Insurance Company Employee Apologizes For Doing His or Her Horrible Job
By Susie Madrak Friday Sep 25, 2009 6:00amI found this in the comments over at Corrente and wanted to share it:
Insurance companies reserve the right to make changes to their formularies at any time, but are supposed to notify you and allow you one month's supply of your current drug in order to give your medical provider the opportunity to "pre-authorize" your access to said drug. Your doctor cannot simply write a letter saying "I'm the doctor by god, and I want the patient to have this drug". No, he must provide evidence that he has "stepped" you. Stepped means that he/she has tried you on "approved" A, B and C drugs to little or bad results first.
Now, A and C may no longer be on the formulary, so they don't count, so he/she has to find out what approved drugs are on the formulary so that he/she can say that they have been tried and if that is true, or he/she will say it is true, then it will go to the Pre-Authorization department.
If the PA department can't sort it, say because your diagnosis does not fit neatly into what the insurance company says the drug can be used for, albeit that it works for what ails you, the application goes to the in-house pharmacist. The in-house pharmacist (average salary $90,000 per annum) will make the final decision based on following company guidelines and keeping his/her job. If the decision is that you get the drug, then said drug will be approved for you as "off formulary", moved to class 3 and if your co-pay was $25.00, it will now be $60.00 or more.
If the drug is not approved, then you will be properly stepped with the ineffective, approved drugs before your pre-authorization can be reconsidered. After you have been stepped, the drug will still be off formulary and the co-pay will still be increased. It sucks and I am so sorry.
Signed Anguished in the PA Department - United Health Insurance Inc
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about the rebates that the pharmacy benefit manager is getting from whatever pharmacy manufacturer they have arrangements with. Back in the day, when I worked for Merck and they owned a pharmacy benefit management company, all of Merck's medications were formulary supposedly because they were the most efficacious..... As an account executive for the benefit manager it was always great fun to explain why the Merck drugs were formulary because they were usually far more expensive than the other medications in the same class.
It's ALL ABOUT THE MONEY, nothing more, nothing less.
Death panels.
...government bureaucrats deciding what medication we get.
These are not gummint people. These are employees of capitalist entities, and just one more reason to shift the whole mess to single payer, government run health insurance so the greed factor is removed.
The government is not involved in this in any way. What planet are you broadcasting from?
Just how does a corporation get a pass to practice medicine without a license?
It is what they are doing . . .
To pretend to know what is best (by what is covered) is de facto practicing medicine.
GOOD POINT!
usually employ an army of medical professionals: pharmacists (mostly) nurses and physicians. The pharmacists contact your doctor to talk to them about changing the prescription and are generally very successful.
They are practicing medicine. I don't care if it's an on-staff pharmacist. I'm not going to their on-staff pharmacist. I'm going to my in-network DOCTOR and he should be able to prescribe whatever he and I believe works best.
Isn't it great how the free market lets me choose my doctor and decide on proper care? NOT.
doctor has to do is refuse the transfer. They can't change it if the doctor doesn't agree. But don't you wonder about the physicians that have love affairs with certain medications? Like the gastro physicians that have offices that are all done up in purple?
Technically they are merely refusing to PAY for treatments they don't feel is covered under the byzantine rules of your policy.
Seriously though, they're practicing medicine, and in the worst way possible. Not by actually examining you, but by examining cost/benefit statistical tables.
Well I don't know if what you are sayin is correct. I will have to refer to Sarah Palin because she is the only one who really cares about my well being.
I'm all truth, all the time.
Lived this, breathed and managed it. Had to manage customer service people to explain it. Generally, they stuck to the "me-too" medications, think Viagra first and then Cialis and all the others. The benefit manager would have a contract with the manufacturer of Viagra and they would then call on prescriptions that they received for other "me-too" medications to switch them back to Viagra. It's looking like they are now really over-reaching and perhaps switching things other than "me-too" medications.
In the early 90's my son was first diagnosed with Dermatomyositis. I had a ten year battle with my Insurance Company regarding his meds. Cyclorsporin and Methotrexate. Since my sons illness is very rare some medications didn't meet their formulary. Prednisone was the standard drug of choice, most insurance doctors had never heard of the illness yet they second guessed my son's doctor on a regular basis. In my son's case prednisone was not enough. You have no choice but to pay for medication until you get it approved or 'off formulary' which is a higher co-pay. These are not 'me too' drugs and a one month supply was over a thousand dollars.
patty lame54's wife
their shareholders. It is illegal for them to not do this. It is also their ONLY legal obligation.
It would be smart to nationalize all health insruance companies.
