Dealing with a Charge of $4,500.00 for a procedure you need....

Okay, hold onto your "hats" because if this one does not upset you, floor you, and make you want to run like hell away from insurance companies and medical care, then you are much stronger than I am...

I have been awaiting a call from the "infusion" clinic all week long. My Rheumatologist and I decided it was time to stop the Humira, which seems to not be working for me. He had two choices for me, both of which are infusions. One of them, I would have to have an infusion once a month, which meant a trip to Dallas every month. The other, Rituxan, that I have two infusions to begin it, two weeks apart, THEN I can go anywhere from 4 TO usually 6 MONTHS before I need another two week treatment!!! Well, you can imagine my decision! Of course going a couple of times a year versus a monthly trip to Dallas was music to my ears, and pocket book. He also agreed that the Rituxan seemed to be a better fit under the circumstances of the fast degeneration we are seeing in my joints . So last week, I believe a week ago this past Wednesday, he began the paperwork. In fact, I went for a new bone scan and blood work while I was there at the University where he practices, and by the time I finished those, the infusion department was calling to tell me they were already working on getting me approved through insurance and so forth. So, I thought WOW they are on the ball with things.  So, I felt like this would be done very soon. I really never gave much thought to my part of the "co-pay". I knew it would be considered more on an "outpatient" either hospital or stand alone treatment center, so my part should not be but about $100.00, possibly $200.00 depending on how they coded the center itself. Even though we have been out a butt load of money lately, I knew we could swing that. Anyway, I did not hear anything last week, but I knew that Humana usually drags their feet on prior authorization stuff so thus I figured it would be this past Monday or Tuesday before I heard anything. Well, over the weekend on Saturday, I went to my Mom's for a short while. When I returned my husband said that a woman from "Humana" (Right Source Pharmacy is how the call came up on caller ID) called and said that I was "approved" for the Rituxan! So we were just elated! We though wow, quick, and for the insurance to call on a weekend, that was a small miracle. So, Monday I waited all day for a call, and nothing. I called the infusion center late in the afternoon on Monday, and was told that they "may" have that paperwork, but it would not have had time to be processed and my "treatment" plan worked out etc. So, I thought okay I will hear the next day. Well, Tuesday came, nothing, Wednesday came, and I even got a letter from Humana saying I was "approved" for the medication. I was starting to get antsy by then, so Thursday afternoon late, I called the infusion center again. I was then told (by someone else) that YES, my insurance approval was in, BUT they were still working on the treatment plans and I should hear shortly, Well, we were "miffed" about it, mainly because they had acted SO QUICKLY right from the beginning, calling me before I could even leave the facility the week before and now it was like, well we will get to you when we can kind of an attitude. AS all of you know, and have read, my last couple of weeks, and more like couple of months have been just about more than a human should have to ever deal with. Everything that can have happened, should not have happened, etc.. DID or DID NOT happen for me. Between dentists (several appointments including two teeth pulled), glasses for us both, the entire realm of our PCP NO LONGER wanting to have my husband as a patient, having my hips and elbows injected, and finding out I have much more degeneration than just a couple of years ago, and the list goes on...I was just impatient as heck. So, yesterday, amidst waiting on a call about one of my own medications that I will be out of over the weekend, and my doctors office has usually called it in well before now, and the infusion clinic, and some other stuff (it is even down to the fact that we ordered Mom's glasses from the same place we did ours, and when they got to final inspection something was wrong, and they had to make them over again..which we are thrilled they caught the problem, but again it delayed her getting them)... that my nerves have had about all I can take. Behind the "scenes" of doctors, being sick, the pain.... etc... I helped my Mom order a new "settee", a new glider recliner, got her on a new phone service that is WAY cheaper than AT and T is charging her for LOCAL SERVICE ONLY, and just a whole barrage of things for her, and our own daily stuff. So, my plate has been full, running over, and just needing to be all thrown out and re-ordered (LOL).. even though some of it is "good stress", it is still stress...
