Doctors vs. insurance

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Michelle Neff is frustrated with her insurance, plan hip 2.0

“Do you feel like you are jumping through hoops? Oh, absolutely. I jumped through that hoop and I’m falling flat on my face,” says Neff.

Michelle has been prescribed a generic form of nexium to control her acid reflux.  Her doctor has prescribed she take two pills a day. But her insuror will only pay for one pill a day.

“They won’t pay for the twice a day and the way the prescription is written, they won’t pay for half of it,” says Neff.

Michelle pays for her prescription out of pocket.  The bill totals ten dollars thirty cents a month.

But there is another part to Michelle’s story: her doctor says the insurance company is essentially dictating the treatment.  A number of physicians see this as dangerous.  Some are pushing back.

They’ve put out a call to action, called the doctor-patient rights project.  The website states: DPRP is a non profit coalition of doctors, patients, caregivers, companies and advocates fighting to restore.

The fundamental practice of medicine and to ensure doctors in partnership with their patients, drive patient care decisions.

“Having an insurance company in the middle of it kind of negates our ability to effectively treat our patient,” says Dr. Theresa Rohr-Kirchgraber, the Executive Director of the IU National Center of Excellence for Women’s Health.

Dr. Rohr-Kirchgraber says she understands insurance companies have to control costs. But insurance companies make it more difficult than the process should be. Many companies don’t automatically suggest alternative drugs.

The patient is caught in the middle. Time is lost and everyone is frustrated.  She recently had to fight an insurance company after she prescribed a generic form of an inhaler, called albuterol.

“They actually wouldn’t pay for the generic albuterol. They would only pay for the brand name, pro-air. How am I supposed to know that? I actually have a nurse in my office, who all she does for approximately four hours a day, is call insurance companies and work on prior authorizations for these kinds of simple medications.”

Michelle is in the process of trying to get her twice a day generic nexium paid.  But one thing that doesn’t make sense to her, is the difference in price between that drug and a muscle relaxant she has to take.

“They’re paying $267 and some odd cents for that, but not ten dollars and 30 cents for the nexium. Where does it balance out? And that is a frustration,” says Neff.

Indiana’s State Department of Health has some guidelines for patients: verify the medications you are taking are covered by your plan. Find out if there is a deductible associated with the medication. Also, find out if a prior authorization is required in order to have this medicine covered. In other words, it’s the patients responsibility to get the drug list or formulary and take it with them to their physician.

But Dr. Rohr-Kirchgraber says the insurance companies switch drugs often and ultimately they are in the driver’s seat. It should be up to them to simplify the system and make it more user friendly.

“If there is a medication that isn’t covered, then tell me which one is. Just tell me,” says Dr. Rohr-Kirchgraber. “Here is one that is most closest to it. They should have a formula that’s an automatic thing.”

For more on the doctor-patient rights project click on the link below.



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