Now I understand..an insurance rant FINAL UPDATE

[kimblebee]

WARNING-- Long rant ahead.

It's no secret that I am going to be having an IV infusion treatment for my MS. Since my surgery went well, I have been working with my nurse to get the process started again and I actually start on Monday.

Back in January (the first time I was supposed to start) the medication was ordered and my provincial insurance paid for it (90K..YIKES). When my plans changed, the medication was put in the fridge to wait for me start at a later date. It had an expiration date in August so there was no rush.

Yesterday, I got the ok to start on Monday and everything was ok. About ten minutes after I got off the phone with my nurse she called back (this is where the stress starts) and let me know that my provincial insurance wouldn't pay for my meds because I hadn't met the deductible for the year (it resets every April 1). I asked my nurse why I had to reorder and she explained that someone else has started the treatment and they had decided to use my med for them since it was already there.

At the time I didn't think much of it because my husband has insurance through work so they would just reimburse my deductible ($1516.75). I didn't have the money on hand so my parents put it on their Visa, knowing they'd get the money back. So, my mom called the pharmacy, gave her Visa #, and I was faxed the receipts to submit to the work insurance company.

After I submitted, just for giggles, I decided to check out the drug section of the policy to see if there were any exclusions.

You see where this is going...

The last exclusion on the page says the plan won't cover any meds that have to be given at a hospital by a nurse or Dr. It includes in patient and out patient. A loud swear word was said at this point. The worst part is that they WILL start accepting these claims in a month. I can't wait a month, because after this treatment I'm having surgery so I'm on a tight deadline.

I'm waiting until 9.01 to call the Winnipeg rep for the insurance to see if an exception can be made. I've never dealt with a problem with insurance so I don't know how it will go or how likely it is.

If it is denied outright I will be calling my MS clinic and raising holy hell that my meds were given away without my consent. I like my nurse and my Dr but this is totally unacceptable. In all honesty though, if they had asked if they could do it I probably would have said yes.

My other option is to call the drug company and see if they can help me out. If not, I'll file a complaint with the hospital if that's what it takes.

Thanks for reading my novel.

 

[mjkacmom]

I think the problem is with the clinic, they should be replacing the drug.

 

[kimblebee]

I think the problem is with the clinic, they should be replacing the drug.

If I can't figure it out with the insurance or the drug company I will definitely turn my attention to the clinic.

 

[katie01]

I'm sorry, medical issues are hard enough without all the stress that accompanies dealing with insurance and other red tape. I hope you can get it straightened out, keep us posted

 

[Gracie09]

yeah I don't see how they can just use one patients medicine for another and not replace it. Dh has a similar thing where he gets quarterly treatments and they order the meds for the next treatment while he is there (the doctor books 6+ months out so it can be difficult to reschedule if the med don't arrive in time). Those are his meds and they don't give them to someone else.
I would start with the clinic.

 

[mi*vida*loca]

I know if we did that in my office we would be liable to get this person's medication. If the other patient started your med they must've billed her insurance and been paid also? So are they double dipping? I would think they would've received another vial of medication when her insurance approved it and kept that vial for you. I would definitely take it up with the clinic.

 

[kimblebee]

I know if we did that in my office we would be liable to get this person's medication. If the other patient started your med they must've billed her insurance and been paid also? So are they double dipping? I would think they would've received another vial of medication when her insurance approved it and kept that vial for you. I would definitely take it up with the clinic.

I'm just speculating here, but I think they used my medicine as hers and kept insurance out of it. Even though it was 'free' for me, it's still on my provincial insurance that it was covered. I will definitely keep everyone updated.

 

[nephthys43]

That's fraud. You need to inform your insurance company that they paid for a med your doctor did not give to you and did in fact give to someone else.

 

[Mizzoufan]

I'm sorry MS is enough to deal with, without having to deal with stupid insurance companies.

 

[The Mystery Machine]

WARNING-- Long rant ahead.

It's no secret that I am going to be having an IV infusion treatment for my MS. Since my surgery went well, I have been working with my nurse to get the process started again and I actually start on Monday.

Back in January (the first time I was supposed to start) the medication was ordered and my provincial insurance paid for it (90K..YIKES). When my plans changed, the medication was put in the fridge to wait for me start at a later date. It had an expiration date in August so there was no rush.

Yesterday, I got the ok to start on Monday and everything was ok. About ten minutes after I got off the phone with my nurse she called back (this is where the stress starts) and let me know that my provincial insurance wouldn't pay for my meds because I hadn't met the deductible for the year (it resets every April 1). I asked my nurse why I had to reorder and she explained that someone else has started the treatment and they had decided to use my med for them since it was already there.

