A quick read for patiients wondering why certain drugs are not approved.

{A parody, except happening everywhere.)

I (48, F) had to do one of those "peer-to-peer" calls with an insurance physician (undisclosed-age, M). I know, it's a commonplace task now, what's the big deal, etc., but let me explain.

From the start of the conversation, tons of red flags. First of all, he won't tell me what specialty he is. And I'm like, "Okay, that's kind of weird, but can you at least tell me if you're an oncologist?" Then he asks, "Why does that matter?" So I say, "It matters a lot because I'm an oncologist and this is about a person with cancer. It's literally a matter of life and death because your insurance company denied their cancer treatment."

He finally says, "No," he's not an oncologist.

"So then, what's your specialty?" I ask.

He clears his throat and says he isn't allowed to say. Then he reminds me that this call is being recorded for quality assurance purposes.

"Excellent," I say. "Then it's being recorded that you're the one obstructing my patient's access to lifesaving treatment."

Then he says there's no reason to be rude and calls me "Miss." I ask him to please refer to me by my title of "Dr," and he drops the "Miss" but instead starts using my first name as if we're old friends or something.

At this point, I'm not making any progress in getting my patient's medication approved, so I let the first name/untitling go and ask him to explain why the insurance company denied the medication (let's call it X).

I hear him shuffling papers, and then he says it's because we didn't try medication Y yet.

I tell him it's correct that medication Y used to be the standard-of-care first-line therapy, but as of 6 months ago, the FDA approved medication X as the more effective therapy. I explain to him the insurance company guidelines are out-of-date. Any board-certified oncologist would know this. Which he, inconveniently, is not.

Then he tells me there's often a lengthy delay in updates to company guidelines, which he can't control. To which I respond, "That's why I, as the patient's doctor, should be in charge of what treatment is approved," not him or the insurance company.

He says he doesn't disagree with me, but it's not in his power to approve it. Because the company hasn't updated its guidelines, I'll have to talk to an oncologist at the insurance company to get an override.

It seems obvious to me it would have made more sense to do that in the first place, but in the interest of time, I keep this comment to myself and tell him, "Fine, please transfer me to their oncologist."

Then he says, "Oh no, I can't do that. You'll have to set up another phone call."

At this point, I've had another patient in an exam room waiting for over 15 minutes so I ask him to please hurry and set that up.

I hear papers shuffling again, and he says they can set me up for that phone call at 4:42 AM the next day.

When I ask for a more reasonable time, he says because they're in a different time zone, that's all they can offer, and if I don't take that time, then my patient's case will be closed, and I'll have to start all over with the appeal from the beginning — which means talking to someone like him again.

Because there's no real choice, I take the offered time. The following morning, the insurance oncologist immediately approves medication X.

So AITA for pointing out that if the insurance company had trusted that I, as a board-certified oncologist, was doing the right thing for my patient from the get-go, we could have saved everyone a lot of time and frustration (and sleep)?

Their response? "This call is being recorded for quality assurance purposes."


LINK: https://www.medscape.com/viewa...5325SY&impID=4478048

This message has been edited. Last edited by: ZSMICHAEL,

You should record their calls for medical malpractice lawsuit purposes.

quote:

Originally posted by ZSMICHAEL:
AITA

quote:

Originally posted by Gustofer:

quote:

Originally posted by ZSMICHAEL:
AITA

I had to do a google search. I believe it means Am I The Asshole.

I just got the same runaround by my insurance for a cardiac catheterization!

My cardiologist had to call many times and we had to jump through several medication “hoops” to get approved.

The whole time I had a failed stress test showing potential blockage!

It took three months!

I used to hear the job of medical insurance is to find a reason not to approve something. Now it looks like their purpose is to partner with pharma and medical providers to extract the most money across time from each patient. If an algorithm says delaying approval of some procedure result in more overall profit, that's what happens.

quote:

Originally posted by bryan11:
I used to hear the job of medical insurance is to find a reason not to approve something. Now it looks like their purpose is to partner with pharma and medical providers to extract the most money across time from each patient. If an algorithm says delaying approval of some procedure result in more overall profit, that's what happens.