Scroo these SOB's who will kill people or make them suffer - needlessly.
It is nothing short of pure evil to profit from others misery. (unless you are Stephen King writing "Misery")
Then you're profiting from your *own* "Misery". And that's okay!
Someone should write a novel about getting even with Big Pharma and the health insurance companies. Or perhaps all blood-sucking corporations and the politicians they own. Nice winter project.
KING should write such a novel. It would definitely get attention - since he's such an icon, the publishers couldn't bury it or claim it "woull.'t sell."
Nobody is getting between me and my doctor.
Except, of course, the profit motives of hundreds of millionaire industry executives and their lawyers.
But at least we don't have socialism.
Remember, government doesn't work because it tends to be corrupted by greed and therefore may not deliver on its intended purpose, which is spending money on the people. But corporations, which are inherently 100% corrupted by greed (because greed is their reason for being) and who only spend money on the people when they cannot avoid it (that is, actually delivering products and/or services), should be relied upon for our municipal and public needs, because they are so much better than government.
As Ronald Reagan once said, "Where's my astrologer? I want to consult him on these arms sales I'm making to terrorists."
The industry executives must laugh out loud when they see or hear some idiot teabagger with a sign or spewing on TV that they "won't let the government come between them and their doctor." It is just too insane for words.
a drinking game involving chugging a whole beer when some idiot shows up with a "keep the government out of my medicare" sign
"...only spend money on the people when they cannot avoid it..." This is not what motivates them. They only spend money to make even more money. When I heard BHO state that corporations were not inherently evil, I laughed out loud. What do you call it then? "Just doing their jobs?" This is the Catch-22 problem. They cannot have any human values or intentions ascribed to them, but they have all the rights of humans. Thus, no matter what they do, they are not held accountable. If their status gives them all the rights of humans, with none of the responsibilities of humans, then humans should be treated in the same manner. Why is this artificial concept allowed to exist in what is supposed to be a democracy? They are evil, because they do evil. And they do this through the people who work for them, the people who profit from them, and the people who defend them. You know who you are.
Be careful of blanket generalizations - that's a trap on two fronts.
First, the evil ones really love it when everyone is lumped together. It muddies the waters and makes their evil seem inevitable. Not so.
And, second, it's mentally lazy. Saying any generalization, (the only good indian....), can lead to real evil.
There are corporations run by good people with good intent. We need to protect and foster those, right now they tend to get slaughtered by the evil ones who have bought protection from evil reps in Congress.
An autonomous robot whose programming changed so that it was now a danger to the people around it would not be evil.
But it would also not be acceptable to leave it running around loose, even if 1 out of 100 people who encountered the robot won $1 million instead of getting their head chopped off.
Corporations are amoral engines that have tremendous political and economic power and few of the practical and legal restrictions that limit individuals from exercising that power. It doesn't matter if the word "evil" has the wrong connotations. Corporations are dangerous to society, even if they immediately benefit a tiny minority, so use whatever word you like.
I wonder if Eric Cantor will explain this for me.
I apologize to my insurance company for actually getting sick and costing them MY money.
... make sure you pay your deductible on time, and don't let it happen again...
No need to worry about paying it late.
If you have coverage, insurance companies MUST pay for what doctor's proscribe. Period.
Think of the money the insurance companies would save by firing all the doctors, pharmacists, execs, etc... they currently employ to medically evaluate your claim.
After all, its not the insured who makes the claim, its the insured's doctor.
When insurance companies 'evaluate' your claim, they are essentially saying "we don't trust your doctor's diagnosis, prognosis and recommended course of treatment" If insurance companies feel they are being defrauded in some way by doctors, let them sue the doctors for fraud, but goddamn it, leave the customer/patient alone!
If the the insurance companies could save money by firing all the docs, nurses, pharmacists, etc., they'd do it now and do as you suggest. But that's not the case.
They profit by perpetuating the myth that they actually provide a valuable service and that you're protected. Then when they're supposed to pay off, they employ all those folks to screw over the policy holder. That's how they make more money.
Granted my idea would make them less money than they are making now. I was pointing out that they amount they lost would be much less than they claimed due to the reduction in staff.
I do presume as you do that they take the course of maximal profit, still it does make you wonder in the balance between actually paying off claims, and money spent on the infrastructure created to deny claims, how close is it?
Gee...there couldn't actually be a correlation between the way we conduct healthcare in this country and how poorly we score, from a health standpoint, when compared to other industrialized nations?
Just askin'.
.
and you'll see the drug pushers.
Pharma reps, dressed to the nines, driving expensive cars, pushing their drugs.
