthcare insanity” fit the description even if it’s not what the thread is about.
Don’t most schools still require a measles vaccination?
There’s been news reports of doctors in New York faking vax papers for decades
For now. There’s rumblings in several states to get rid of all vaccine requirements. I don’t know how seriously they’re being pursued.
What will Fauci do for secret income if states abandon mandatory vaccines?
I’ve mentioned before I suffer from cluster headaches (they’re not migraines.) Long story short, my neurologist prescribed high flow oxygen (an effective abortive for most, she even included a letter) and Emgality, a drug developed for migraines but with promising results to shorten the cycle for CHs and approved for treatment by the FDA.
Insurance denied both. It’s ludicrous that bean counters get to decide my treatment instead of my doctor. Now I have to call the insurance company to appeal - I don’t even know what to say, I’m not a trained medical professional. “Hey shitheads, maybe you should defer to the neurologist instead of your profit margins”? (Read a description recently that US healthcare is “more like a coupon book with fine print.”)
I don’t know if UHC would be any better, I just happen to have a fairly rare condition that’s not been well studied (almost all treatments are anecdotal. Verapamil, Vitamin D, psilocybin also are reported to be effective, but neither Verapamil nor Vit. D have helped me. Not tried mushrooms, don’t know how to get them and I’m hesitant to grow them myself) but wanted to bitch just the same.
(Luckily for me my cycle ended early and now I don’t need either but I will the next time. The longer version: I’ve been prescribed a triptan nasal spray which does work to abort a headache but I only get six doses at a time, I can only use it once a day, and can only get it refilled every three weeks. During the peak of my cycle I can four to six headaches a day. I was also prescribed prednisolone, a steroid which worked in reducing the intensity but not the frequency nor the length of the cycle and I can only get use that treatment once/cycle (enough pills to last roughly 10 days, cycles can last for me up to three months). Both these have their own side affects. The only OTC abortive that works most of the time is pounding a Monster energy drink (80 to 220 calories a pop depending on what’s available.) Aside from falling asleep (unavoidable lol) winter hats, headphones, eyeglasses, and simply lying down on a couch can trigger a headache (along with alcohol but I have that up years ago.)
Insurance companies are rat bastards. Sorry for your pain.
You have to figure out why they denied it. I am surprised the pharmacy didn’t mention why. Typical scenario is prior authorization. You need to find the PA chart/procedure for the drug. They may require step therapy (proof that you used shitty stuff before) or simply just don’t cover it because it’s out of formulary.
High flow oxygen I don’t know, it could be durable medical equipment which is another process. Never done those.
I don’t really understand what this means. :( It’s a new drug AFAIK and there aren’t any generics (I got a form for financial assistance from Eli Lilly so I assume it’s not cheap. It’s an injection and doesn’t look simple to use but it’s the only drug approved for episodic CHs.)
For the 02, I didn’t exhibit “decreased oxygen levels.” Yeah no kidding, it’s being used as an abortive. I can probably afford that without insurance though which I’ll pursue when the next cycle starts (there’s a medical supply company right in town I can get it from.) For the Emaglity, I got a recorded auto message from the insurance company and it only said I’ve been denied and to call the number on the back of my insurance card, nothing from the pharmacy nor from the doctor’s office on why.
If you want to dm me the insurance name I can probably find a link to the procedure
When I’ve run into something like this before, my healthcare provider did the leg work. Ideally, you get the professionals (your pharmacy and your healthcare provider) to figure it out with the insurance provider. What you need, as wisefool indicated, is a reason why it was denied and a path to coverage. If that path is reasonable and your MD can/will follow it, you should get there. The insurance companies won’t just take an MD’s script as carte blanche for any drug and they will throw up (hopefully) reasonable barriers/requirements to getting it done.
A few reasons why a medication can be denied, just for reference.
First, many medications and other durable medical goods or procedures require “prior authorizaion” AKA PA which means you have to request it through the insurance and jump through some hoops. In theory your doctor’s office should have some knowledge or info about this unless your insurance is super weird. The insurance is also supposed to be giving you clear info as to why there was a denial and what your options are.
Second, you may have to do some precursor steps before getting a particular med or procedure. In theory your doctor’s office should have some knowledge or info about this unless your insurance is super weird. The insurance is also supposed to be giving you clear info as to why there was a denial and what your options are.
Third, in the case of a brand name medication it may not be in your insurance formulary. That means it’s not in the list of meds the insurance has contractually agreed to provide you. In many cases, this means you have to get a generic or if a generic is not available, then you must seek an alternate medication. In theory your doctor’s office should have some knowledge or info about this unless your insurance is super weird. The insurance is also supposed to be giving you clear info as to why there was a denial and what your options are.
You see the common thread there? We’ve created a bizarre situation in this country where we put a huge burden on doctors and on the patients to know a bunch of procedures to get care. It absolutely sucks but is very common.
It seems to me you want to seek more info both from your doctor and your insurance. You may have options.
