Well, they did it again. You may remember that HAP, my insurance company, denied me any medical treatment from December until March, requiring test after test that had to be done one at a time before I could get any help. So it took 3 months before my RD was able to prescribe a medicine. She said my RA was very aggressive, and said she didn't think MTX would work for me, so she prescribed Humira. My insurance company denied it - but they waited a week to do that. Then, I had to get ANOTHER appointment, a month later, to actually get the MTX. So - December to April, basically no care.
Well, the MTX, as my doctor predicted, isn't really working. The swelling is back, the pain is back, and now I have terrible heartburn and really bad cramps in my neck and feet.
So my doctor prescribed Celebrex. I was afraid to take it, and it doesn't agree with me, but it helps the terrible cramps in my neck and feet. She gave me a sample, and then wrote a scrip. HAP, the HMO, in its infinite wisdom and to save a few bucks and make more money for its shareholders instead of taking care of its patients, denied the prescription. Do you believe that? I am so angry right now, I'm thinking of filing a lawsuit.
Man, they do really suck! Can you switch insurance companies? I would raise hell like crazy! Maybe your local news consumer defender could help you.
Try this first. There is usually a patient advocate in most insurances and you can file a complaint with them. I have actually had that person get up and walk over to the person holding up the authorization, chew them out and get me started.
Also, these doctors can help push these through. Keep bugging their nurse until you get what you need.
I will not go with an HMO because that is their policy and their slow attention nearly did me in.
If you don't get results from either of these, then call your State Health Insurance office. You may be able to raise a complaint there. But your doctor should be pushing these authorizations through. At one point, I discovered the problem lay in this lazy, uncaring nurse.
So, push.
I'm going to push, Deanna - I have the feeling they'd be just as happy if I died and got out of the way.The goal of most HMOs is cost containment and not patient care. If you talk to most doctors regarding HMOs they are just as frustrated as their patients. Someone in the HMO office is deciding the medical care for their patients. I don't know if HAP is an HMO. But I have found that PPOs are much better. You pay more up front but it is worth it. I do not have to go to the referral cycle on anything. If my doctor suggests I need to see a specialist, I just have to find one in my network. I can still see someone outside my network, but I pay more.
Justme is right about the state of affairs in a lot of doctor's office. If you see the little cartoons making fun of HMOs in the office, then you know that they are experiencing this type of problem.
I would look for a PPO and not stay with your current one when you have the chance to change. In order to change the attitudes and policies of these companies we need legislation that does not allow them to rule the nature of our medical care.
Yes, they want you to die off. There have been many investigations into their practices. RA is one of those illnesses that insurance companies have to keep paying and paying on. It is heartless in the extreme because it is about your life. But for them it is about the money. The one thing you might be able to do is to get an investigation started on their practices.
Right now, though, fight for the care that you know you are entitled too. Get better, then fight the war. Just document everything as you go.
Oh God! As if there weren't already so many things to worry about with this disease! I think the patient advocate is the right direction now, but don't stop there or rest until you get appropriate treatment. I would sue the pants off them too, if they kept you from treatment and as a result caused deformity or loss of earnings! Make sure you document everything you get from them in the event that you have to do that!!Thanks for the support, everyone. I've calmed down a little (okay, a lot). I can't do anything more until I talk to my doctor, and that will have to wait until tomorrow.
I wish you luck with getting the right medication SOON!
Trisha
I heard a story on the History channel about how Brazil made it a consitutional amendent that everyone is entiled to decent health care. This had a powerful effect on the country. For instance, one lady who had aids and was dying was able to sue for those expensive medicines. I truly think this is what we need first, an amendent to the consitution. Then, let them figure it all out from there. Seems the way it is happening is only paying the insurance and drug companies. Many RDs are quitting because they cannot make the same money as say a Cardiologist. Roxy, the way we treat people with mental illness is disgraceful.Fiona: There are several steps you need to take to have the prescriptions and treatment plan approved.
1. Have your RD write a letter stating diagnosis and his/her treatment plan. Backup with copies of lab, xrays, etc.
2. You need to write a letter of appeal and send along with the RD letter and support documents. Your insurance company has a set of rules and regs that you will have to follow for appeal.
3. Make sure you have the correct address for the appeal or review department. Don't send it where you send claims. Either they'll have a different address or P.O. Box.
4. Besides mailing I would fax the above to the insurance company.
5. A couple of days after you've fax'd I'd call the co. and find out if the paperwork made it to review/appeal.
6. Make sure you get the names of each and every person you talk to at the ins. co. and jot down dates and times that you called.
7. Call the offices of the Insurance Commissioner for the state where you live. Ins. Comm offices are usually in the state capitals. Look on internet for telephone number and address. Find out if there are any other complaints lodged against this ins. co. Ask the person that you called how you can lodge a complaint. Follow up and file an official complaint against the company. Send a copy of the complaint to the insurance company.
8. During all this time keep checking with the insurance company about progress of appeal. Keep notes as stated above.
9. If this doesn't elicit a positive response from the insurance co. I'd call your state Senate representative's office and explain the situation to them. Elections are coming up!!! They need to be makeing big points with their voting public. Once again get names. Package everything up along with a cover letter stating that you spoke to so and so on such and such date and here is your complaint and appeal paperwork. I've done this when I was an advocate and Senator Reid in Nevada was always helpful and several times the client got what they needed.
These are the only suggestions that I have except don't lose your cool, be calm, direct, and don't take no as the final answer. You don't want the ins. co. as your best friend but then you don't want them as your enemy.
I spent 15 years as Director of Managed Healthcare and Workers' Compensation for the dreaded insurance company. Please don't throw darts at me. I've since retired.
AZ, that's an excellent suggestion. I was wondering how much Celebrex costs - and I'm sure the pharmacy will tell me. I also think my doctor will give me some samples. We pay a lot more for our insurance than they will pay for me - at least this year. And I have tried to be very careful to contain costs. But I'm not sure I'm willing to do that anymore.