Anybody want to discuss who comes between you and your doctor?

I've been experiencing increasing daytime fatigue and sleepiness for several years. I've been tested and treated for depression, hypothyroidism, anemia, etc. Two doctors have reviewed my medications to ensure that they aren't the cause. Finally the psychiatrist calls the GP and proposes I take medicine X. I take it, and everything is NORMAL. No sleepiness during the day, good sleep at night, no extra energy, just everything back to normal.

The only problem is that medicine X is abused by healthy people to stay awake for hours at a time. The pharmaceutical company can charge whatever it wants since this stuff is legal and easy to get on prescription. The insurance company wants me on nice cheap amphetamines. The doctors say no way. The insurance company says it will pay for medication X only if there is a documented diagnosis of hypersomnia. So, I get sent to a neurologist and he orders a sleep test.


Now the insurance company doesn't want to approve the sleep test.


Boy, am I glad I don't have any government bureaucrats coming between me and my doctors!

It will all be much smoother under single payer universal health care.

during the day! If you've ever worked back shift, it's like being awake at 3AM, except that that's what it's like from 10AM on!

Insurance Companies come between you and your doctor!!!

the insurance companies get between you and your doctor and the pharma companies do too with all those commercials. i liked keith olbermann's comment about how thune must be pro choice then since he doesn't want any politicians or beaurocrats to get between you and your doctor. sounds about right. sorry you are getting the runaround from the insurance company.

I just laughed.

Life has improved for me.

Still, I have not forgiven them for putting a clerk between my son and further extended plastic surgery following an accident 15 years ago. My husband had to just about pry the phone from my convulsing hands as I tried to climb through it and strangle the non-medically trained low-level person in question. I was a bit overwrought, perhaps. Hubby had to be the intermediary after that. (Son got the rest of his surgeries.)

I hope you can get that sleep test done and paid for by the insurance company you've been shelling out to for all these years.

Hekate

There is a difference between someone getting plastic surgery because everyone in their group does it and someone just trying to look normal again. I can see an insurance company not wanting to pay for someone's sweet 16 boob job. The problem is, too many doctors make their living doing vanity plastic surgery, so the insurance companies take the default position that all plastic surgery is unneeded. In effect, I am facing the same problem. Because so many doctors are willing to write a prescription for people who don't need this drug just to function, my insurance company is suspicious. I suspect much the same thing is going on with the sleep study. I received an ad in the mail all about a local hospital's luxurious arrangements for sleep studies. I have to believe that hospitals are making a mint on sleep studies, and that insurance companies are tired of footing the bill. Again, it's up to doctors to police themselves.

but most health insurance companies have either an HMO or PPO arrangement with them. In an HMO you go to the doctor they choose on their schedule. With a PPO you get a list of doctors who are part of the network and choose one. Most of these doctors work on the cheap for a price they have agreed upon in a contract with the insurance company. The same with hospitals, pharmacies and diagnostic tests.

My husband has obstructive Sleep Apnea, and has had it for years. The insurance company did not want to pay for a sleep study for him. After he had open heart surgery and an ICD placed to keep his heart in rhythm, his Cardiologists wrote a detailed report to the insurance company stating that he needed to have a bipap because the snoring was raising his blood pressure and putting a strain on his heart. He was still in the acute hospital at the time. The insurance company then said this was not enough verification, even though they had his hospital records and tests including tests to show the benefits of the bipap he was using in the hospital. Now, they said they needed the sleep study they refused to pay for before. They were counting on the fact that he would have to go to a facility other than the hospital he was in, which his doctors had stated he could not do.

Much to the surprise of the insurance company, the hospital my husband was in did sleep studies and so he had one which supported the position of his cardiologist. The insurance company was given the results and then began to pick at things like whomever signed the report on the sleep study had to sign the prescription for the bipap and send the original of the sleep study. Finally I called and got the manager of the pre certification department who had told me before, that tests done in an acute hospital did not have to be pre approved. I asked her why she was trying to kill my husband? She hemmed and stuttered and said she was trying to help him. I told her the only thing she was trying to help him with was to take a long dirt nap. I was beyond furious. She said she would look into it, and I told her that was not enough. I went to the head case worker at the hospital who managed to shake the bipap free. I do not know what I would have done without her help.