I think it’s a conceptually workable system, barring medical emergencies. We see the same sort of things in the legal industry, especially when working with government agencies and such—the initial denial is just that and is one of the vehicles for getting the info needed to get an approval. What’s unclear in this particular case is whether the insurance company is transparent about the requirements or if they are intentionally making it difficult for the healthcare provider(s) to figure out what is needed for approval.
It’s workable but it’s one of those “default systems favoring the powerful” that I consider a major issue in our society. Why should the patient bear the cost of this sort of administrative thing? I can see imposing some burden on the medical provider as they have the specialist knowledge but in general I feel the burden should primarily be on the insurance, which is the entity responsible for administering and paying for the care. The patient should have the least burden as they have the least knowledge and ability. But often, the patient ends up with the heaviest burden.
There has been some improvement in this area in recent years to my understanding as the ACA has imposed some rules and regs on insurance companies but certainly in the example in this thread it doesn’t seem like the insurance is explaining things very well, especially options and next steps.
One specific thing I will call out, as someone who has represented insurance companies for over 25 years, is that insurance companies feel their responsibility is to respond to the requests made with an acceptance or denial but they don’t have any obligation to actually deliver health care. They are not very good at providing options and next steps.
From a standpoint of actually delivering needed care to patients our system is horrendously inefficient.
For me, what’s not 100% clear here is how much info the insurance company has provided to the pharmacist and the healthcare provider—I’ve certainly dealt with some incompetent healthcare admins in my day. The observation that it hasn’t gotten back to MrGrumpy isn’t proof that info wasn’t provided. Plus, I think it is frankly best that it be dealt with by the professionals, as patients shouldn’t be expected to know what to do. But this illustrates the fallacy of market-driven healthcare, too. Like insurance companies, patients are well equipped to shop for providers, including on the basis of how adept they are at navigating the administrative requirements of providing healthcare.
What is the alternative? That insurance providers approve all reimbursement request from a provider, without imposing requirements? I think we need more details on this particular case to see how things shook out on the various sides of the equation.
Yes, I do! I can take triptans and suffer rebound headaches, yay!
So here’s what I did find out: My dr. office did request a PA. It was denied. Insurance thinks I should use different types of triptans (generic sumatriptan injectable and generic zolmitriptan nasal spray). These work to abort one headache, and worse can frequently cause rebound headaches. My neurologist cautioned me not to use the nasal spray I now have more than one dose a day due to that and other possible side effects.
The drug they denied (emgality) is a calcitonin gene-related peptide (CGRP) antagonists, a new class of drugs specifically designed to prevent migraines but also it turns out decreases the frequency of cluster headaches attacks during a cycle (and the only medication approved by FDA for CH fwiw.) IOW they do entirely different things.
I called my insurance company and according to them the only recourse at this point is for my doctor to appeal and do a peer-to-peer review which I gather from reading about these from physicians on reddit is not something most doctors have time for (for some context, there’s a 10 month waiting period to get an appointment with my current neuro.) I can pay for it OOP and it looks like the cost is $400/per dose at one per month during a cycle (so at most three doses.) I’ll also have to pay for high flow oxygen OOP although that’s apparently a lot cheaper (can get that by the tank, each tank lasts ~four headaches.) IOW as an individual there doesn’t appear to be much that I can do except pay for it myself (on top of already paying for insurance that won’t cover shit, but I digress.)
In any case, I don’t see how an insurance company thinks they know better than a neuro what should and should not be used for a given condition.
In my 20 years in admin it is a handful of patients that ever do anything. The burden is 90% on the clinic.
Every week patients will call saying they ran out of prescriptions. I go look and they still have refills left. The pharmacies fuck it up constantly, but they don’t bother the pharmacies. They will use the path of least resistance, which is us. I stopped calling pharmacies for them, I tell them to call the pharmacy back and tell them they are wrong and that the script was filled on XXXXX and YYYY.
There should be some sort of health cost control. The problem is that there’s so many different companies, and plans within companies so the workload is even higher. You need to maintain web accounts for dozens of shitty companies which have their own intricacies
Single-payer is a non starter politically because these fuckers have too much money. They are locked right into medicare and medicaid too, leeching money from those systems. I don’t even know why there’s a choice, it’s a choice between more or less equally shitty plans from equally shitty companies which spend lots of money on marketing.
One thing that helped the last decade is when my state medicaid put out a universal formulary. Since 90% of patients are poor and on medicaid this makes life much simpler.
But we can’t have universal healthcare in this country b/c that would be RATIONING!! OH NO!!
Jesus wept.
I messaged my dr. office and this is the reply they got from insurance:
The denial for Emgality states :Denied emgality pt to have used generic sumatriptan injectable and generic zolmitriptan nasal spray. The individual has had inadequate response to one of the covered alternatives or has a contraindication or intolerance to both covered alternatives .
(I explained in my previous post how triptans are nothing at all like the drug they denied.)
One thing I want to add is that although insurance companies suck and are part of the problem, the problem is actually the entire system, not just the insurance companies. Health care is overpriced in the US and has many other issues.