At the time I didn't think much of it because my husband has insurance through work so they would just reimburse my deductible ($1516.75). I didn't have the money on hand so my parents put it on their Visa, knowing they'd get the money back. So, my mom called the pharmacy, gave her Visa #, and I was faxed the receipts to submit to the work insurance company.

After I submitted, just for giggles, I decided to check out the drug section of the policy to see if there were any exclusions.

You see where this is going...

The last exclusion on the page says the plan won't cover any meds that have to be given at a hospital by a nurse or Dr. It includes in patient and out patient. A loud swear word was said at this point. The worst part is that they WILL start accepting these claims in a month. I can't wait a month, because after this treatment I'm having surgery so I'm on a tight deadline.

I'm waiting until 9.01 to call the Winnipeg rep for the insurance to see if an exception can be made. I've never dealt with a problem with insurance so I don't know how it will go or how likely it is.

If it is denied outright I will be calling my MS clinic and raising holy hell that my meds were given away without my consent. I like my nurse and my Dr but this is totally unacceptable. In all honesty though, if they had asked if they could do it I probably would have said yes.

My other option is to call the drug company and see if they can help me out. If not, I'll file a complaint with the hospital if that's what it takes.

Thanks for reading my novel.

Hang in there and get a calendar, a journal, and start taking names, dates, times of calls. Write down what was said in the call. You need to start a trail of information. You may need it. Good Luck & (((Hugs))).

 

[mi*vida*loca]

I'm just speculating here, but I think they used my medicine as hers and kept insurance out of it. Even though it was 'free' for me, it's still on my provincial insurance that it was covered. I will definitely keep everyone updated.

Then that's fraud. Double billing. They need to bill her insurance and get a new vial for you.

 

[Gracie09]

Then that's fraud. Double billing. They need to bill her insurance and get a new vial for you.

exactly.

 

[kimblebee]

Then that's fraud. Double billing. They need to bill her insurance and get a new vial for you.

That's the thing though. I don't think they billed anyone for her meds (mine) because they had already been paid for. It's like they just took a Kleenex out of an already opened box..except the Kleenex was earmarked for me.

The clinic can sometimes take days to return a call because of the high patient load (over 2000 patients for this one dr) but I left a very terse message just now so hopefully I hear soon.


I called the insurance company and just as I feared, the claim will be denied.

LOUD SWEAR WORDS BEING YELLED

 

[Kaytie]

Is there any way your nurse or any other medical professional can administer the medication in your home?

 

[aejammers]

Sorry you are dealing with this. I am not the best on insurance issues, but basically, you just paid for the same medication twice. No wonder your insurance is denying you. This is a clinic issue. You paid for medication in January that you did not use. You should not have to pay for medication again. Your clinic should be reimbursing you for the medication that you paid for in January that they used on someone else.
Good luck and feel better!

 

[mi*vida*loca]

That's the thing though. I don't think they billed anyone for her meds (mine) because they had already been paid for. It's like they just took a Kleenex out of an already opened box..except the Kleenex was earmarked for me.

The clinic can sometimes take days to return a call because of the high patient load (over 2000 patients for this one dr) but I left a very terse message just now so hopefully I hear soon.


I called the insurance company and just as I feared, the claim will be denied.

LOUD SWEAR WORDS BEING YELLED

I see. But they are double billing you/your insurance. That's illegal.

 

[kimblebee]

So, after talking to the drug company, they are going to reimburse me and a cheque should be in the mail by the end of the day.

I'm still going to mention to my clinic NOT to do this again.

 

[Gumbo4x4]

Imagine you get an estimate on your car of $2,000 to replace the transmission. While replacing the transmission, they discover an engine oil leak. That's going to add another $500 to your bill. Okay, fair enough.

But wait, because the engine oil leak was discovered during the transmission replacement, the quoted price for the transmission is now null & void. And the new price is $10,000 for the transmission plus the $500 for the oil leak.


There is no way the mechanic could get away with that. But, that's pretty much what goes on with medical billing. In any other industry, there'd be no way.

 

[kimblebee]

More than a few people on these boards think I am very anti American. This is very untrue. I have a lot of sympathy for anyone who has to deal with insurance on a regular basis. This was one relatively small issue that was solved in a day. I can't imagine if I had to keep this up for months on end and going in circles.

To clear something up. My January drug was not double billed. It was paid for by my provincial insurance (NOT work insurance). The new patient got it with no billing involved. It just came out of the fridge as if I was going to use it. That doesn't make it any better, but I just wanted to clear up that it wasn't double billed. It was billed to me (and covered by me) but used for someone else.

 

[Klayfish]

I'm waiting until 9.01 to call the Winnipeg rep for the insurance to see if an exception can be made. I've never dealt with a problem with insurance so I don't know how it will go or how likely it is.

See, there's your problem right there. You're in Canada. You need to come to the United States...our system is oh-so much better... Scratch that...try Mexico...

Hope it all works out well for you!