To end this long post, which I appreciate you taking the time to read, I think it is the insurance companies who are coming between us and adequate medical attention. They set fees for the doctors who have PPO status in a fee for service plan, for hospitals in the plan, for tests, for prescriptions and for Durable Medical Equipment. They enforce this by charging you so much more for doctors not in their network that you can barely pay it. We need to get the insurance companies out of the doctor business, and get them regulated and competing with a public plan like medicare.

I'm sorry you are having such a hard time getting your sleep study and your medication. Some facilities will do sleep studies in your home. I don't know if that would be more or less expensive. Ask your doctor and see what you can find out. Good luck, and keep fighting. You are worth it.

#2, it'll be tough but we'll manage to pay for it.

It's worse for people who can't get a diagnosis or treatment, and even worse for people who know what they need and can't afford it.


The problem goes beyond simply insuring everyone; we have to find a way to make sure people get what they need and not what certain doctors and hospitals talk them into as a means of making money.

It's an expensive drug because a lot of people are using it recreationally because they are getting their doctors to give them a diagnosis of narcolepsy.

http://www.newyorker.com/reporting/2009/04/27/090427fa_fact_talbot

Only the new ones like Vyvanse are very costly. Barr makes a generic of adderall that is every bit as effective as Shire's was. Shire no longer makes the brand name in the instant release. Barr and Shire reached a settlement and now Barr is making a generic of Adderall XR I believe.

"Not just no, HELL NO!"

It works. If your insurance company won't pay for it...go to the manufacturer. They may be able to help you out. Despite the bad rap, most Pharma companies do want you to be able to afford your meds and many have programs that will help you. They also may be able to help with the insurance company.

Our daughter will be 2 years old in September, and she is small. She weighs just under 18 pounds right now, which is off the bottom of the growth curves. She was a full term birth but small at birth, 4 lbs. She is healthy, she is developmentally great, she is just petite.

The other thing is, she was collicky for the first year or so, she didn't sleep through the night until after a year. She was up a LOT during the night.

We have a great pediatrician, and good health insurance. We've been to a pediatric GI 3 or 4 times, an endocrinologist, and a pulmonary specialist just to rule anything out.

One thing they tried was prevacid. With that she started sleeping better, and started sleeping through the night and the collick reduced. It looks like at least a part of her problem was simply acid reflux, that she was just that uncomfortable. So this drug is making a change in her life.

This is an expensive medication, around $300 a month, and so the insurance company decided in April that they weren't covering it for ANYONE. Since there was no generic available, they would cover other generic antacids.

Well, here is this medicine that was making a difference for a kid. I don't want to over-react here. We aren't talking about cancer or heart disease. But we are talking about a baby with two highly educated, doting parents who would meet the criteria of "failure to thrive."

The bad part was the run around. At first I was told that the pediatrician could appeal by writing a letter, which he did. But we never heard back. So I called back - and I am smart enough, but the thing is the medicine coverage is through a different place, so you have to call the health insurance and get through their voice mail, and then get a person and explain it and get transferred to this other company that does the prescriptions and go through their voice system and then get a person. So the next person tells us, oh, they can fax a questionnaire, the doctor completes it, then you only send in a letter if it is turned down. OK, here is the pediatrician's fax number. Only he never gets a fax. So I called back last Friday, and finally get a person, and oh, the Doctor should just call and then if needed a fax, then if needed a letter. Really? Because that is a new one. So we are going to the pediatrician Monday afternoon so I call back, and they give me a number for the ped. to call. So he calls, and gets approval for one year over the phone.

Now here is the thing. That was a good bit of run around. We are lucky to have a pediatrician who is basically a family friend and who will play that game for us. Almost every time we have any bill the insurance company first turns it down, then you call them up and get somebody to recode something and resubmit and they cover it. But it is constant. My wife had an emergency appendectomy. She goes to the emergency room, they give her emergency surgery. The insurance covers the hospital, but they don't pay it because they don't cover that surgeon. Hello, he was dude in the ER at 2:00 AM. But it is a run around. I know that there are folks out there with less wherewithal then we have, and I know they must get screwed.

you were. They're hoping that run-around eliminates a fair number of claims. It's sick, it really is.