So, late yesterday afternoon (after the phone RINGING ALL DAY LONG FROM JIM'S CLIENT) I had just about given up on a call. I was NOT hearing from the infusion center, I was NOT hearing if my medication got mailed out, and we both were just puzzled about all of it. Okay, the phone is FINALLY from the infusion center. So, we got excited! I began with an introduction from "Lynn", and as she started off, I could tell in her voice, she was "hesitant" about discussing benefits etc.. The first part of that conversation started with well, we have spoken with your insurance company, and your part to pay is $4,500.00!!!!!!! YES!! You are not seeing things! She did day FOUR THOUSAND FIVE HUNDRED DOLLARS!! And quickly she began saying BUT we have a CHARITY PROGRAM YOU MAY QUALIFY FOR ON THE BALANCE! Well, all I heard was that astronomical figure and here I was thinking $200.00 at THE MOST!! So, I started asking questions, like YOU ARE IN NETWORK with HUMANA RIGHT???? She told me yes several times. Now by then I was in tears, and I still have some of the laryngitis, thus I told her I would let my husband finish the conversation with her. By this time I was sobbing uncontrollably with my puppies on the sofa. Here was one FINAL HOPE with MEDICATION to possibly SLOW DOWN the horrid symptoms of RA, Lupus and possibly now they feel I "may" have MS, and my insurance has totally lost their minds., and there was NO WAY, NO HOW, I could EVER AFFORD that! I am already still reeling over the cost of a damned root canal and crown! Jim was still talking with her about this charity application, and continuing to question her about my insurance. It just was NOT RIGHT! All I should owe if they are IN NETWORK was a 100. or 200. co-pay! Hell I have had inpatients stays, major surgeries, was in the hospital 6 WEEK! and none of that cost anywhere near that figure. Inc fact for the most part I paid very little with the exception of an inpatient room charge on a couple of occasions. So nothing made sense. Jim was being send via email this "charity" application, and in the process he asked her if they would PLEASE HAVE ONE OF THEIR SUPERVISORS CALL HUMANA and RE-VERIFY benefits!??? She said of course, and Jim also got on the phone and call Humana also. He is so lucky, he got through quickly and even got transferred up the "food chain" to several people that were "higher up" and had more knowledge and more "pull". In fact they even put one of their "reps" online to go over my benefits again and see what the hell was wrong. Well, I KNEW, then they were trying to put the medication under PART D DRUG PLAN, rather than as an OUTPATIENT VISIT TO THE INFUSION CENTER! I knew that had to be "co-pay" in regard to "dough nut hole" crap with my Part D, drug plan by the conversation he was having with this guy. Well, in the meantime, after a very long talk with him, and I am saying benefits were verified WRONG, they are trying to say it is like me going to the "pharmacy" and picking up some "prescription" medication that costs thousands of dollars, then of course I would owe a co-pay etc.... and so forth, meet "deductibles" and so on. The phone rings again as we are talking about all of it, and I am saying NO WAY, NO HOW, and I WILL NOT TAKE CHARITY! I will just go back on less expensive injection at home. It is Lynn, the first lady that called me. I walk outside and Jim is saying, say that again?? He said, well we can "deal with" that. And he is smiling at me... I am so totally distraught by now, I did not even care. Well, come to find out, I WAS RIGHT! HUMANA verified benefits UNDER PART D, NOT PART B and that was totally WRONG! I do and will only OWE 100.00 !!!!!! They totally did not give any information correctly to the infusion center, and I guess the infusion center (even though they said that kind of out of pocket they do not see often) never questioned why so high??? Humana was basing everything on like I said I went in and got the Medication itself from the pharmacy.... and NOT as an outpatient "treatment".... By the way, Humana got their butts reamed by the Infusion center supervisor, and I have not called them yet, but believe me they are going to get an ear full...this has happened more than once this year with myself and my Mom... SO TO MAKE A LONG STORY a little shorter. the fact is I ONLY OWE 100.00 "CO-PAY" & I am set up to have my 1st infusion TUESDAY! So, I am already deciding what to take with me, since it is about a 6 or more hour process... :):) My main question and moral to this is HOW does someone elderly without anyone to help them DEAL WITH THIS??? If no one was around to help my Mom, like I do fighting them tooth and nail all the time, she would be paying lots of money out of pocket that she does not owe. She tried to do it with the surgery center last year. They filed with a wrong code, Humana paid it wrong, and they tried to charge Mom over 600.00 that she DID NOT OWE! It took me A YEAR to get them both straightened out... with an apology finally from the head guy at the surgery center... So, this frightens me on so many levels... I feel for those who "do not know" better.. and also HOW AND THE HELL IS ANYONE SUPPOSED TO AFFORD THOSE KINDS OF ASTRONOMICAL TYPE OF CHARGES... IT IS INSANITY!!!!! It is a wonder I did not have a heart attack... I am so very, very thankful that God was walking with me through it all... That is MY STORY and I pray I do not have to EVER GO THROUGH THAT AGAIN!


