I would like to start by introducing myself. I am an Internal Medicine Physician. That means I have gone through medical school, 3 years of residency. I am writing this because in the last several years, I have found myself bombarded with health insurance nightmares and I wanted to tell people about it from the physicians perspective.
Yes, we hate insurance companies as much as you do, and it is not for the reasons you may think. Yes getting paid for all of our hard work is getting more and more difficult, but the biggest stinker is the bigger and bigger hoops we have to jump through to get you your medication and doctor's services!
Let me start out with letting you know I have worked in the Kaiser Permanente Medical Group (www.kp.org) system, where whatever I prescribed was covered in some capacity depending on the patient's exact plan. I would write a script and it would be covered. Sometimes more expensive, but never denied. Never. I did not think to much about this luxury until I started worked for other hospitals that deal with a lot of different insurance companies.
Here is my first of many examples. I have a patient with a serious medical condition who has failed treatment with the first line medications. Now one would think it would be straightforward to just prescribe the next more potent medication for him. But no! Even though I filled out a prior authorization explaining how he had failed treatment and needed the stronger (ie: more expensive) medication, it was denied. The denial letter was faxed to my office and no one bothered to tell the patient. The poor guy went to the pharmacy to try and get his medication only to be told it would cost him $500 if he wanted to pay for it himself. What! So I call the insurance company who's representatives can't even pronounce the name of the medication I am trying to get only to be told that his diagnosis was not even on their little algorithm for prescribing this medication. Hence, denied. Well there is logic for you! You think you might want to ask a medical professional before a denial, but no. I ask to speak to the medical director- there is not a medical director on site. Well that explains a lot. I ask how I may appeal this denial and I can't even get a phone number to call! One hour later, I have no way to appeal and may patient is still without a medication that will work. I guess I will spend another hour of my time tomorrow. Because didn't you know I have spent 20 years in school and 6 years of training to spend hours of my day on the phone to be blocked by someone on the phone who does not have a clue what I am talking about?
This story being just the tiny tip of the iceberg.
Yes, we hate insurance companies as much as you do, and it is not for the reasons you may think. Yes getting paid for all of our hard work is getting more and more difficult, but the biggest stinker is the bigger and bigger hoops we have to jump through to get you your medication and doctor's services!
Let me start out with letting you know I have worked in the Kaiser Permanente Medical Group (www.kp.org) system, where whatever I prescribed was covered in some capacity depending on the patient's exact plan. I would write a script and it would be covered. Sometimes more expensive, but never denied. Never. I did not think to much about this luxury until I started worked for other hospitals that deal with a lot of different insurance companies.
Here is my first of many examples. I have a patient with a serious medical condition who has failed treatment with the first line medications. Now one would think it would be straightforward to just prescribe the next more potent medication for him. But no! Even though I filled out a prior authorization explaining how he had failed treatment and needed the stronger (ie: more expensive) medication, it was denied. The denial letter was faxed to my office and no one bothered to tell the patient. The poor guy went to the pharmacy to try and get his medication only to be told it would cost him $500 if he wanted to pay for it himself. What! So I call the insurance company who's representatives can't even pronounce the name of the medication I am trying to get only to be told that his diagnosis was not even on their little algorithm for prescribing this medication. Hence, denied. Well there is logic for you! You think you might want to ask a medical professional before a denial, but no. I ask to speak to the medical director- there is not a medical director on site. Well that explains a lot. I ask how I may appeal this denial and I can't even get a phone number to call! One hour later, I have no way to appeal and may patient is still without a medication that will work. I guess I will spend another hour of my time tomorrow. Because didn't you know I have spent 20 years in school and 6 years of training to spend hours of my day on the phone to be blocked by someone on the phone who does not have a clue what I am talking about?
This story being just the tiny tip of the iceberg.
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