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Insurance blues...

Discussion in 'Hip Replacement Pre-Op Area' started by Poodles, Jan 7, 2018.

  1. Poodles

    Poodles member
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    I pay a lot for medical insurance and I am getting very irritated with them. So, my surgery was originally scheduled in November. The insurance company decided the x-rays didn't show enough arthritis...although my doctor said my right hip was now as bad, or perhaps worse than my left was. I have curtailed all my dog activities this time so it's not as painful. Last time I was on crutches two weeks before and had no sleep. This time I am so careful. But, I feel like a slug for not getting out!!

    In October, after surgery was scheduled, the insurance company and said I had to have an MRI to prove arthritis. We were leaving on vacation...our first in 26 years. My husband had just sold his business. Surgery was canceled and I opted for an injection. The injection didn't make any difference. I relented and scheduled an MRI when we returned. The MRI was so painful (not moving for 40 minutes) and I was in tears and shaking by the time I was done. My dr prescribed Oxycodone with acetaminophen when the pain went for multiple days, along with muscle relaxers. The muscle spasms were not like anything I experienced before. It took a few days, but got to "normal".

    However, just as I got home, like walking in the door, from my MRI, my surgeon called from between surgeries and said they found a mass during the MRI. They wanted me to see a Gynecologist STAT! Her office made the appointment for an Ultra-sound and Gynecologist for the next week...first week of December. After one cancelation by the Gynecologist, I found it was nothing to be urgently concerned about, not cancer, but she would like to remove it the end of January OR at the same time I have my hip replacement. My dr said "no". God Bless her! Later...like March for the gynecology!

    So, then the Gynecologist sent me to an internist because she couldn't believe a "fat" person could be so healthy. Sigh... Okay, I go to the internist and after her set of blood tests (now the 2nd set of blood tests), an EKG, and stress tests, and quizzing me over and over about medications I take (NONE), she said I was an excellent candidate for the surgery.

    I am scheduled for my LTHR on the 19th. I had my pre-surgery appointment with the PA at my surgeon's office on Friday. All is a go. She gave me the prescriptions to be filled before surgery, soaps to be used before surgery, instructions, etc. I dropped the prescriptions off at the pharmacy yesterday.

    So, the insurance company will NOT pay for the Oxycodone for the pain after the surgery. The pharmacy notified me today. I "suggested" to the pharmacy they advise my doctor's office. Does that sound reasonable? I had asked the PA about the Oxycodone with Acetaminophen that they had prescribed earlier for me while I was in the office on Friday. She said absolutely not. It needed to be without Acetaminophen. SIGH...... It's not that expensive, but I kinda feel like the insurance company should pay for it. Am I being unreasonable? It's not like I'm taking it now. I'll start taking it at home on the 20th.

    BTW, the insurance company was a piece of cake with the THR on the left side. They just paid the bills! Same company.
     
  2. MammaT

    MammaT supremo

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    Oh @Poodles, who can figure out insurance companies. I think I have read some of them are being stringent due to opioid epidemic. I would have docs office get involved. Perhaps the issue is filling it prior to surgery? I agree if you have drug coverage it should be covered in accordance with your plan.
     
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  3. SaraK

    SaraK post-grad

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    Unfortunately, you might have to do some of the leg work here. You're going to need to get (in writing if possible) answers on why ins Co is declining and why OS says must be without Tylenol. OS should also help in appealing the declination. If all else fails, threaten to (and if necessary follow through) with Dept of insurance in your state. They do help as a go between when necessary. It sounds like this isn't a case of them trying to save money but responding (and overreacting) to the opioid crisis and substituting their view for the doctor's medical decision when they might not have all the facts.

    Meds won't be that expensive, so it's a question of how far you want to take it. I'd at least have the OS file an appeal with info on why prescribing this med). That does sometimes work.
     
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  4. Poodles

    Poodles member
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    @MammaT the P.A. insisted I fill the prescription this weekend. I wonder if they expected something like to happen? My husband said it was filled only a couple days early last time.

