Insurance companies practicng medicine.

[LeftyFingerPop]

My left arm has been horribly non-functional ever since I went to NYC (3 months ago?).

Locked up and the make ya wanna weep type of pain....everyday for 3 months.

I sleep only 2 or 3 hours a night because of the pain.

GP did x-rays, which are negative. She prescribed Vicodin, which don't really help unless I take enough of them to make me loopy to the point that I don't care about the pain. I have a big fear of getting hooked on these things, so I take them 3 at a time, but very sporadically, maybe twice a week. Obviously, Vicodin is not the answer over the long haul.

I finally get in to see a pain specialist. He suspects either a pathology in the muscle or tendon, or a bad disc in my neck.

He ordered an MRI on my arm and neck.

I cannot take oral NSAID's because of my kidney problems. He gave me a sample of 2 Flector patches. They work!! Holy Christ...pain free for an evening.

I went to get the prescription for them filled this morning. Insurance will not approve because they want me to try oral NSAID's first. Well, since I have kidney problems which prevent me from talking them, the pharmacy now has to begin the dance with my doctor and the insurance company, explaining to the insurance company why I need these patches.

The smallest they can dispense is 30, at $10 each for $300, which I don't have right now.

So that means more pain.

If I am not posting this weekend, it means I am hunting down the desk jockey at the insurance company who denies these things...and breaking their fucking arm.

[yellowdogintexas]

1. as a former desk jockey I can tell you that unfortunately they can only work

with what the insurance coverage arrangement allows. The doc and the insurance co will play a little fax tag and hopefully get it squared away. A fax from the physician explaining that you can't take NSAIDS orally due to other ongoing physical problems, and that they have already been tried, and this is an excellent non narcotic approach,
etc.

This is most likely due to a clause in the RX coverage regarding new drugs, or what is called First Tier medications. There isn't a generic alternative, and the policy requires all less expensive alternatives to be exhausted first.

There is a list called the Drug Formulary that accompanies this type of coverage and if your drug is on that list then the doctor has to support the ordering of it. I ran into this when my MD switched me from Effexor to Lexapro recently.

Just keep on the doc's case about this to get the paperwork done before they go home today so you can go get your meds, and beg for some additional samples to get you through the weekend if they can't get it done.

[LeftyFingerPop]

2. I know....

and my beef is actually with the system, rather than the people who administer it. But GODDAMN, it is a lot of work when you are in pain. I've been down this road before.

By the way, how did you do coming off the Effexor? :hi:

[yellowdogintexas]

4. great. My doc is very thorough on this. She wrote me out this game plan

I take the Lexapro every day. For two weeks I took Effexor as well every other day. Then she gave me samples of a lower dose of Effexor to take for an additional 2 weeks. I have 3 of those left. So I am scaling down the Effexor while taking the Lexapro. These two drugs actually work on different uptake receptors, which is why these drugs have different results with different people.

I started with Zoloft then went to Celexa then Effexor and now Lexapro. My doctor thinks a medication change is in order every 3 to 4 years.

One of the coolest things about the Effexor which I am hoping is not disrupted by the med change is that for years and years I suffered from irritable bowel syndrome...after a month on the Effexor I noticed a distinct improvement in the IBS turns out that is a desirable side effect that doesn't always happen.

She took me off the Zoloft for a while just to see if I still needed it and she had me do a scale down on that too as she put it..if you cold turkey on Zoloft you will feel like you have the flu: all the aches pains lethargy and exhaustion but no fever or respiratory symptoms. As it turns out the Zoloft was more necessary than I thought and I have not wished to be without antidepressants since then

[LeftyFingerPop]

8. Your doc is doing a good job...

I am happy to hear this. Effexor withdrawal can be nightmarish, but it sounds like you are doing it right.

Best of luck with the IBS on the new meds.

[yellowdogintexas]

12. Thank you. We LOVE This doctor, she is the best. When my husband's

physical indicated he could be diabetic she turned into Doctor Tornado and before we knew it he was scheduled for Diabetic Education classes, a baseline ophthalmological exam and other stuff all diabetics should have evaluated. He is still insulin free after 10 years.

she also helped me work through an extremely painful lumber pain episode; started with NSAIDS and muscle relaxers for 3 months, and a walking program. Then she ordered the massage therapy which really has helped.

if you do try massage, be sure it is medical massage, with deep tissue and myofascial release as part of the description of the therapist's skills. Regular spa massage is not the same, although quite pleasant.

My massage therapist has this thing that looks and sounds like a rotary floor polisher which she runs all up and down my back, neck and shoulders before she actually does the hands on work. It helps loosen the scar tissue around the joints and ligaments. She has a miniature one that she uses on my hands, and it is the BOMB. I have really bad arthritis in the joints at the base of my thumbs and that thing really does help.


You may just need to get in a good physical therapy program to do the right moves to loosen that shoulder up, it sounds a lot like frozen shoulder syndrome to me...but I am not a doctor..I just acted like one when I was an insurance desk jockey.

[LeftyFingerPop]

15. I love it!

"Doctor tornado" :rofl:

Thanks for the advice on the massage...I will keep it in mind.

