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The sheer absurdity of the New world of medicine

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nvrthesame98
Veteran Member
Joined : Jun 2008
Posts : 6706
Posted Today 2:40 AM (GMT -8)
I have worked n medical for 30+ and been a CPer for close to 20 yrs and the past week has literally floored me.

I have had the same PM for 6 yrs here and the one before that in my home state for 13. Background,I'm Medicare with Humana as a Medicare advantage plan and last year the primary they had assigned me lost his license for sexual misconduct(had seen him once) I was automatically assigned to a place called Island doctor's and they see no one but Medicare advantage patients and let me say here that the 8 times I have been there their names misleading because there's no doctor's in there only Nurse practitioners and physician assistants.

I went for initial visit to establish a relationship,several visits for flare ups of COPD and a few other piddly things because they have to make referrals to my PM Dr and their policies are for 3 month increments where my ther primarys were once a year.

At initial appointment they started giving me all these papers for labs,scans tests and prescreening stuff and I told them I would NOT do all that. I am 60 yrs old and I would opt not to treat vigorously the results of those tests. Having them is not necessary then but since the taxpayers pay my premiums and copays its wasting money,their money!!

Everytime I would have to go in they would start again with having all these done and again I said NO.

Then they started calling me two to three times a week and every time I said NO. First they prescribe nothing but a blood pressure pill I have been on years and zantac and a inhaler which again I have been on long before seeing these clowns.

Let me say here that they have huge and numerous signs all over the office lobby and every wall and hallway that states they DO NOT treat pain with narcotics unless your a cancer patient. Up until this month I have had no problems getting the referrals needed to my PM.

I saw the PM Dr last week and the record's manager whom I have a awesome relationship with came to the room before my PM Dr and said we have a problem and that after this month island doctors(NOT drs) would not reissue my referral and had told them I was a noncompliant patient and that was not going to go over well on DEA regulations on top of Humana not paying for the PM visits.

I was irate!! Those idiots who are not even doctors have no right to say I'm noncompliant simply because I refuse to do thousands of dollar's in tests that are not going to satisfy or benefit anyone but them? If I have a terminal illness I don't want to know so why do they have to know? So they can tell me and ruinwhat time I have left worrying about it? I already said NO treatment!!

Get to the pharmacy and they had been called as well and told the same thing and told they would not refill my primary meds. Really? Is this extortion and bribery? The pharmacy then says they could not fill the PM meds after this month because they don't fill PM meds only for patients. This is crazy.

If I have to take this to a lawyer I will but they had better have a MD somewhere behind this mess and he had better have a record of seeing me.

I Will not be coerced into having something done medically that I don't feels necessary and needed.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted Today 4:32 AM (GMT -8)
Vickie, why don't you look into AARP's medigap plans. They are run by United Healthcare and are quite good. You can even choose your doctors, I believe, and I think you can choose the hospital you go to also. Check the AARP site for more info. I don't think you need to be an AARP member either to use these policies. It would be worth the phone call.

I use AARP's Medicare Part F that is run by United Healthcare and it's excellent. It also was the least expensive for the Part F policies. It's quite expensive but everything that Medicare doesn't cover is paid by them and I have had excellent service from United Healthcare so I'm sure their Medigap policies are great too. (The reason I have the most expensive plan is I end up in the hospital frequently because of Crohns and also a huge, inoperable hernia that causes partial bowel obstructions. My policy covers all the hospital expenses including MRI's and CT scan...everything! It's worth the money for me.)

Humana doesn't have the best reputation from what I understand. I know I wouldn't want someone assigning me a doctor! I choose my doctors carefully. My doctor doesn't take Humana and that speaks volumes to me. They wanted to pay him a lot less than other policies so he dropped them. This tells me that the best doctors are not in their plans.

Sherrine
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1 day at a time
Regular Member
Joined : Nov 2012
Posts : 319
Posted Today 4:59 AM (GMT -8)
I'm convinced the ridiculous tests that docs order is a result of lawsuits. They see a hang nail & order a CT scan to rule out some obscure disease. Been there so many times I swear I'm gonna get more cancer from the radiation from unnecessary CT scans.
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jujub
Elite Member
Joined : Mar 2003
Posts : 10424
Posted Today 5:06 AM (GMT -8)
Vickie, your culprit may not be your healthcare provider, but Medicare. They do have all sorts of regulations about what tests need to be done when, and sometimes we don't need them but still have to get them.