This is something a lot of folks don't get. There is no assurance you will get the coverage you think you have, just because you pay premiums.

I would follow your doctors advise of course. I have taken both the ritalin and adderall in brand name and generic form and couldn't tell any difference other than a $5 copay versus $40.

months ago and it doesn't seem to be performing nearly as well.

I found out which pharmacy carried the other generic and switched pharmacies.

I take lisinopril for my blood pressure. Before it had a generic, it was called Zestril. The prescription arm of my insurance company manufactured what they claimed was the same medication. They called it Prinivil. They told me it was a generic for Zestril and would act in exactly the same way. They implied that it was a generic substitute and switched me over to it.

It was not the same. I took it and found myself having chest pains, shortness of breath and dizziness which I had never had with the Zestril. My blood pressure went up. I told my doctor, who said to discontinue the medication at once as those were severe side effects which had the potential to be harmful. I called Merck, the prescription provider for my plan and described what was happening. I also pointed out that there was no price break for me. I was paying the same amount for the Prinivil.

Merck informed me that the Prinivil saved them money because they manufactured it, and that was their concern. They also refused to switch me back to the Zestril. I called my doctor who wrote what she called her "harsh letter" to Merck and they finally switched the Prinivil for the Zestril. The doctor did some research and told me that there was still no generic for Zestril. The Prinivil was a propriatary name for a medication that Merck manufactured to compete with Zestril, and after what she read, not a medication she would prescribe or recommend as a substitute. In the meantime I had to buy my Zestril outside the plan and full price was a lot of money.

The generic for Zestril which was finally marketed, does actually work fine for me, but others gemerics might not. It is like a giant shell game that the pharmaceutical companies are playing with us. With all due respect to the other poster who suggested that they might have programs to help people acquire necessary medication, I can't believe that it is because they care whether we live or die. Those programs exist as a tax break for them, just as there are tax incentives for hospitals who have a non profit status. There always seems to be a catch somewhere with the drug manufacturers and it never seems to me that they deal with us in good faith.

to push the insurance company out of the way.

Sorry you are having this difficulty.

Us disabled Minnesotans get free healthcare.

because they will still have standards that need to be met and the plan will still be administered by the Insurance companies.

right now the insurance companies are making huge profits because they do not have to compete. The public option would force some competition. In order to compete effectively, standards and contracts would have to be negotiated, more to benefit the insureds, and less to benefit companies which feed off of us. Now they don't have to answer to anyone. They make their contracts without guidelines or any standards other than their own greed. The public option would force more accountability and attempt to lower premiums across the board and other amounts that we, the public, have to pay out of pocket for the mostly scanty health care we may or may not be getting.

Also the addition of a public option would might eventually help to lower drug prices by forcing different ways of contracting for prescription coverage and dispensing prescriptions. If it wasn't going to make a substantial dent in the monopoly that the insurance companies have, why would they be spending so much money buying congressmen and senators to fight a public option? Why would they be digging into their pockets for all that advertising money they are spending? Why would they pay to organize a group of right wing thugs to disrupt meetings where people are trying to have dialogues with their elected representatives about health care? And finally why would they be sending their apologists out to try to dissuade internet bloggers, forums and other arenas for debate from speaking out against the status quo?

I don't know what I find more offensive in this behavior. The foregone conclusion of the insurance companies that money is more important than peoples' lives, or that those of us who disagree with them are so stupid that we do not know what they are doing, or in some cases who we are posting with? They seem to be convinced as are most conservative activists that the talking point is king and people's desperation and needs are a distant afterthought.

Fortunately for me, these meds are from my Mayo Clinic Specialist. Even Mayo gets confronted by the insurance company on their decisions. Thank god Mayo has my back, although the weeks long delays that have happened aren't exactly great for me. I think I have another 9 or 10 months before Mayo has to "prove" its effective again...:eyes: