Topic: Out of network specialists

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Jul 2, 2010 01:58PM

Posted on: Jul 2, 2010 01:58PM

icandothis wrote:

The information in this thread is incredibly helpful when you are coping with bills for out-of-network docs, especially pathologists, anethesiologists, out of state, etc.

http://community.breastcancer.org/forum/8/topic/754866

Sue - Proud to be Krista's Mom Dx 12/28/2007, IDC, Left, 1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR+, HER2-
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Jul 4, 2010 05:05AM palaminoridesagain wrote:

Hello Sue and thanks for starting this thread.  I have worked as a nurse for 41 years and have paid for health insurance the entire time.  Most of those years, I didn't need to use it but my contributions did help others who were older and in need of health care.

Something awful has happened in this country and with the healthcare system.  Instead of being there when we need them, they now try to do everything they can to get out of paying health care costs when one gets ill.

I am still working full time for a rehab facility and I see this everyday.  As soon as someone wants rehab with private insurance red flags go up immediately.  This applies to all insurance companies, not just the bad ones like Humana, Unicare, or United Health Care.  For example if there is a patient with cancer who has private insurance, you will likely not be accepted into many facilities for rehab because the cost it too high for the facility.  Meaning it would cost the rehab to take care of that patient.

Being stage 4 it sickens me that we turn  down most patients that have cancer.  Very sad indeed.  Blue Cross/Blue shield which I consider to be one of the better companies will not allow their patients to go to an acute rehab.  Instead they want them to go home with home health services or to a nursing home  - skilled nursing facility for their rehab.

The sad thing is, my job is to go from hospital to hospital to evaluate and approve patients.  If I reviewed my own paperwork, I would deny myself.

So here I am fighting cancer for 5 years and being stage 4 for 17 months on chemo the entire time without a break.  So many disappointments regarding chemo not working.  Each time I changed chemo's it was a fight with Humana.

In March 2010 I was switched once again.  I was changed to Gemzar with Tykerb and Herception and after 17 months of disappointments my tumor markers were almost back to normal and I was feeling good.  I have a rather large area of mets to my left femur and rt. malignant pleural effusion which has had to be drained 4 times.  We were ready to put a pleurovex catheter in when all of a sudden the Gemzar kicked in and the fluid collection has stopped.

My initial dose of Gemzar was pretty bad and it looked like I wouldn't be able to tolerate it.  We decreased the next dosage, put me on prednisone and gave me benadryl and aloxia as pre chemo medications.  Instead of giving it to me in a high dosage as the Gemzar is recommended, my ONC changed it so I would get lower dosages 3 weeks on and one week off.  This is when all my troubles began.

My insurance denied the third round stating the package insert specifically says only 2 weeks on and one week off for breast cancer patients.  Now mind you before I started Gemzar my ONC's office called to see if they needed precertification and they were told they did not need precert for Gemzar.  Amazing!  They didn't say anything about changing the frequency might be an issue.

Then on May 24th they denied payment on my third round.  They told my ONC I could only have 2 weeks on at a dosage that was toxic for me.  We started the appeal process and I ruffled some feathers going to my human resources department and the owners of the company.  I had to miss my third week of Gemzar on 6/17/10 because they would not pay for it. 

Went for chemo 6/24/10 as that would be the first round of 2 weeks on and one week off.  They have now denied that.  It has gotten so bad that my ONC's office has had to go to an outside arbitrator for my final and last appeal. 

There was another thread discussing some specialty physicians who are not part of the patients plan.  I wrote on that thread and coincidence?  I'm not sure but the following morning I received notification from Humana that they are now going to deny my Gemzar, Herceptin, and all pre chemo meds.  My Tykerb comes in the mail and they will only give me a 28 day supply which forces me to pay two copays per month.

This is when I found out they will not pay the radiologist who reads my x-rays, the emergency room physician who saw me before I was admitted for a severe reaction to Zometa.  They say these specialists are out of network.  But who thinks to ask if a radiologist or emergency room doctor is part of the plan.  I carefully chose my physicians and hospital based on the fact that they did accept Humana.  I also pay a higher rate because I specifically chose a PPO so things like this would not happen.

My company changed to Humana 2 years ago come September.  Since that time I have pulled all the money from my 401 K plan, all my money saved in a credit union, and all my savings.  So I went from a wonderful career being a nurse for 41 years to a person who is totally broke because of cancer.  More importantly because Humana chooses to use these deny and delay tactics.  I am about to lose everything.  My house is going into foreclosure, I will be forced to file for bankruptsy and have to move in with my husbands sister.  My salary is considered too high for assistance.  Wells Fargo who gave me my loan would not let me be part of Obama's program even though for 7 years we never missed one payment.

In one month because of their denials I now owe over $16,000.00 to my ONC, radiologists and ER doctors. A good friend said you can't get blood from a turnip but if they deny my chemo they are giving me a death sentence at the age of 60.  It makes me feel that the person who is denying these claims is helping to put 30 million dollars in some CEO's pocket. 

This whole situation has put me into such deep depression.  My husband and I are fighting all the time now.  My life is in ruins. 

Another thing that shocked me was that my chemo costs $6,000 weekly so I have to put some blame on the pharmaceutical companies and the health care industry in general.  I have worked full time on chemo for the insurance - many days it has been so hard but I did it so I could get treatment and keep my house.  Seems like that is all for naught now.  I just had my 2 round of chemo on July 1st so I guess I will now owe $$22,000 dollars. 

Today is July 4th a day to celebrate America and yet it's a sad day in this country that many people like myself are going through this.  I have always been a fighter but this makes me want to throw my hands up and say forget about it.  Stop treatment and just go in peace. 

Maybe in the end the arbitrator will win the appeal for me, but what about the stress, anxiety and tears I am shedding everyday.  I think about this from the time I go to sleep and it's the first thing I think about when I wake up. It's hard enough fighting stage 4.  I am just so overwhelmed and unhappy and all I am asking is to give me my chemo so I have a chance at fighting this disease.

Nicki   

Imagine the freedom of riding a Palamino bareback. Freedom of spirt and heart.
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Jul 4, 2010 08:37AM MaryNY wrote:

Nicki: I'm so sorry to hear what you are going through. It's unbelievable and so sad.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jul 4, 2010 11:18AM karen333 wrote:

Nicki, I feel like crying with you.  I just got started in this cancer and insurance business [sp?} and it is all so overwehlming, to be fighting on two fronts at once.  I see a therapist and take antidepressants also.  My therapist will see me for $5 a session if I lose my insurance, I cried when he told me.  I wish he ran an insurance company, but he's too humane for that.  You will be in my thoughts - Karen

Dx 8/8/2009, 2cm, Stage IIA, Grade 1, 0/1 nodes, ER+, HER2+

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