The problem is that when you start making rules and guidelines for a group of millions of people, they seldom make sense for everyone. The original intent of the requirements is to protect seniors from the sort of doctor who pats them on the head and gives them another pill every time they have a complaint. This kind of care used to result in overmedicated, sometimes barely able to function oldsters. So we have rules intended to help us that sometimes seem ridiculous.

When Big Brother says you have to have test A before you can have treatment B, it's often easier just to take the test if it isn't going to harm you. But also be aware that the Advantage programs are basically HMO's, and this sort of organization highly rewards total compliance. Trying to stray from the norm, as you're learning, sometimes has unpleasant consequences.

Good luck to you, and remember there's plenty of blame to go around. You might want to take this global concern up with your representatives in DC.
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Lynnwood
Forum Moderator
Joined : May 2005
Posts : 8119
Posted Today 5:09 AM (GMT -8)
You have been treated horribly!

However, I must say it depends on the specific plan. I also have Medicare with Humana as a Medicare Advantage Plan. However, I've always insisted on choosing my own doctors, so I purchased the PFFS plan. (And in 8 years I've never run into a Dr that didn't take it.)

There are 4 types of Medicare Advantage Plans
Health Maintenance Organization (HMO) Plans
Preferred Provider Organization (PPO) Plans
Private Fee-for-Service (PFFS) Plans
Special Needs Plans (SNPs)

It sounds like you may have an HMO, where you can only get coverage with certain assigned Doctors.

But the bigger problem is with being unable to choose the level of treatment you want. If a person doesn't want treatment beyond a certain point, it's insane that insurance companies, Drs, pharmacies, etc can use the "non-complainant" label and refuse treatment.

I've had a similar issue, but not nearly as severe, with my dentist of 30 years -- they want to do X-rays every year instead of every 2 years, and when I refuse them (don't want the radiation or to spend the money) they get all huffy. Haven't yet refused treatment, but I won't be too surprised if it gets to that.

I'm really interested to see how your situation plays out, Vickie, please keep us updated.

Post Edited (Lynnwood) : 6/6/2016 9:51:00 AM (GMT-6)

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Alcie
Veteran Member
Joined : Oct 2009
Posts : 5183
Posted Today 6:11 AM (GMT -8)
I am also on Medicare and glad I chose an "F" plan. There are many, and by law they are all the same, except for price. See list at medicare.gov.

On an F plan you can see any doctor who takes Medicare, no referrals, and have no copays. There is also no "out-of-pocket."

The problem is they don't have to take you if you are switching plans. The only time they can't refuse you, and pre-existing conditions don't count, is when you are first starting Medicare.

I always see real doctors, no assistants, nurses, etc.

Definitely see a lawyer ASAP, make as many calls and emails as you can, and get treated right! You've already put up with this too long.
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1 day at a time
Regular Member
Joined : Nov 2012
Posts : 319
Posted Today 8:14 AM (GMT -8)
Will you be ok if the pharmacy won't fill your Rx? You mentioned you have respiratory issues. Are they refusing to fill those? If so that's just plain dangerous.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted Today 10:33 AM (GMT -8)
This looks like you could change your Medigap policy but I sure would call Medicare to find out for sure. This is a Medicare site but in one breath they say you can't and the next breath tell you how to change it! Also, I could be having a very foggy day. LOL

/www.medicare.gov/supplement-other-insurance/when-can-i-buy-medigap/switching-plans/switch-medigap-.html

Sherrine
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nvrthesame98
Veteran Member
Joined : Jun 2008
Posts : 6706
Posted Today 1:00 PM (GMT -8)
I in fact have a HMO,I didn't pick this conglomerate of Drs they did when the previous one lost his license and I didn't like the fact they have numerous offices all over Florida and to me that says big profit and very little actual patient care. I imagine one or two doctors own the places and never see patients but hire NPs and PAs to staff them. I have a call into my humana rep.

Sherrine my Neuro office actually suggested looking into warp and United dual complete replacement plan or United health aarp.
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Lynnwood
Forum Moderator
Joined : May 2005
Posts : 8119
Posted Today 1:39 PM (GMT -8)
In general you can't change until the "enrollment period" in the fall, I think it's Oct, Nov, Dec.