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Next post to go with the one above...

I can say that I am GLAD that I DO KNOW it well enough to KNOW THEY WERE WRONG! I guess if I have any type of thing the Lord has given me, is the "sense" enough to know when someone is being ripped off, used, abused, and taken advantage of. I have helped my Mom, and several others with things that without my help, they may have paid a great deal out of pocket that they DID NOT OWE! So I am very thankful that I have been given that "talent" if you want to call it that. It burns me up to no end to watch someone take advantage of someone else. Or someone do something or not do something right just because they are lazy, inconsiderate, OR like a good for instance just today with me, someone feels the "need" to exert their "power" over another to show they can.. I have ONE medication that comes from a pharmacy in Dallas. Always has, always will. That is how that doctor wants it, and he had them ship it "priority" mail to me. But, I still have to call about 5 days early, I usually do it about 4, unless a holiday is in there, or sometimes I know he is only in the office on Friday half a day. So, that is what happened this time. I called my script in Tuesday afternoon. I am due to RUN OUT by SUNDAY. So, because he is only in the office a half day on Fridays and he also does surgeries now sometimes on Wednesdays. I wanted to make sure I did it just early enough that I would not run out and be left hanging. Well, the "usual" woman that takes care of all scripts must be out for some reason. Because she usually gets it out the same day, or always the next day, I get a call from that pharmacy, they send me the meds, which unless something happens, and it has before, I get them the next day. Well I called and just left a brief message asking the other lady if she did get my request (you have to call their refill hotline to ask for refills) and make sure that the hotline did her the message. Well, this other "hair brained" witch must be doing the scripts for some reason. Maybe the usual woman is out this week etc. So, this other "butt" calls me back yesterday about noon and says "yes, I am calling it in today.. you were a day or two early... well no I was not, it has to be mailed... but I kept my mouth shut... well I know how she is... she loves to "play" MS. Authority... she WAITED (and I knew she would, I just felt it in my bones ) until LATE LAST EVENING. to call it in. so the pharmacy did NOT get it in time to MAIL IT YESTERDAY. SO, NOW, I call them and they are "getting it ready" and it will go out today!!!! Well that is cutting it TOO CLOSE!!! SHE should have DONE HER JOB CORRECTLY and called that script in early yesterday. She had it for two days, and could have already done it. It was only about 4 or 5 days before it was to run out... but she is that kind of person, if she thinks she can MAKE HERSELF LOOK LIKE SHE IS SOME KIND OF AUTHORITY, then she does it and guess who suffers??? The Patients!! There was NO reason to HOLD it up, other than being a jack ass. The normal woman would have called it in on Wednesday, I would have them no later than today... no harm, no foul... now if something happens, I may not have it tomorrow... hopefully the mail will go as it should and I will receive the package tomorrow... but SHE wanted to make herself LOOK like she was IN CHARGE!!! Those are the kinds of people that just burn me up!!! They DO NOT give a damned about anyone but themselves. She could care less if she harms or hurts someone else as long as she "got" her way... and that was just to be ridiculous!!! I see it time after time... and not just myself... I watch people bless their hearts get run over like a tractor trailer by garbage like that... and they just "take it" because they do not know NOT TO! People do that with their doctors. We were "taught" that doctors are "Gods" ..What they said was the BIble and we MUST abide by it... BULL, if you go to a doctor and you are not satisfied with their practices, or you feel like they are not taking care of you as they should, then GET ANOTHER ONE!!! Do NOT think they are PERFECT! We now tend to know better, but many people still and my Mom is one of them, think what that doctor says is gospel,., it happened with her heart... the "1st" test they ran on her heart back in January showed "extreme mitral prolapse" BUT MOM was NOT having the SYMPTOMS that really showed it being to the point of being SERIOUS! The doctor was already talking about taking her to Dallas, doing a procedure, then doing open heart surgery etc... and it MAY COME TO THAT LATER BUT... I sat down and said, can we not do something else first, before we jump off into major heart surgery??? So, due to her NOT taking her meds that morning of the first test, and having a great deal more fluid on her than usual, the doctor thought that could be contributing to it "appearing" worse than it was. Well, the doctor put her on a larger diuretic pill, and asked her to drink some "less" fluids, especially the 3 days before the next test... and when they did another test... it was NOT severe, and in fact it was not even bad enough to go for another special test in Dallas! So, there are times if you do not say something, or someone does not say or do something, you may go through something totally not necessary.... and I guess somewhere in my "genes" is something that makes me want to "protect" those that are taken advantage of, in any way, abuse, of any kind... and of those out there that are like a pack of wolves, just waiting for some poor soul to come along they can "pounce" on..


