DENIED!!!

[Rain6866]

I got a call from my Gastro Doc today that my Insurance company denied my authorization for my pegintron. The funny part is they appoved me for the Riba... My hubby called the insurance company and they are saying they didnt get enough info from my doc. My doc is saying they sent everything that was asked for which I dont believe because the nurse called me back this evening and said she convinced the insurance company to resend the papers they were needing. I just feel stuck. I want to get this over with and I dont want to spend the whole year doing treatment and/or worrying about doing treatment considering I only have to do 24 weeks.

[zrjl]

My fiancee's insurance company did exactly the same thing. Denied one and approved the other. The letter was so confusing - we called the GI doc's office and got the nurse on the phone (THEY know WAY more about what's going on) she reissued the authorization request and they approved it right away. She said it seems like they just automatically deny it the first time with some insurance companies...you have to push on through it to get it approved. The awesome thing is his total monthly cost for the Peg and the Riba??? FIVE DOLLARS!!!
I only hope I have such good luck with my insurance company when it's my turn to do treatment!!

[pjhep80]

the entire insurance system in the USA just *****...period...

they will do everything they can not to pay, they dont give a flying **** about anything except their bottom line....

and with prescrips is absolutey 100% the way the dr words things... my sister is an RN who works for a Humana hospice group, she has to tell the dr's how to write the scrips so the insurance will pay

[nygirl7]

Welcome to the world of treatment, as you see this is actually fairly common enough.

What Bill told you above is 100% spot on.  You always want to make sure you have at LEAST one weeks meds on hand in stock in advance before you start.  It will give you some peace of mind because you can see from another thread on here that this authorizations and junk DO get messed up ALL of the time around here.

Incompetence isn't the word that I use for all of this insanity but unfortunately I can't use that word in here or it will just end up like *****************************.

Stay calm and remember you HAVE to be your own advocate - you can do it, the people in here will help with their own experiences (of which there are many).

[Facta_non_verba]

I'd love to see a show of hands for everyone who had trouble with their insurance or doctor's office. I'm betting the majority would raise their hands. I was initially denied treatment because the insurance company's treatment algorithm conveniently didn't include me. Looking at it, one can tell it's designed to deny treatment to some. My doctor had to appeal, and I was finally approved. Actually, it was the physician assistant (a shout out to Brijie - I love you!) who kept things moving. She was the one who really got me through the months of treament.

I wish I had started treatment two weeks after receiving my meds like Bill suggests. My insurance company authorized my meds for only 24 weeks, so there was a glitch when it came to getting a renewed prior authorization (PA). It happened again when I extended treatment and then again when my Procrit PA expired. The PA's for my meds ended up out of synch, and it caused problems getting my meds filled on time. You would think there would be some method to alert the patient or doctor that a PA for a critical medicine needed to be renewed. Think again.

All I know is that I spent a lot of time pissed off trying to get it straightened out. I had a hard time actually getting to the pharmacist to explain things since my insurance company went through their own pharmacy system, and it was a tangled web. As a physician, I knew it was required by law that a patient be able to speak directly with the pharmacist, so I reminded the company of that. As I recall, I also told them to remind the pharmacist that he was dealing with an irate physician on Interferon. That seemed to work.

Good luck to you. If at all possible, find out when the PA's for your various meds will expire and take it upon yourself to get your doctor's office to renew them in advance. G-d willing, I'll never have to treat again, but if I do I'll do things differently.

Jeff
Facta non Verba

[Rain6866]

Im not so bad as of yet on the anxiety. I had my reg doc put me on AD and xanax over a month ago. BCBS anthem is what my Ins comp is. This does all get frustrating and my ability to cope with pre treatment jitters and the fact I lost a nephew on xmas eve is why I asked for the AD. I know myself well enough to know I would need them sooner or later anyway.
I really appreciate you trying to help with my anxiety. That means a lot but what I really need is the honest truth. Ive never been one for people to hum haul around with me. It just confuses me.

Thank you all.. I have learned so much from this board that I feel totally ignorant without it.

[R Glass]

Sorry you see it that way but I had to fight Blue Cross B.S. Tooth and Nail all the way through tx. I am not going to lie about it in hopes of preventing "needless anxiety to a pre-treater"

[HectorSF]

Sorry to hear about the red tape communication breakdown...

I've been lucky because my doctor's office has a women who knows exactly what the insurance companies want in order to give their approval for medical services. Sometimes it is just the wording from your doctor, believe it or not. I did initially have my insurance company (Anthem/Blue Cross of California) denying my anti-viral treatment, blood tests, scans, etc. Once I got approved after about a month's delay, they approved everything from then on.

I do agree with Bill, you don't want to have an issue when reordering meds while you are being treated, as you may being feeling ill and the meds may have zapped your energy and your patience. So put in a time buffer so you will have your next month's meds BEFORE you need them. You don't want to be in a situation where you may miss taking your meds on schedule because you have to wait for them.

Hopefully at some point in time we will be able to get health insurance companies to standardize the information they need from doctors and streamline the process. And people wonder why the overhead costs of healthcare in the U.S. are so high?

Best of luck to you.
HectorSF

[portann]

I don't quite see how that applies in this case, given that the insurance company already approved the ribavirin.

Really, you're causing needless anxiety to a pre-treater. This is a bureaucratic oversight, not a plot.

[R Glass]

I went through similar battles myself. I think the insurance companies are hoping you give up. I wish they would compensate us for our time.

[Bill1954]

One thing to seriously consider is to wait for a week or two when you do receive your meds before actually starting. This will give you some cushion to re-order your meds; if you think this is frustrating now, wait until you *are* in treatment, and run into delays. Your patience is generally reduced further when on the meds, and it’s sometimes hard to focus on telephone calls, etc. My meds were shipped from Florida, and I nearly missed a dose once waiting out a hurricane.

Take care, and good luck—

Bill

[portann]

Since you're not currently treating, your situation isn't urgent, only frustrating. What you want to avoid is having a glitch in your delivery once you start but even in this unlikely case, there are solutions.

I'm sure your doctor's office will sort this out with the insurance company, so save your strength for the weeks ahead. You probably have the pre-treatment jitters, which most of us have had.

Most nurses in this field work very hard, are competent and care a lot. Mine is often there before seven in the morning and until nine at night. Perhaps I was one of the lucky ones but she put everything into place seamlessly. My husband and I were amazed at how thoroughly she knew the ropes.

[jmjm530]

Its the epidemic of incompetence and indifference that you would hope would escape a medical office but it's really the same all over. I often wondered the same thing myself talking to the doctor's staff. Dont they realize what kind of drugs we're on? Apparently, no one really cares. Reality.

Good luck, I'm sure it will go through, eventually

[Rain6866]

Thank you jim. I have been on the phonw so much with the doc office and the ins company and the pharmacy the insurance company insist that I use my head is spinning. Its like.. do they NOT realize having hcv is bad enough without them trying to throw a wrench in everything I need to get done? What kind of world is this we now live in where you cant get the meds you need without going through a year of hades first? Just gimme the peg and let me go on my little road to hopeful recovery!!!

[jmjm530]

What you describe is par for the course. You would think that a doctor's office has enough interaction and familiarty  with the insurance companies protocols that things would run smoothly. Think again, cause it doesn't work that way. In fact, it sometimes seems that like your request is the first one they ever processed. The solution? Unfortunately, you've got to pick up the phone, find out exactly (talk to a supervisor) what the insurance company needs, then call your doctor's office and shepard the entire process.

-- Jim