However, I wonder if Humana would help you change from HMO to PPO or PFFS if you stay with Humana. Might be worth calling your Humana representative and asking.

Post Edited (Lynnwood) : 6/8/2016 5:04:23 AM (GMT-6)

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Joan M
Veteran Member
Joined : Jan 2006
Posts : 2096
Posted Today 2:41 PM (GMT -8)
I am so sorry you are having so many problems. Frankly, I think the docs are a bunch of creeps. Also these so-called nurses are for the birds. The insurance people also play dumb and are not advocating for the patients.

This has nothing to do with Obamacare either. All I can say is that you are not alone. They also would not renew my meds because they want another co-pay, insurance pay-out etc.

I am allergic to drugs so don't use controlled substances.

Doctors are flunkies for the government and all they care about is money. That is my assessment of the situation and I am no dumbie and that is FOR SURE.
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Sometimes i am me (HT)...
Elite Member
Joined : Mar 2009
Posts : 22617
Posted Today 9:21 PM (GMT -8)
healing thoughts to ya mate.
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nvrthesame98
Veteran Member
Joined : Jun 2008
Posts : 6706
Posted Today 10:45 PM (GMT -8)
This came up once before about changing outside the enrollment period and if I recall there's a way for me to do so because I'm SNP or rather Medicare with Medicaid which is limited to only paying my premiums and copays. ExtraCare in the state of Florida and some states called QMB. I will check on that later today.

My reason for saying that to have all those tests done is wasting taxpayer's money,its them that are funding all those outrageous copays for some of those expensive tests. Yet twice my Neuro has attempted to get primary to order a new knee mri since the last one 8 years ago showed broken hardware and they have denied both times. So they want to order a slew of stuff I don't need but won't order something I should have already had done.

My first visit to that primary Dr or PA Humana was billed $983? Lol for a office visit? Yea they checked 02sat, they did a series of breathing exercises and a history and physical but nothing I could see was anywhere close to a grand in cost.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted 6/7/2016 4:30 AM (GMT -8)
Yes, that's a rip off, Vickie! Did you report this to Medicare? I sure would! I can have a complete physical and bloodwork for a lot less at my board certified Internist's office who is also a Diplomate!

I have never been denied anything my doctors have ordered.

Do check out AARP. They do get great plans and have a variety to choose from I believe. And, they all are run by United Healthcare. AARP negotiates lower prices for their plans I believe. They were the least expensive for my Part F that I got and I checked many companies out. Hopefully you will find one that is perfect for you! You need to be treated properly and you shouldn't have to jump through hoops to get the treatments and medications you need.

Sherrine
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straydog
Forum Moderator
Joined : Feb 2003
Posts : 19434
Posted 6/7/2016 8:14 AM (GMT -8)
Vickie, I have had calls from my primary drs office wanting me to have certain tests too which I declined. I simply said if I feel at some point I need these I will let you know. No problem. None of my care has been in jeopardy as a result of my refusal nor has Medicare forced me into having these tests, it does not work that way with Medicare.

I have regular Medicare with a supplemental plan thru AARP (United Healthcare) that is expensive as hell. We pay over $400 a month for the plan that pays the 20% Medicare doesn't. I plan to shop around for a new plan for the next enrollment. Because of not being 65 I am limited to a certain supplemental plan. I stayed with regular Medicare because none of my drs would accept any of the other plans out there. The costs varies from state to state too. We are paying over $500 a month between Medicare & the supplemental. I do not have drug coverage was too expensive. Between the premium costs monthly & the cost of medications, its cheaper for me to pay cash & use GoodRx coupons.

I hope you can either find a different dr on your plan or get some help with this mess. I would call Medicare about Humana.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted 6/7/2016 10:04 AM (GMT -8)
Okay. I'm 69 and have regular Medicare and my Part F supplement that covers all deductibles and co-pays runs me around $184 a month through AARP United Healthcare. The only thing I have to pay are the premiums for Medicare and the supplement. I've been hospitalized and everything is paid for. So it was good for me.

I didn't realize that if you were on Medicare but under 65 you had to pay more. Before I turned 65 I bought an identical supplement policy through Physician's Mutual and it was around $350 a month but I was hospitalized seven times while carrying that policy so it more than paid for itself. But needless to say I was glad when I was able to get Medicare Part F.