    @SaraK I am happy I have time to argue the issue. It has been such a long road this time to get to where I am today. I am willing to fight for what is right. But I can pay for it if need be. I don't have any problem with filing a complaint with the Insurance Commissioner and welcome the discussion.

    Overreaction to the opioid epidemic or not, I am so tired of the physician overruled time after time. I'm sure it's not true but feel there is a 19-year-old sitting at the insurance company with a REJECT stamp, hitting whatever I send in. With all the extra deductible I get to pay for on the extra tests, I'll let them chew on a complaint being filed.

    Now to stay away from everyone with colds and flu for the next two weeks. I have sequestered myself in my office for the past week with the flu and colds going around. That won't change for the next two weeks for sure!.

    Thank you for your comments.
     
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  5. Jamie

    Jamie ADMINISTRATOR Administrator

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    You've received some good advice. Just be sure you're up for the fight with everything else you have on your plate. Yes, it's the right thing for them to pay for the drug your doctor prescribes and it probably is a HUGE over-reaction to the opioid epidemic. But the pain meds aren't that expensive if you buy them yourself and you may not really want all this extra stress.
     
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  6. crispy

    crispy junior member

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    OH the opioid crisis. I work in a family medicine office as a medical receptionist They have
    been in practice for over 30 years. I have been there for 5 years. It is shocking what we prescribe. my doctors were completely deceived by the pharms and how harmless the pain drugs were. They are now treating the withdrawals and not the pain. Then the most shocking thing happened the other day. We often have to get what is called a prior authorization for an insurance company to cover a medication. When we sent in an rx for methadone for a patient that had been on it for some time the insurance company came back to us and said that they required the patient to be on long term morphine AND a fentanyl patch for over a year before they would authorize methadone which is far less addictive.
    The insurance companies now seem complicit in this crisis and I am sure because the pain meds are cheaper than other methods.
     
  7. smstok

    smstok junior member

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    I absolutely hear your frustrations with this. I experienced very similar problems prior to my THR in December. Even had to do the EKG and nuclear stress test (At age 47)as well. I too am very healthy all around yet overweight at this point. Losing mobility definitely aids in packing on the pounds. What I found most frustrating is that I was instantly able to get my Norco RX prior to surgery (insurance did not cover) but I had a hell of a time getting Celebrex which I was instructed to start prior to surgery. That was going to cost me over $300 out of pocket if I didn’t get insurance to cover it. It took me 3 loooooong weeks of constant phone calls and walk ins to the pharmacy to facilitate the insurance co and Dr ‘s pre approval to the pharmacy. I almost felt like I was in the middle of a bad joke and literally had to contact people and directly provide them with necessary info and phone numbers so none of them had to do any work but to make the call or fax a form that I was not able to do as the patient. Such insanity!! In a sense I didn’t mind because I will do what I have to do to make things happen but it shouldn’t be that difficult just prior to a major and stressful surgery.



    Sent from my iPad using Tapatalk
     
  8. anny

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    Oh @Poodles they are making you jump thro hoops! I can't offer any advice as I really don't understand the US health system, but when it comes to anything to do with insurance you have my utmost sympathy, as they want maximum money from us, and will pay out as little, or preferably none at all, if they can manage it. It sticks in my throat to say it....after all, we should challenge unfair companies....but I'm with Jamie on this....maybe you should pick your battles and let this one go while you have other things to deal with. Hope the next 11 days fly by for you, and that you will soon be out of pain :thumb:
     
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  9. Mojo333

    Mojo333 FORUM ADVISOR Forum Advisor

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    I paid for mine a few times when the insurance company hadn't sent approval. Annoying, but under fifteen dollars and necessary!
    The insurance company refused to pay for my anesthesia...like that was unnecessary?! Go figure:shrug:
     
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  10. Poodles

    Poodles member
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    Thank you all for your input. I decided to just suck it up and pay for it. Honestly, I don't want to argue with anyone. I just want to get fixed. And since they "got me" for my deductible for both 2017 (with all the extra tests and Dr. visits) and 2018 for the surgery, another $53 is not a big deal right now.

    Thank you, all!
     
