How to Get What You Want/Need

Getting what you want or need in healthcare – is that possible today?  That was the topic of discussion with my rheumatologist during my last appointment.

I really don’t think much about the process of insurance.  It’s difficult to track at times, but essentially you go to the doctor, they file the information, the insurance provider determines the negotiated rates and pays their portion and then you get an invoice from the doctor for the unpaid amount.  If there is something out of the routine the doctor seeks approval from the insurance provider.   Sounds easy enough – most of the time.

But …. what happens when the insurance provider and the doctor don’t really agree.  Are we really prohibited from getting the medication or treatment that we want — one that the doctor suggests we need?

During my last appointment we discussed the results of a specific test.  I was somewhat surprised by those results and mentioned it to the doctor.  He responded by discussing medications.  While reviewing my labs, he suggested another medication I might try.  He was looking at my chart on the computer and then advised that my insurance did not agree with his choice, but they did allow two other medications.

His comment seemed odd to me.  I asked if the insurance company dictated which medications he could prescribe for a patient.  His response surprised me.

He told me that the insurance company did not dictate what he prescribed.  He then told me that if I took a prescription to my pharmacy and gave it to them along with my credit card I could get whatever I wanted.

What???  Wait – but that takes my insurance out of the picture, right?  He again said you can get any prescription you want by giving them your credit card.

I again asked – what about my insurance?  If it will not cover what you prescribe and I have to pay for it out of pocket, what purpose does the insurance serve?  I got no response.  However, once again he made the point that insurance did not dictate what he prescribed and that it was up to me.  For now I don’t have to worry about who might have to pay as the decision is to remain with status quo regarding my medications.

Months ago I wrote concerning a friend who encountered a significant issue with her insurance provider (The Scary Side of Insurance)  A treatment plan that had been approved and then denied by her insurance provider.  The issue is still not resolved after a year of inquiries.  And, as you know, if they do not pay, she is responsible.

It is not uncommon to hear from rheum-mates that their insurance will not cover a specific medication suggested by their doctor.  While some drug companies may offer assistance to patients in need, there is an application process.

This is a serious concern for patients — whether it is for a new medication or a series of treatments.

Have you had a situation where the doctor preferred one medicine for you, yet it was not the choice of your insurer?   Have you had to pay for mediation or treatment out of pocket?




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