I also have Medicare Part D for my prescriptions and my plan costs $23 a month but I think you have to be 65 for that too. (Im not sure about that age. It seems I've had my Part D plan for many years). I'm just informing you as to what you can get when you are a few years older. I'm a Floridian also.

Sherrine
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straydog
Forum Moderator
Joined : Feb 2003
Posts : 19434
Posted 6/7/2016 11:42 AM (GMT -8)
Yes, the plans do vary based on age. My husband is 71 & we are almost paying double with me being younger & I am limited to certain plans only because of the age thing. I also assumed that a supplemental could be bought in any state & found out that is not true. I strongly disagree with that one, it forces people to go with an HMO. I refused an HMO even when we had private insurance, The coverage was very limited & we had crappy drs to pick from. We stayed with a PPO simply because the drs selection was so much better & were not as limited as we would have been with an HMO. Believe it or not insurance is our largest expense, home owners, health, auto, boat, & motorcycles, we are truly insurance poor, it just makes me sick the money we spend a month on it.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted 6/7/2016 11:59 AM (GMT -8)
Susie, me too. I have a reduced rate social security because I had to take it early when my husband died suddenly. I was only 50 but when COBRA ran out I couldn't find an insurance company who would insure me! I have too many chronic illnesses. My doctor told me to apply for disability. I didn't consider my self disabled but my doctor said I was. LOL. But by taking disability being a widow, I was drawing on my husband's social security so I only get 71% of what I would have gotten if I could have waited. I couldn't take that chance with my health problems so I took it out.

Now, my health insurance payments take out 1/3 of what I get! But I'm so thankful I have the insurance because one bad health problem could make me have to sell my home if I didn't have the insurance. We won't even talk about homeowners insurance with hurricane protection. smhair

Sherrine
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rocckyd
Veteran Member
Joined : May 2012
Posts : 1115
Posted 6/7/2016 12:50 PM (GMT -8)
I've been paying a fortune for insurance since I was awarded disability years ago. I talked with the case worker at Duke and multiple supplemental insurance plans, in addition to Medicare, and nothing could be found that would cover the meds and the manner in which they were to be used except for the current employer plan. I've been paying $650(cobra) a month for supplemental insurance, but I wouldn't be able to afford the meds otherwise.

We calculated that insurance was covering $99,000 a MONTH of meds. Plus, many many of the meds were used off label. By the time the battle of copays were figured out monthly, I would be paying $1100 a month, and that's without additional clinic costs.

This Oct I'm going to try again and see what we can come up with. The social worker/case worker for the main dept that I'm treated in is working with my Drs. It's the Duke crew that runs up the $$$$. Treatments that could be done locally are the more traditional route and would be covered.

I totally agreed-it's absurd!!!
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted 6/7/2016 1:31 PM (GMT -8)
Roccyd, won't the pharmaceutical companies help you out with such an enormous expense? With all you take, that should be considered. I see I. Commercials where the makers of drugs say if you need help with the expense to contact them. But somehow I'm sure you've check d to hat out already.

I'm so sorry you have to deal with this! Pharmaceutical companies need to make their medications more affordable. What good are they is they are out of reach for most people? Your expense isn't even realistic!

Sherrine
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Mary in IA
Regular Member
Joined : May 2016
Posts : 25
Posted 6/7/2016 2:34 PM (GMT -8)
Hi there everyone! I am not only new to this group, Healing Well, but also to any kind of forum or chat........so I am just jumping in here. I saw the word absurd and that pretty much sums up my situation as well. I have been through six surgeries in the past five years and when the doctors have now recommended this last one the insurance company has deemed it 'investigative' and won't pay for it. I am in pain constantly and am loosing my strength. I'm at the end of my rope and loosing hope...
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straydog
Forum Moderator
Joined : Feb 2003
Posts : 19434
Posted 6/7/2016 6:38 PM (GMT -8)
Sherrine, l went on disability not because of CP, instead for crohns disease. At the time my husband was still employed and I continued with private insurance. One he retired Medicare became my primary & the private was secondary. I had a very good drug plan too with the private insurance. However, the private did not work like a Medicare secondary so I spent a lot of money out of pocket. At the time considering the drugs I was on such as Humira I needed that coverage. At retirement the private jumped to a little over $600 a month. Then we got the wonderful letter saying effective 1-15 the premiums would be $1,220.00 per month & thats when I got a regular secondary policy. Its like we just can't win for losing. In Tx at 65 your secondary picks up your yearly deductibles since I am not there yet I get penalized, lol, or at least that is how I feel.
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rocckyd
Veteran Member
Joined : May 2012
Posts : 1115
Posted 6/7/2016 6:40 PM (GMT -8)
There is assistance available for lots of meds, and quite often I was approved. The problems started when meds were used off label, so I didn't always meet the requirements, even with a Drs appeal. Ex:I could get assistance for Cytoxan OR Rituxan, but not the way I'm using them now. I get BOTH of them at the same time-very very long infusion-like 12+hrs long. I did not meet enough requirements for IVIG assistance.