Hey, they gotta make their $100,000K plus a year, don't they?
The company that has my 85 year old Mother's Medicare Part D plan tried this crap. No longer weanting to pay for ther heart med after she'd been stable on it for ten years. Out of the blue they called up her primary care physician and ORDERED him to prescribe a generic.
No way they're experimenting with her. We took the samples (with a wink and a nod from her doctor), went home, flushed them down the toilet, and called him usp the next day and said "wow, they made her so sick she almost had to got to the ER". He filled out the form and we were set, back to the old medicine being approved.
Damn them all to hell.
Aren't generics chemically identical to the brand name medicine?
All I know is that taking generic medicine lowers costs, promotes competition and puts a bit less money in the pocket of fat pharma.
I'm in Canada, and the use of generic substitutes is pretty common place here and I don't seem to hear of any horror stories stemming from that.
I'm open to being corrected on this if this is not the case.
and seem identical. Some aren't.
Think about it; if you need an essential part for your car, do you insist on the original manufacturer's part, or accept an after-market knock-off?
Short answer..Probably most of the time.
Here's a summary of an article from the Journal of the American Medical Association discussing the use of generics and brand name drugs in treating cardiovascular disease. In their review of literature in this area, two calcium channel blocker studies did not show clinical equivalence between the brand name and generic options.
http://jama.ama-assn.org/cgi/content/short/30...
they are supposed to be, however, as a nurse there are a few that cause concern - warfarin/coumadin being one of them. And, then there are all of the other things that complicate the situation: poor kidney or liver function, age, general health, individual sensitivity, etc.
The propofol situation with Michael Jackson was interesting because we use it all the time where I work. I've seen a tiny amount knock down a huge man and I've seen a MUCH larger amount barely dent the consciousness of a petite woman.
Having worked in the business I can tell you that generics are generally much cheaper because you're not paying for the drug manufacturer to take lunches to the doctor's offices and buy pens to hand out to staff. Personally, I take them whenever I can and when they are appropriate because I can get them through my plan for no copay. What you also find is that you end up taking more pills a day with generics as the newer stuff is usually the extended/continous/long-acting form.
released, the original drug company's patent is about to run out. This allows all other manufacturers to produce the drug and ends the original company's "monopoly" on it. The original company, armed with a new patent for reformulating the drug, try to squeeze every last cent out of it. Sweet.
.
me too. There's generally no need to insist on the brand name, there are very limited exceptions where it would be, as I mentioned above warfarin/coumadin could be one, but generic antibiotic versus brand name version is unwarranted. It's one of the ways that really works in helping to reign in costs, if that is a concern.
They have different fillers and other ingredients that can affect how they work in different people.
The active ingredient is the same, but the inactive ingredients can mess with you.
In most cases, there's no difference in patient effects taking a generic--look at Motrin, Advil, and your local pharmacy's variation on ibuprofen. But for some drugs, especially heart medications and blood pressure medications, you don't want to mess around with a slightly less effective version. A less effective medication, or one that causes side-effects (even upset stomach) that make it more difficult to take can affect your life.
Thanks for all of the responses.
I've never used generics for serious medication like heart medicine. I've accepted generics for basic antibiotics and they worked fine.
The important thing to realize is that Obama actually does want to lower the cost of health care and generics are going to play a role in this.
And not to make everything about the boogey man, but pharmaceutical companies would obviously want you to use the name brand medication for the sole reason that it costs more. Could some of the stigma around generic medicine also be coming from people profiteering on over priced medication?
know. There was actually a case quite a few years ago where the brand manufacturer was paying the generic manufacturer not to produce the generic version. There was also a case where the brand manufacturer had monopolized the active ingredient in the medication and generic manufacturers could not obtain it. I could go on and on. Don't have links, but was working in the industry at the time.
insurance. You'll wish you'd kept the generic prescription when you have to pay the full price for the brand name out of your pocket. Good luck to you both.
So repukes, the Democrat's plans for Healthcare Reform will take medical decisions out of the hands of doctors and put them into the socialist hands of the gummint, right?
Where are these decisions being made currently? This comment posted at Corrente is just one more example of how insurance companies dictate patient care.
Doctors have very little say anymore. After all the insurance company executives have to get their righteous bonuses, and the insurance companies themselves have to make enough in profits to buy and own the votes in Congress that keep them in the catbird seat.
Hit men working for the Cosa Nostra have more scruples, but hey -- whatever puts food on your family.
Roy Orbison: Working For the Man
This post is authored by Ian Crosby, a partner at the law firm Susman Godfrey LLP whose practice has focused on antitrust and patent matters. He lives and works in Seattle, Washington.
