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Living Below Your Means
The Health Insurance Nightmare

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By oncqueen
January 24, 2008

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[Reply to: Health Insurance Coordination of Benefits]

Unfortunately, there are several ways that people with insurance can be worse off:

People whose companies fight about when the secondary insurance kicks in.

People who were able to get their expensive oral chemo drug for free from the drug company who suddenly become Medicare eligible, at which time the company says that since the drug will be "covered" by Medicare, they are not going to provide it anymore. Problem is, the 20% NOT covered by Medicare is more than the person can afford ($$$) so they are now out of luck.

People who had their medical bills covered by state aid who get a job: suddenly, they have insurance, BUT A PREEXISTING CONDITION, and are cut off from state aid. You have a cancer survivor who is NOT disabled, who is trying to get a job like a decent person, and suddenly in doing so they sacrifice their ability to get their follow scans, etc paid for.

People who are getting chemo covered through Medicare, their primary insurance, whomever BUT they need shots ($$$) to support their counts so they can get chemo. They have a prescription card, the idea of which is that they can send off to get 3 months worth of Prozac or Viagra for the price of 1...suddenly, the primary insurance tries to say that since the shot is not "chemo," it falls under their prescription card, and they are not paying for it. The prescription card folks say "that's stupid, we are for pills only," and suddenly the patient is on the hook for $14,000 that should be covered; of course, the problem does not come to light until weeks into therapy.

People whose insurance mandates getting radiation therapy at only a designated center that contracts with them, even if it is a 2 hour drive away. They drive past closer places and spend 4 hours a day for 6 weeks commuting, in the snow and with the price of gas.

People whose insurance company mandates "brown-bagging" chemo from a central pharmacy. You go pick up the "groceries" and take them to your doctor's office to "cook" the day of treatment. Your drugs may or may not be shipped in time for your appointment, may or may not be the right dose, and best yet, may possibly have frozen or thawed en route, so may not be potent---good luck!

People who have mail-order med coverage BUT MUST WAIT TO BE REIMBURSED for their initial cash outlay, often 3 months later. I have one patient who had to "front" nearly $10,000 for his "covered" Gleevec for CML. They eventually paid for it, but each month's Rx has to be floated by him, so he basically has $10,000 tied up at all times in his "100% covered" drugs. How many people can do that and still make rent??

People (self-employed, mostly) who opt for a "hospital only" insurance plan---sounds like a great idea: you pay for your cold meds and Advil, but the big things like surgery are covered. The problem is that MD visits are NOT part of the "hospital" part, and that more and more surgeries are considered "outpatient" even though they are DONE at the hospital. In addition, chemotherapy, radiation therapy, and other treatments often are done at freestanding centers, NOT at hospitals...Yet having any "insurance," however ratty the coverage is, may knock a person out of the various charity programs that exist.

One of the scary things is that often, the benefits/HR folks who are signing up people for the various options don't know what the coverage really is going to be for a certain situation, and even the people who work at those companies don't always give the same answer.

My nurses spend HOURS on the phones every day, often with "Voice Mail from Hell," trying to get preauthorization for various treatments and tests for our patients; it's a nightmare! Often, they run into a dead end: "Oh, we have contracted that part of the preauthorization process out to this other outfit, even though that is not listed on the insurance card, our website, etc.---sorry about the 45 minutes you wasted. Call them." Sometimes, even preauthorization is not a guarantee of payment, and the patient is STILL stuck with a bill, because someone decided on further review that something else might have been cheaper. We have gotten faxes that said, "What is X drug that you want for this patient? Please tell us what it is, and then we can decide whether or not to approve it." Excuse me, but you DON'T EVEN KNOW WHAT IT IS, and you are going to have control over whether or not it will get covered???!!!


Today, my nurse was working on getting an anti-nausea medicine for 2 patients for chemo, around $300 worth. (It is the standard for people getting chemo of a certain intensity.) Once she was told, "no, give them something cheaper, but if they throw up so much that they have to go to the ER ($$$), then NEXT time we will cover the med." The other insurance company said, "We won't approve the med as a stand-alone, BUT if you also prescribe these 2 OTHER DRUGS at the same time, we will cover them all," so suddenly the $300 has ballooned to over $500. 2 other patients this week had theirs go through no questions asked, yet they all had the SAME diagnosis and the SAME chemo regimen. Our office spends the time because our patients deserve the best care we can give them, but the RN on the phone has an hourly wage, and the insurance company is paying the folks on the other end something, too, so it's an expensive and inefficient system. Lots of offices don't even bother: "Here is what your chemo will cost; pay $20% down and YOU have to deal with the insurance companies to collect," which is awful because if my specialized RNs have difficulty, how on earth is little hard-of-hearing, 80-year-old housewife of the patient going to be able to navigate this???

It's a nightmare, and won't get fixed until Congress doe not have free VIP medical care; they are so out of touch with what it is like to be a regular patient, and any concerns that the medical folks raise is chalked up to the whining of "rich doctors."

All you can do is try to pay attention to deductibles, catastrophic caps, any maximum outlay from the insurance company (folks with a certain chronic leukemia are now starting to outlive the max their insurance will pay for drugs), who locally is in and out-of-network, and how you will be expected to get your medicines (mail order, local pharmacy, whatever), and how your insurance will cover if you remain employed, or if you or your spouse's insurance lapses.