I'm not on a traditional treatment plan, for really any disease. It's a cornucopia of fun:)

I have a love/hate relationship with insurance companies. I know that I've cost them an incredibly large sum of money. But, I also know that there are waaaaaay to many hoops to jump thru. I have an awesome team of med folks to work through the process, but they can only do so much.

The whole system is absurd, but I'm at a loss as to how to fix it. I know for a fact that regimes I've followed here, would not be available in other countries.

Vickie, I think it's asinine that you are being treated this way. Just another fun horse on the merry-go-round of healthcare.
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nvrthesame98
Veteran Member
Joined : Jun 2008
Posts : 6706
Posted 6/8/2016 2:31 AM (GMT -8)
Wow I can't believe how they treat us on Medicare,something we paid for out of paychecks for many many years and if I live 15 more years I doubt I would use up what I paid in. Let me add I disabled out in 2002 after being on WC for almost 2 years and won on loss of knee and pain with severe hearing loss at the ALJ hearing. Since I had battled denials until the hearing level my Medicare was effective almost immediately. I have had 4 arthroscopic surgeries,one partial knee replacement and a total since being on Medicare. I have had 1 overnight hospital stay,and the rest are day surgeries,I was on methadone for many of those years so med costs with the other 3 meds I'm on were at best $40 a month to Humana and $10 for me,the morphine I'm currently on isn't much more expensive.

I have had maybe 4 occasions in 10 years that I have been to the ER,I see orthopedic once a year,PM who is also a Neurosurgeon once a month and thats not my doing but DEA regulations and primary only when I am sick. Thats it. I don't have any other specialists,don't have huge medical costs because I am relatively healthy other than the neurological disease process from a pars defect from a MVA in 2006,the broken hardware from partial knee replacement which I opt not to fix,and that's it. Treated by primary for the COPD so far.

Very very little cost to Humana or medicare and you would think that would make them happy... I just don't look for trouble where there is none. Its just the way I am. My mom died at 76 on no medication and never had a surgery or been in a hospital other than 6 kids.

I didn't think about calling Medicare but I sure will do that today as well. No wonder healthcare and insurance costs are ridiculous when you have these Drs and hmo's ordering tests and trying to find something wrong with people. I went to these PA's on 6 meds,3 written by the PM Dr and 3 by primary and I left with 9 from the primary alone. I don't take any of other but the original 3 but have to fill them all. I currently have 57 large tubes of Voltaren gel which Humana paid $59.76 a tube for an 14 bottles of the pills at a cost of $$112 for which I fill and don't take as well. I am on mobic that my PM writes,we discussed the volteran and he only wanted me to take during the winter months when its cold. Lol I live in Florida!!

See the waste that is being forced upon us? Who pays for all that? The taxpayers and those who have to pay out of pocket for meds and insurance that's who. I refuse to do more than I already have to by agreeing to a series of expensive tests and procedures so they can get answers to questions nobody's asking or wants answers to.
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Sherrine
Forum Moderator
Joined : Apr 2005
Posts : 18435
Posted 6/8/2016 4:12 AM (GMT -8)
Vickie, I think it's more the HMO and doctors you are with. I've been on Medicare for over 18 years due to disabilities and have had only good experiences. I've never been denied, been hospitalized with no hassles afterwards, plus my doctors don't force anything on me. But I have excellent doctors and that makes a big difference. Plus, these HMO's I think do things like you are experiencing to earn more money for themselves. Medicare pays them for all of that stuff so it's a bigger profit for them. It's not Medicare's fault.

I do check my Medicare statements to make sure there are no overcharges, double charges, or charges for things I never had done, and all have been fine. If I ever found any, I'd be reporting it to Medicare.

Sherrine
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