A University of Chicago law student with a prior career in the pharmaceutical industry whom I interviewed for a job the other day shared some knowledge regarding drug pricing that I thought quite interesting. It hadn’t occurred to me, though it seems perfectly obvious, that drug companies price drugs over which they possess a patent monopoly according to the avoided costs of the next best treatment for the diseases they address. If an insurer typically has a hundred heart attacks in its risk pool every year, and a new wonder-drug will prevent fifty of them, it will pay just under its cost for treating the fifty avoided heart attacks for a supply of the drug sufficient to achieve this result.
And it turns out, according to my source, that pharmaceutical companies do typically set the unit price of non-copycat patent drugs in relation to the avoided cost for insurers for on-label use. But then a funny thing happens. The pharmaceutical manufacturer begins promoting down-label and off-label uses of the drug – i.e., use of the drug by patients who are not as at risk of the condition as those for whom the drug was approved to treat, and use of the drug to address other conditions than that for which it has been approved, respectively.
The avoided costs for treating down-label and off-label patients is typically less than for on-label patients, if it can be quantified at all. But at this point, the decision whether to administer the drug is within the hands of the doctor and the patient, and the insurer reimburses for the drug at the price that was negotiated based on the higher on-label rate of cost avoidance. Over time, the down-label and off-label use of a drug can and often does exceed the on-label use, often by a significant degree. As a result, an insurer will often find itself paying out significantly more in reimbursement for a patent drug than the cost of avoided medical treatment the drug achieves. Yet another hidden cost driver in the Freakonomics of our crazy health care system.
http://theincidentaleconomist.com/a-funny-thi...
Just three words:
Death Panels
you are talking to me, I worked for a company that managed pharmacy benefits and did just that, so I know of what I speak. They can't just change the prescription outright, so they employ an army of pharmacists that do nothing but call doctor's offices to get prescriptions changed, and they do get them changed. They do it by the book and according to federal and state prescription laws. Trust me, it happens all the time. It even happens in hospitals.
about 10 years of my life.
After being diagnosed with an auto-immune, chronic pain condition, I went through a decade of "stepping" through various attempts to find a cocktail that would work for me.
My doctor, God Bless her, was dedicated to working with me through this. We found a combination of drugs that worked for me. One of them was a drug called Provigil, (Monofindal?). This is a drug that was developed for Narcolepsy. I had not been diagnosed with Narcolepsy, but I did have one of the symptoms, "Sudden onset extreme debilitating fatigue".
This med worked great for me. My doctor told me I would probably need it forever, along with a couple of other meds I took regularly.
The insurance company began denying the claim for this drug, even though it was working. They insisted on "stepping" me through drugs on their formulary - drugs which did not do the same thing, were not effective, or we had tried earlier, (this had been going on for years - we had tried a lot of different drugs before we had this success).
I ended up having to get a sleep apnea test in order to appease the insurance company's high paid desk jockey who was now in control of my ability to function and work.
Sleep apnea tests are not cheap. Why did I need one? My doctor didn't think I needed it. I couldn't afford it. I didn't want it. And it was being forced on me by someone who had never met me, treated me, looked at my med records or test results.
When I hear the right-wingers screeching about the government coming between us and our doctors, I'm honestly baffled. Do they not realize that there are already dangerous barricades between patients and doctors? Barricades predicated solely on the profit motive of drug companies?
I don't get it.
It's the efficiency of the free market at work!
What's not to get?
efficient - or free.
that the plutocracy has always been interested in.
"Free Market" is easier to sell than "Work all your life to make someone else rich off the market, and be prepared to be thrown to the curve when you are no longer of any use or you start to cost us money, whichever comes first"
You have my sympathy. I am in a similar boat. I have opted to pay cash for my meds, thus leaving the insurance companies to fend for themselves. If only they cared that I reject them. The cost to me is close to the cost of the insurance itself. When I did have insurance through COBRA and the Teamsters, no one ever questioned any medication I had prescribed for me. That is because the Teamsters are self-insured, and that is the ONLY reason that happened. Single payer could work. The Teamsters Health and Hospital Fund proves it.
most self-insured plans are much more participant friendly. COBRA was a nice idea, but now it's outrageously expensive for most people. I was on COBRA in 1989 and 1990 and was paying $585 a month then. I hear horror stories now of how expensive it is, with most people being forced to choose between that and paying their rent/mortgage and food.
Right now.
Like how CVS/Caremark blamed my $90/30-day supply co-pay vs. $90/90-day supply co-pay on my doctor.
