“We don’t want no government death panel. We want a corporate death panel!” - Conservatives
No, they want both. Case in point, red states and predatory and deadly abortion bans. Ken Paxton felt he was qualified to essentially doom that woman to a potential death.
The US government is the government that spends the most per capita for healthcare even if the public system doesn’t cover everyone, people need to then pay for private insurance over that and can still end up indebted if they’re denied coverage.
In the end healthcare in the USA costs more than twice as much per capita than universal systems in many other rich countries.
https://en.m.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita
In the USA:
Prescriptions are legal documents. Your doctor (with their signature) is saying they’re willing to put their license on the line to say you need this.Upon an initial decline from your insurer have the doctor re-write the prescription and include the words “Medically Necessary”.
Upon the second decline, pick up the phone and call the insurer. Get whoever you can on the phone “who can help with this situation and answer a couple questions.” Once that person is on the line, specifically ask for the LICENSE NUMBER of the physician that decided that it was NOT a medical necessity. DEMAND this information as you are entitled to know who on their end is Making Medical Decisions with regards to your care.It takes a doctor to nullify a doctor. If a doctor is NOT making those decisions on their end, then someone unqualified is Making Medical Decisions about your care. I’m not sure how you feel about that, but in my state there are laws against “practicing medicine” (aka making medical decisions) without a license.
I’ve never had it get past the second step, but if they do provide an actual license number take that number to Google and verify that the license is valid. Be sure to ask what state they’re licensed in. If asked why this information is relevant, explain to them you need to vet their doctor against your specialist. If necessary you’ll need to file an ethics complaint to the medical review board and licensing state.
My experience is with BCBS, YMMV.
There’s nothing I’d rather do when I’m sick than fight with an insurance company.
Best country ever.
/s
The thing I’ve never understood about this…
Why are they willing to pay for the visit with the doctor if they don’t think the doctor’s opinion means anything?
Because if they denied doctors visits then you would pick a different insurance. They only pay the minimum that keeps you paying them.
PSA from someone who works in the industry. Drug manufacturers offer “patient assistance programs” where people who are under insured or uninsured can receive treatments at a discount or sometimes free. They are not broadly advertised and I had no idea they existed until I started working in the space. Just search the drug + patient assistance or financial assistance.
Also to state the obvious… The US healthcare system is fucked — mostly insurance companies but also pharmaceutical companies and hospital systems in the US are all doing everything they can to increase their profits at your expense.
- Hospitals and pharma set high menu prices in order to negotiate with insurance companies. 2) Insurance companies make money by NOT paying. So you’re fucked unless you’re fortunate to have a cushy white collar job with good benefits. The people that get fucked the most are the ones that can’t afford the premiums
Genuine question… What defines “under insured” here?
I’ve heard bits about this before, but I always assumed it meant it was for if you’re totally uninsured or on some shitty basic coverage insurance. I’ve always had extremely expensive “best care you can get” type packages, but always end up getting shit declined anyway because the insurance claims shit “that medication isn’t on our list of meds for the diagnosis/disease you have”. After rounds and rounds of contacting the doctors office and having them the insurance company about how it IS actually a drug for that diagnosis, the last thing I have the patience for is more phone calls that seem hopeless.
Obviously the insurance company actually dictates your healthcare and the prescriptions you receive, not your doctor. If you have great insurance, more physicians and treatments will be covered. Under insured is just having insurance that doesn’t cover your treatment.
Anytime a drug comes to market, manufacturers need to make sure drugs are covered by insurers. So, pharma companies go out to the “payers” (it’s what’s we call them at work) and vie to get a good position on the payer’s “formulary” (the list of drugs covered by insurance).
In this negotiation, you have things like “prior authorization” where the prescriber needs to make a case to the insurance company before a drug can be prescribed. There’s also different tiers for a class of drugs. This means the payers allow certain drugs to be covered only after a patient steps through other (cheaper) treatments. If it’s not covered, you can pay out of pocket but none of this shit is priced for an individual.
There’s a cold calculus on both sides where the pharma company has sunk $300 million to $5 billion dollars to bring a drug to market that can sometimes take a decade to go through clinical trials and receive FDA approval — they need to charge a lot to recoup their investment and hopefully become profitable. Meanwhile, insurers have a population they need to cover and a set pool of money and they don’t need a new $50,000 therapy when there’s a generic that will treat 80% of patients. The other 20% can jump through the hoops or get stuffed…
For non-life threatening contexts, are you aware of exceptional request forms? Just try a couple covered things then demand what you want and appeal it till they cave, no?
I get this doesn’t really always work and really shouldn’t even be necessary at all but you also have to work within the system and try and get the changes that need to be made
Meanwhile you are dying without the drugs that are needed.
Obviously that’s an issue
Let’s say you get diagnosed with a treatable autoimmune disorder. Treatment isn’t cheap, so usually someone who recently got diagnosed and referred to a specialist to perform care will find that their insurance denied approval for prescription of medications and supplies needed.
The insurance companies will want the doctor to re-submit while providing documentation of the diagnosis (as proof) and an outline of the treatment plan. The insurance company can say “your plan states six months of injections but we will only approve for three.” At that point, the patient is stuck with a three-month plan because the cost of treatment is too much to pay out of pocket and the doctor won’t go forward with a six-month plan unless the patient pays in advance for the three months that wouldn’t be covered.
Another example is rare disorders where the medication may cost hundreds of thousands of dollars. Insurance may decide the cost is too high and deny coverage for the prescription.
Finally, there are instances where more common issues (such as diabetes) may have the insurance artificially limit how many doses of a drug they decide to cover. If a person has a special case (like needing to take twice the amount due to tolerance or it being based on the person’s weight), insurance may deny it because it exceeds what they believe the average person should need.
All of these are examples where someone is stuck waiting for what is essentially life-saving medication just because insurance doesn’t want to pay out, or doesn’t care that you have a special scenario that requires some exceptions for it to work properly.
Not American, but are you sure they’re not just delaying it (even if they will eventually pay out) because they’ve calculated that some people will die or give up, which increases their profits?
Of course, I definitely didnt mean to minimize the issue. It really is insane there’s all these ridicululous middlemen and compromises that add to whatever condition as a threat to people’s health
Nah I didn’t read your original comment as minimizing it, but rather saw it as someone who might not be from the USA. It sounded like genuine shock to how life-saving meds could just be flat-out denied for somebody.
Thats very insightful and correct, altho we don’t have universal coverage here either (yet) and I’ve done this process several times. There are people who try once and give up and I just want people to be aware of what parallel structures or processes might be available to help give that a second look