I've seen that quite a lot with myself, Mrs. Flash and our friends. We're seen as cash cows and treated accordingly.

They really hate it when you don't play along with them, though.

Just went through something similar.

After being borderline for several years, and trying unsuccessfully to control it through non-Rx means, my cholesterol is now just high enough to need medication. I also have a family history of high cholesterol and heart disease.

I cannot take statins due to unwanted side effects. (We tried that already with simvastatin.) So my doctor prescribes a relatively new non-statin cholesterol Rx that has been out for ~3 years now - Nexlizet.

Immediately denied by my insurance. Doctor appeals. Appeal denied. Final decision.

Yesterday, I got the formal denial paperwork from my insurance. It states that their criteria for approval of this cholesterol-lowering medication is that I must have an active diagnosis of heart disease.

So my insurance company won't approve the medication needed to lower my cholesterol and stave off heart disease, until I have actually developed heart disease and it's too late.

Cool. Thanks, "health" insurance.

This is a great post for the forum Bitch section. Do agree big insurance sucks. Imagine what the ignorant of the facts BS the average lay person gets when we call in. Dr.

Well, I guess you could take simvastatin and get a one week hospitalization for Rhabdo. That would teach them, but sadly punish you.

With your family history it is possible you have subclinical CAD. Lets order lots of expensive tests and prove them wrong. CAD develops very slowly over time as you know.

A perfect example of benign neglect

The insurance company probably thinks the doctor is getting a kickback for prescribing a more expensive drug.

No. It is GREED pure and simple.

Yep, it's new enough that it's still under patent, and therefore it's expensive with no generic alternative until the patent runs out.

So insurance doesn't want to pay the full name brand price for it. They only want to approve the drastically cheaper generic statin medications, with no regard for patients for whom a statin isn't viable.

The manufacturer offers a supplemental copay card that's supposed to bring the patient's out of pocket cost down, but the copay card only provides assistance if your insurance doesn't cover the full amount. It provides zero assistance if insurance outright denies coverage altogether, as mine did.

Crazy system we have here. Pharma wants to hang onto their patent as long as possible and we pay the price. In the long run this sort of thing costs the insurance company more.

And Pharma wants to hold onto their patent as long as possible first to recoup the enormous R&D costs for coming up with the drug in the first place, then reap profits that are the driving reason for patents in the first place.

Why bother inventing something great and marketing it if you can't turn a large profit off of it?

Profits encourage and reward inventiveness and inventiveness is part of what makes the U.S. great.

^^^^^^^^^^^^^
You left out the main reason: INCREASE the stock price. BTW Americans pay more for their drugs than any other country. To be brief we are subsidizing low drug prices for Canadians and Europeans who pay for less. As I said the issue is Greed. Big Pharma is always touting research costs. You see what the CEO of Pfizer makes? Did you support Pharma Bro?

quote:

Originally posted by ZSMICHAEL:
Did you support Pharma Bro?

I did and do support Pharma and all other medical R&D.

And we are subsidizing other countries, but that's not Pharma's fault, that's Congress's fault.

quote:

Originally posted by ZSMICHAEL:
I hear papers shuffling again, and he says they can set me up for that phone call at 4:42 AM the next day.

When I ask for a more reasonable time, he says because they're in a different time zone, that's all they can offer, and if I don't take that time, then my patient's case will be closed, and I'll have to start all over with the appeal from the beginning — which means talking to someone like him again.

I see you're consulting with "experts":

This crap costs lives! My oldest son had 3 deteriorated disks in his lower back. Pain killers were useless, no therapy was going to fill the missing parts of his spine. He found a surgeon who could help, but the insurance wanted him to first go to a pain management doctor (previously done) and denied the surgery. Even after the surgeon appealed the ruling twice, they denied his request. Two days after the second denial, already depressed and in pain, he took his own life. This BS is all about money for the insurance company and has nothing to do with the patient’s health.