Wednesday, September 16, 2015

Who Died and Made my Insurance Company Lord and Doctor to All

I am a firm believer in national health care. This new system needs some tweaking - OK, this new system (the ACA)  needs a lot of tweaking. Since I am not working we bought our own insurance. All I can say is that I am glad I have a college education, am somewhat literate, and can put one foot forward (most days). Dealing in the land of health care is personal warfare these days with the gloves off. It is the patients and the providers on one side against the insurance companies and the insurance companies are winning.

When I went to get my prescriptions refilled for the first time after we switched insurers, I learned that they denied coverage on two of the drugs. When I called the insurance company I was told that they did not think one of the drugs was necessary, but they would suggest several alternative drugs to my physician to prescribe in lieu. Now, one of the drugs they had denied had been on the market for years and I was taking the generic version - so cost should not have been a factor. I called my doctor in total frustration.

My doctor called me back after talking with the insurance company and said that they had, at first, said that he had to prescribe treatment using the other drugs and see the results before they would consider payment for the current drug I was using. Knowing that it had taken years, and courses of several different medications, to finally find the one that treated my condition with no side effects, my doctor said he had to argue with the insurance company before they would back down. Since when did an insurance company I just signed onto and that has never met me or seen my medical records know what medications I need more than the doctor who has been treating me for 18 years?

My DH went to get his flu shot at our local pharmacy - where we have been getting them for years, 

According to the ACA: 
"Adults 19 years and older who are enrolled in new group or individual private health plans will be eligible to receive vaccines recommended by the ACIP prior to September 2009 without any cost-sharing requirements when provided by an in-network provider as of September 23, 2010."

But he was told that our insurance would not pay for it. He came home and called the insurance company. After waiting on hold for 15 minutes, a young man came back and said that the flu shot was only covered if he got it at the Regional Medical Center (the RMC, our local hospital). So my DH called the RMC and after getting transferred from the pharmacy to outpatient to general information, learned no one knew anything about the hospital offering flu shots to anyone except employees. 

I picked up the phone and called the local Walgreens, after several minutes with the helpful pharmacist, giving him my insurance information, he was able to tell me that, yes, my insurance covered the flu shot, with no out of pocket to me and I could come in at anytime to get it.

Now the kicker is there are 2 types of flu shots - a trivalent and quadrivalent (basically one covers 3 strains of flu and the other 4 strains). Our insurance will only pay for the trivalent, not the quadrivalent. The retail off the street cost difference between the two shots is $4. So in the almighty wisdom of the insurance company, they are saving the $4 by denying coverage of that 4th strain of flu. However, how much will the health care cost be if I come down with that 4th strain of flu that the trivalent did not cover but the quadrivalent would have? 

In reality, probably not that much for them. I will be too sick to fight with them on the phone over their nit picking when they tell me that the only doctor they will pay for is 70 miles away. Of course, if I stay on hold long enough, select the correct menu options, and reach the proper person, I will learn that yes, they will pay for me to see a local doctor. But, that knowledge is only for those who are able to jump through enough hoops, run in the right circles, scale the walls, and withstand intimidation. The rest are lemmings going off the cliff because the insurance company made it so hard for us to get what we are paying for. 

Oh, in their defense, the services are not always denied, you just delayed due to red tape, paper work, layers of bureaucracy and anything else they can throw the consumer's way to get us to give up and not pursue the benefits we are paying for. 

What about the little ol' lady (on insurance but not old enough for medicare) who goes to get her flu shot and is told that, no, her insurance will not pay for it. Is she going to call the insurance company and ask why? If she does, is she going to take no or their company line and back down? Is she just going to go through the winter with no flu shot? Probably not, she will just take $35 from her pocket, pay for the shot, and go home - and pay her premium next month.  

Not all insurance companies are this way. But the ones that are have a front seat in Hell as far as I am concerned. 

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