I hope I did not insult you with my "desk jockey" comment. Hey, I'm a desk jockey, only not for an insurance company. I know several people IRL who are though...and they hate it.

[Breeze54]

3. Did you dislocate your shoulder?!

That can't be right that they haven't a damn clue! What kind of morons are you seeing?
I'm sorry you have that kind of pain... I had my ribs broken once and they told me the
xrays and my ribs were fine but I was still in pain and I insisted and then they did
some sort of "better" xray and discovered 6 hairline fractures!! I knew I wasn't crazy!!!

[LeftyFingerPop]

5. Yikes!

I'm sorry to hear that happened to you!

My x-rays looked fine...I had two sets done. No bone problem.

Arthritis in the neck, along with a narrowing of disk spaces in the neck...but he said it did not appear to be severe enough to cause this kind of pain.

My "pathology" in the muscle or tendon, he is referring to a possible tear that would not show up on traditional x-rays. Or, it could be a blown disk in the neck...that is why he wants the MRI to confirm. :hi:

[Breeze54]

11. Is he a specialist? I had to see a neck and back surgeon

specialist for my whiplash and he said I had a lot of "soft tissue" damage after my car accident.
I had Severe Whiplash. maybe you also have soft tissue damage... maybe a pinched nerve?

[LeftyFingerPop]

16. Orthopedic "pain specialist" who is referring me next to...

a "hand and arm" specialist.

He is thinking a possible pinched nerve also, that is why he is looking at the neck too.

[Breeze54]

21. That's the word I was looking for... "Orthopedic Surgeon"

That's who took care of me after my car accident.

He was such a nice Dr and sympathetic to me.

I hope you find someone that knows what they're doing.

Neck & Shoulder pain are the worst! It effects everything you do!!

:hug:

[yellowdogintexas]

7. it sounds like frozen shoulder syndrome to me

and it is weird in that it will come on very suddenly and just as suddenly resolve.

I have had excellent help with my stiff shoulder from deep tissue massage therapy. You have NO idea how good that feels and how much it has helped. I was able to eventually start yoga which also has helped

[LeftyFingerPop]

10. Mine is...

6 inches either side of my elbow, on the top of the arm. Radiates to top of wrist and top of hand. Very occasionally into the bicep.

I'm happy your therapy has worked out for you...I'm sure I'll be going that route somewhere down the line.

[sir_captain]

30. the etiology of pain is often almost impossible to figure out

particularly if it's neuropathic. doesn't mean the patient is crazy or that the doctor is a moron.

[fizzgig]

6. i'm sorry you're dealing with this

i've had a few go rounds with insurance companies and it is so frustrating. i had to pay $60 out of pocket for my psych meds last year because i ran out but i hadn't signed up for the mail order plan, they denied my refill. then the woman told me the plan would reset at the first of the year (this was a few days before new years), but when i went to fill the script, it was still denied and another rep told me i had only a certain number of pharmacy refills in a 12 month period.

but i found a way around the system and, with the help of the on-call doctor, was able to get my meds refilled. being off my meds has the potential to cost the insurance company much more than simply refilling them.

[LeftyFingerPop]

9. Damn....

How do the old people do it kagehime?

It is difficult enough not to be feeling well, but to have to deal with this too?

:hug:

[yellowdogintexas]

13. in all my different 'customer service' jobs, in health insurance, mortgage loans

and other things. I always worried about the old people. Even with my detailed professional understanding of the policies, I could get confused and I would think ..how does anyone with even 50% less general knowledge of this stuff manage?

[fizzgig]

14. it adds unnecessary stress and it's unconscionable

but hey, it's all about money, right?

:hug:

[Patiod]

17. Can you get PT?

That's what I'm going through now with my shoulder. PT and a re-usable ice patch.

[LeftyFingerPop]

27. It may come to PT, but, I sure would like to know what's wrong...

before that. :(

Good luck with your shoulder...I'm sorry you are in pain.

[LeftyMom]

18. You should be able to get an approval for a non-formulary med if you can't take the approved one.

I had to get that done for my birth control medication- I can't take any of the usual suspects, and the one I can is expensive and not approved by my insurer. My NP made some calls, and I was approved. It took about 15 minutes, and that was with Kaiser, which is widely known to suck gray fuzzy donkey nuts. It took longer than that for the pharmacy to special order my medication.

[LeftyFingerPop]

28. Yes, I've done this before with my oral meds...

and it worked out fine.

The problem here, however, is that I can't take the oral NSAIDS, hence, he prescribed the patch. I believe this is the only company that makes this, and I'm assuming a generic does not exist. :)

[Lydia Leftcoast]

19. My brother the doctor HATES insurance companies

He complains that people with no medical training are making decisions about what insurance will and won't pay, based on a checklist for various conditions.

Since he successfully uses a holistic approach to pain therapy, avoiding drugs and surgery as much as possible, the insurance companies don't know what to do with him.

[LeftyFingerPop]

29. Yes Lydia....

a lot of docs hate them.

I like your brother's approach. :) More should be like him.