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Third to go with 1st two....

The "benefits" and entitlements we "should" get that honestly, we the people paid in for all the years we worked seem to have gone for everything but OUR entitlements! That "robbing" Peter to pay "Paul" ... thus now when we are having people work many more years, and then retire at later times, they also collect more of their entitlements like Medicare and Social Security for more years. I guess no one thought about that when people lived to be only in their 60's or so. Now we have MANY elderly that are still driving their cars and taking care of themselves into their 80's plus! Thus we are going to need more money to pay our their benefits, and then we have children that soon will be in the work force headed for either "put your own money aside for retirement" or get older and have nothing. It has not been that long ago, that my Dad retired. After 45 years at the same place, he got a retirement and between that and his Social Security, they did okay. But, that was also when interest rates were high and they made a good deal of money on investments. Now that same money is making NOTHING! I see what tiny amounts Mom's little bit of nest egg makes and there no way one she could "live off what little interest" that money makes now. IT is insanity. It seems I use that word a lot lately... but it is this entire nation, our entire world has just dropped down to dog eat dog, and GREED is the name of the game. I am truly "ashamed" of humans and some of the horrible stunts they pull. So, I get the entire thing about trying to get "benefits" you are due to even work for you. And now I read that our UPS corporation is cutting their employees families completely out of the health insurance! I don't even think they are going to "offer" the benefits if you pay out of pocket for them! And UPS is NO SMALL corporation! I also cannot fathom that "cities", huge cities in the US can go "bankrupt"???? How does a city spend so much money when taxes are paid by citizens and all kinds of "revenue" is made, go "belly up?" What does that tell us about our nation? heck our World? WE have "nations" in the same shape! Their "money" is not worth the paper it is written on... same way with homes here. How can you take a home that was just valued at 300,000. a couple of years ago, and it only be worth 100,000.00 today!???? Where the hell did all of that come from??? Property "used" to be the "best" investment you could make. We were told it "always holds its value"... well I am here to tell you NOT ANYMORE! I don't think there is one item in this world that truly will hold its "value"... everything is volatile... nothing is "steady"... we live in a world much like a volcano... we never know when it will explode or worse implode all around itself...


Ah, and I am quite sure... and am NOT quite... through....