  11. MammaT

    MammaT supremo

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    @Poodles, sometimes we have to decide what fight we have the energy for. I would probably just pay it too. And this way, if they give you a refill after surgery sometime, you certainly won’t be accused of filling it too soon!
     
  12. Bumblebee

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    So your insurance company will only pay for certain types of pain meds? And not OXY?
     
  13. Poodles

    Poodles member
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    @MammaT The PA for my OS sent me home with a prescription for Oxy with Acetametaphin when the MRI I had sent my hip related area into debilitating muscle spasms and just downright nasty, sleep preventing pain the first of December. Although I only needed them for 3 or 4 nights to get back to "normal" then I was done with them. The PA said I cannot take those after surgery. They must be without Acetametaphin. At this point, I don't have any fight in me. I didn't hear from the PA, the insurance company or the pharmacy today. So, we are still at the same point. I am going to call the pharmacy tomorrow and just pay the price to get the meds they want me on. It was so easy with my left hip...

    Of course, this is tax season and my most busy time of the year. But life is good. I have surgery coming up quickly! I am looking forward to it and just want to move forward.
     
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  14. AgilityDog

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    We have learned that not all States are dealing with the 'opiate crises' differently. The laws have been changed and make filling a pain Rx more challenging. Pharmacies have a difficult time keeping some drugs in stock. Some won't dispense certain pain Rx. We moved to a new State a couple of years ago. Some Rx require a visit to the doctor every 30 days. Those same prescriptions must be filled in 7 days. If your regular pharmacy doesn't stock what you need, or have any in stock, you must personally visit pharmacies until you find one that can fill your Rx. Your doctor may inform you when laws change. Sometimes, it is just a surprise.

    I wonder if the doctor is concerned about liver damage and that is causing the 'no acetaminophen'. I have my liver & kidney functions checked regularly and I am not on pain meds. I visit Mayo clinic or WebMD to learn 'why' about my Rx.
     
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  15. MammaT

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    Hey @Poodles, saw in another thread it’s your birthday! Happy day! Not much longer for you and new hip. Don’t blame you staying to avoid catching things. Hope prep is going well.
     
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  16. Poodles

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    Thank you, @MammaT! It's going to be a nice day and weekend. Typically I don't work Friday's, but brought home a mess of work for the weekend and am just going to work slowly through it, stay home and stay well. All the laundry will be done (husband won't have much to do when I can't), the replacement tv remote came today for the bedroom tv (I don't have to get up to make a channel change) the poodles have been to the groomer and are good for another 5 weeks, hubby did the grocery shopping, and I only have to run pick up my meds! Bring on the 19th!:spin::dancy::happydance:
     
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  17. MammaT

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    Good deal @Poodles ! The prep will take some of the worry off your mind. You’ve got this!:egypdance:
     
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  18. Layla

    Layla FORUM ADVISOR Forum Advisor

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    Happy Birthday @Poodles A flower for your special day :flwrysmile:
    Hope you're doing something fun to celebrate!
    Wow, you sound very well prepared!
    The final countdown is on. Only one week to go and it will be bye-bye hip pain.
    Wishing you comfort as you await your surgery date.
     
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  19. SaraK

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    @Poodles - you're much more prepared and organized than I was. I had so much I needed to do at work to free up the time to be out that all my plans to have things prepped at the house went out the window and I just stumbled and lurched my way into the surgery!

    I already had a recliner because I'd been sleeping in it for over a year (i think it's getting replaced this weekend). My idea of pre-planning meals was waiting until my son had his driver's license before I had surgery so that he could pick up take out! Getting the house ready was lecturing that same son everyday that he couldn't leave his shoes in the middle of the floor or leave clothes all over the bathroom floor because he'd have more work to do if I fell and broke something. The second time around I figured I'd survived the first time, so I didn't sweat it!

    Good luck as you get yourself and everyone and everything around you prepared. You got this!
     
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  20. Mojo333

    Mojo333 FORUM ADVISOR Forum Advisor

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    Happy Birthday, Poodles!
    :puppysmooze:
     
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