[Brigid]

20. The reason for all this unnecessary stress and suffering is very simple:

The insurance company is not there to collect your premiums and in return cover your medical bills. Insurance companies exist to make a profit, and nothing more. As long as the insurance company lobby and the pharmaeutical lobby are allowed to continue their fearmongering about "socialized medicine," this sort of thing is going to continue. :grr:

[LeftyFingerPop]

26. Totally, 100%, absolutely agree with you.

:(

Hence, my earlier comment about the "system". When people in other countries see how it is here...they just kind of get a blank stare.

[TZ]

22. You know I know this game all too well...

I'm sure you'll get what you need EVENTUALLY..hopefully you will get the bullshit done faster than I did..btw, I can't remember if I told you but Wednesday I got my refill from Mayo--for 30 dollars!
Heres hoping your idiot insurance company moves its ass....:hug:

[LeftyFingerPop]

25. Thank you...

:hug:

Oh, I'll get them to move. I'm batshit aggressive on stuff like this...problem is, it's the weekend.

[Bullwinkle925]

23. definitely contact the Dr's. office for more *samples* while they are dealing with the

insurance issues. as yellowdogintexas stated - keep on the dr's. office today with the info. faxes to the insurance agency.
i've worked in physician offices and i know the back-and-forth dealings of getting a drug (hopefully) approved.

if you need any $$ assistance, let me know - PM me.

[LeftyFingerPop]

24. That is a generous offer....

and you are very kind to make it. :hug: Thank you.

I would never accept it though, because I probably could put my hands on the money this weekend if I had to. I guess if it were for something other than pain, I would.

It's almost like a matter of pride for me. You can bet that if this were for insulin, or a diabetes oral drug, I sure as hell would be beating the bushes to get it anyway I could.

But for a pain med....I don't know. I think I can ride it out for a few days...I'll have a few drinks tonight, and maybe have some Vicodin tomorrow or Sunday...I don't know. But in any case, I can take care of it one way or another.

I'm really disappointed though...these patches took the pain away in about 10 minutes.

[SPKrazy]

31. Yes, Insurance Companies Have Been Practicing Medicine Since The 80's

they just slipped up the beach head and took it all over.

In the 80's psychiatry and chemical dependency treatment

In the 90's Hospital care

Now outpatient practice, treatments, drug formularies, algorithms that must be followed and documented in order for the insurance to pay, treatment plans that must match the insurance company's interpretation of best practices. Most insurance companies follow Medicare rules and guidelines pretty closely.

Hey, a whole new profession came out of it all, professional coders. No offense to professional coders, but they are charged with the task of getting as much money from the insurance company as possible by coding every action that can be... hey a good coder is worth a bundle in today's medical world.

Oh, and people thought we weren't getting health care rationing and that we wouldn't be practicing socialized medicine. :rofl: :rofl: :rofl:

WAKE THE FUCK UP AMERICA!!!! YOU'VE BEEN HAD!

We have health care rationing, enforced often by clerk level personnel that have no medical training but can read the Qual Choice guidelines and can question the fuck out of a caregiver who can't even practice the way they may want to or have been trained if it isn't paid for. Why do you think people aren't going into medicine so much anymore?

This is fucking why Phil, this is why...

that and malpractice insurance and frivolous lawsuits are a constant nuisance and the insurance expensive beyond belief in some areas.

[eyesroll]

32. I hear you. I'm in the process of convincing my insurer that I am, indeed, "at risk"

of ovarian cancer by their definition and therefore am entitled to have screenings covered (right now, "routine care" is capped at $200, which means I got to pay for my routine cholesterol test out of pocket--I neglected to remember the fine print before consenting, but yeah, it's there, and plainly so).

Their definition includes "clusters of breast cancer among female relatives." They do not define "clusters" or require a certain degree of relative (like they do for other risk factors)...I'm basically arguing from a contracts standpoint. Both grandmothers, a maternal uncle, and a paternal aunt have had breast cancer. My mother and sister and I have not. That still sounds like a cluster to me. Their contract is ambiguous. Contract ambiguities are construed against the party who drafted it. They drafted it. If they didn't want second- and third-degree relatives to count as a "cluster," they should have said so. (I'm a rising third-year law student--law students shouldn't be practicing medicine any more than insurance bureaucrats, but at least I can give them a convincing legal argument, on law firm stationary with my boss's signature if necessary.)

[ikojo]

33. I work for an HMO and this is how they work it when

a doctor prescribes a medication that is not on the formulary...now your doctor can write a letter to the pharmacy benefits HMO detailing why you cannot do the step treatment to find out which drug is good for you (and good for the insurance company's bottom line, because that's what it's really about. The drug prescribed by your doctor costs the insurance company more money so they want to do everything to avoid paying for the more expensive drug).

I suggest that if your doctor does write a letter to the APPEALS DEPARTMENT at pharmacy benefits HMO, he/she also cc's your state's department of insurance. You are far more likely to get the results you need and want if it is done this way. Just don't have the letter sent to the PO Box indicated on your insurance card, get the address you need to send an appeal. However, before you send an appeal you first need a rejection from the insurance company saying they will not pay for the more expensive drug.

More hoops than are found at your local gym, I know.