The Call:
“I took my prescription to the pharmacy today because I had to be somewhere else after my visit on Friday. The pharmacy said the insurance wouldn’t pay for it unless the doctor gave them more information. But he said I needed to start it immediately, I really need him to call the insurance company right away.”
The nurse is thinking, but does not say…..
On a Saturday?
For a $20 antibiotic that you could have paid for in cash yesterday, and have been well into the treatment phase of your infection by now?
Come to think of it, in Mexico, it is probably available over the counter, without seeing the doctor at all. It probably costs less money there, too.
But premiums these days are enormous, and people want to get their money’s worth out of insurance more than ever before. And many Americans feel insurance should cover everything, since healthcare is now a right. So people get upset when they don’t get what they need, when they need it.
Has anyone noticed that paying directly is the only way that happens— that when others are involved with paying for something, they have a say in how the money is spent, and it takes longer?
I wonder… is it just possible that this back and forth, indirect payment, and expanding coverage may have something to do with our premiums going up?
Have we in America completely forgotten that “He that pays the piper calls the tune”?
“I’m sorry, Ma’am, the insurance company is closed on weekends. I will pass along a message, but you will need to contact the doctor’s office on Monday.”
The Back Story:
Insurance companies keep costs down by listing the cheapest, first-line drugs in an approved formulary. Prescriptions for these drugs are processed automatically by your insurance when you present your card at a pharmacy. Over time, doctors become familiar with the most common insurance formularies, and are guided by them in their prescription-writing. Patients may not even be aware of their insurance company’s role in determining their medications– until they need a medication that isn’t on the preferred list.
When a patient asks a pharmacy to fill a prescription for the more expensive second-line or “off-formulary” drugs, it will be denied until the prescribing physician provides additional prior authorization or pre-authorization. Company policy requires the doctor to convince the insurance representative that for particular reasons, the (generally) more expensive choice is necessary and first-line drugs will not work for you. Finding the “magic words” to persuade the insurance representative often requires repeated phone calls and multiple forms, or even proof that first-line drugs failed you recently. “Prior Auth.” consumes hours every day from doctors and staff at the typical office, contributing to higher medical practice costs and patient charges.
It becomes a battle of wills between the two offices, and the real question is whether the patient comes out the winner. Can you ever be sure that the final decision was for your health, and not for someone else’s bottom line, or peace of mind?
He that pays the piper calls the tune. Are you calling it, or is your insurance company?
To become the one calling the tune:
Web search or call to obtain your health insurance formularies. Find out if your new and routine medications are first-line on the formulary.
Consult with your doctor whether a formulary recommendation is best, and why.
Most patients will view an experienced physician’s statement that “This is the medication I have found to work best for this problem” to be a perfectly valid reason — but you should be aware that your health insurance may not agree. Be prepared to make the decision to pay cash because it’s your body and you trust your physician more than you need to have insurance cover this purchase…. or not.
The rules of comparison shopping apply to healthcare, too. Cash is king: check the yellow-pages and on line. Ask friends what they do for affordable meds. Direct purchase is the answer for many people. I have been happy with both product and service at Canadian Pharmacy Online. Other professionals recommend GoodRx for the coupons and price-checker for major US pharmacies. I tried it today and (pending phone confirmation) my next refill just may be local: the GoodRx free coupon saves me an amount comparable to Canadian Pharmacy Online, over 50% off the usual local price. Email refill reminders are a helpful option, too. And for routine medications I get at least a 3-month supply. Time is money, too!
And always, always, always be the final quality check that you have the right med and it’s doing the right things in your body.
He that pays the piper calls the tune.
Start calling it!
That’s the question, isn’t it? Who to trust.
The short answer: it’s a judgment call, each and every time a difference arises between the doctor and the insurance. (This post doesn’t really address the question of when you or the internet disagree with the doctor, but that’s a great idea for the future!)
All those involved are human and fallible. I can’t give you a final answer on who to trust, because that will depend on individual circumstances– but I can clarify the blog and point you toward some questions to ask in order for you to make the best decision when the time comes.
The doctor is the one educated for the purpose of looking you in the eye, examining you, and reviewing your records to formulate a plan of care on the spot. Why NOT trust the doctor? Are there any conflicts of interest? Is someone else paying him to treat you? In case of a conflict, what is his bottom line– your health, or someone’s balance sheet, or adherence to a protocol?
The insurance company controls the purse strings, which gives it final decision-making (subject to legal requirements) over what it will cover. Will you trust it to make the right decision for you, or will you simply follow the road of financial necessity?
Obviously, some battles are more important than others. We need wisdom to discern which ones to fight, and how to engage. I hope this helps.
Are you suggesting that we trust our doctor, the insurance company, or neither?
When trying to do research on the internet, it seems that it can be difficult to know who to believe when there are so many forums that can provide opposing opinions.
Pharmacy issues have proved to be a huge hassle for me! Love your insight.