Yeah, my doctor "forgot" to write the more expensive daily prescription as a 90-day supply even though he wrote the other one I take daily for 90 days. Yeah right. I asked if they had a bridge to sell me. I could have paid $90 for two months supply if I had continued using a local retailer... but CVS kept pushing their $90/90-days via mail order only to RIP ME OFF! I paid as much for two months as I expected to pay for six. Some savings, assholes.
Don't be so selfish.
there used to be some wiggle room on this, but they've really cracked down and physicians have to indicate the supply, 30, 60, 90 days, that they want you to have and then the number of refills that you can have. I always have to make sure that my prescriptions are written correctly, although I actually had the pharmacist take a 90 and fill it as a 30 and when I asked why he did it, he asked why I cared, because it was free. I resisted the impulse to tell him that with 90 days of medication I didn't have to deal with his asshole ways.
It's really too bad that the idiots who do not want health care insurance reform and us other enlightened (or smart) people can have our own choices. Let the people who think they are doing just fine thank you have their insurance and we can have ours. The way we want it.
I'm amazed since their are MILLIONS in our population that have amazingly nasty stories about pharma plans and the amount of time the insurance companies dictate that it takes to get a claim processed, even if it is approved, for most people to tolerate.
WHY are people and groups fighting so hard to protect this COMPLETE CRIMINAL ENTERPRISE that the insurance companies have set up??? Are folks that stupid?? Are they so hood-winked that they believe one thing that the industry told them in a flier of lies versus reality in their practices??
This phenomena of folks protesting positive changes in the rules that govern health care companies seems amazingly short sighted to me.. maybe I'm way too rational.
Most people are so totally, and I mean totally involved with their lives to even try to imagine what it would be like if something bad happened to them. It's tempting to just let them get what they earned. Nothing but screwed. That would be immoral, though.
For crying out loud?!? Why do we even discuss the difficulty of getting something done in Washington regarding healthcare as if those difficulties were unique to healthcare? They are all derived from a common problem, and that is that the Republican Party is now the Atwater Party. There is not a single Republican leader today who doesn't worship at the alter of Lee Atwater. Every issue is an opportunity for them to scream "The liberals want to take away our freedoms and DESTROY AMERICA!!!" and "OBAMA IS *SOOOOOO* FAR-LEFT!!!" It doesn't matter that it's healthcare, or Afghanistan, or abortion: it's an opportunity for them to lie and manipulate and demagogue and swiftboat.
Either we raise this issue at every media opportunity, and MAKE IT THE STORY, or else they will continue to cry "wolf" and the media will continue to come running.
Congress has become nothing but a whore house because we as a nation refuse to take the special interest money out of politics by demanding public campaign financing.
Buzz off, we don't need your help. We are not invalids. We don't have limited mental capacity.
And if we were or did...it wouldn't be covered anyway.
had to downgrade our firefighters' health insurer from a bad Aetna to a worse United Health.
So we try not to use our insurance by not seeing doctors or getting routine tests for fear of cancellation.
And few firefighters manage to retire without some degree of chronic injury.
I wonder how many of the peoples' lives that I helped to save were insurance execs?
Ah well - too late to take it back and let 'em die.
Because I think that I might just do that if I could.
Feckin' corporate murderers.
I have often wondered how these corporate exectives would feel if the public started burning their houses down. (No advocating, just wondering._
Like - if I had a terminal disease, who could I remove from the face of the earth
in an effort to improve the lives of others?
Or for pure revenge....
but no, I've been a pacifist my whole life and spent much of it
tending to others' sufferings and emergencies...
as an atheist I believe that "heaven" must be created in the here and now. (I don't think that we'll make it)
But if I, a pacifist, find myself thinking those thoughts - I wonder how many non-pacifists might be thinking that way?
When I was a young boy my father told me that I should never tell someone else to do something I would not do myself. He taught me to be prepaired to defend myself, but to try and deal honestly with others. In the early 1970s the job market was maybe not the best, but I always seemed to have some marketable skills. I got a job at an auto dealership as a repair and warranty scheduler. My first morning at work the owner came to me twice and told me that this customers warranty was about to expire, and if I put them off having the repair done he could charge them for it when they came back. I thought about it until lunch time. I needed the job, but I didn't need it bad enough to cheat someone. At lunch break I walked out the front door and never looked back. I went home, I never ask for my pay. I just could not do that to people who had the right to have their car repaired under the warranty.
My point how could these people do these things to others? I mean my god this is someones life we are talking about. How do you have so little compassion? What is wrong with you if you would do these things because someone else tells you to?
republicanism is a mental illness!
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