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Pride In Service -- Are You Kidding? |
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Written by Administrator
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Tuesday, 07 July 2009 07:00 |
For me, it was fortunate that I had been through rehab and knew the exercises and before I left the hospital, I was already working on my own to make certain I had two working knees. I started physical therapy immediately and my recovery with the right knee was almost equal to that of the left knee.
That is just one example of how health insurance companies dictate our lives. Another problem is when doctors’ offices and health insurance companies’ make decisions without taking patient input into account. It’s well known that Tricare (and all of its variations) set acceptable rates that are not in line with other insurance or what doctors and hospitals charge for their services. Tricare Prime is considered to be the lowest and slowest paying of all the health insurance in my geographic area. So, in June, as a matter of economics (and business decisions), my orthopedic doctors group notified all of their patients with Tricare Prime they were no longer accepting Tricare Prime as of this September. It was an administrative decision with no input from the patients, or from some of the doctors. They were simply told it was a done deal. And, apparently they have a large number of patients who have Tricare Prime and are now scrambling to find another doctor.
Therein lies the crux of the problem. There are no other “in network” orthopedic practices nearby. I live in an area that is far and away from military bases and military treatment facilities. The nearest MTF is Seymour Johnson AFB, which is about an hour’s drive, and while they have some facilities and clinics available to retirees, they can only provide on a space available basis. The next nearest MTF is Fort Bragg, which is a good 3-hour drive. So, in my case and anyone else in this area with Tricare, we have to use civilian doctors and hospitals. With Carolina Regional Orthopedics making the decision to no longer be in network with Tricare Prime, it leaves a big hole in this area for orthopedic care.
The nearest in network orthopedic doctor/group is 55 miles (as the crow flies) from my location. According to Tricare Prime, because of the distance they would authorize an out of network doctor, but we know that means extra out of pocket money on my part. Tricare Prime still has their acceptable rates and doctors’ offices want the difference up front. If I had an unlimited bank account, there would be no problem, but that just isn’t happening. My best option is to go with a reputable orthopedic group who can give me the best care and still be in network. It sounds like an incredible task, but it isn’t. The doctor who did the surgery on my left ankle ten years ago was with an orthopedic group in Durham, and they are listed as “in network”. He is no longer with them, but they offer every possible type of orthopedic care. I am currently in the process of transferring my records and setting up an initial appointment.
You would think the saga ends here. Back to “pride in service” and the lack thereof. I really can’t complain too much about my doctors. I’ve looked long and hard to find acceptable health care. Their support staff leaves much to be desired. I have severe asthma and have spent years with a pulmonologist’s help to find the best treatments to keep me breathing. At one time I was taking every possible medication and still having problems. A few years ago, my normal at this time of year would be 2-3 asthma attacks per week. Then along came Xolair. This is an injection that reduces the response that causes the asthma attacks. It took months for Tricare Prime to authorize it and I have been getting the injections every 4 weeks for over a year now. The problem isn’t the injections but getting the authorization for them. At first, Tricare Prime authorized 6 months. My last authorization was only for 3 months. And there were problems. When Tricare called my doctor’s office to verify, someone on his staff told them there was no such request for authorization. Not true. So they denied it. It took several phone calls and faxes to get the authorization so I could get the shots, two weeks later.
This time, in the first week of June, I called my doctor’s office to get the authorization process started so I would have a new one in effect before my appointment this month. Two weeks ago, I checked the authorization list and it wasn’t listed as pending. So I called my doctor’s office and left a message with the nurse. She never returned my call. The next week I had an appointment with a different doctor in the same office and cornered her. She told me she had given it to Rebecca who handles authorizations and referrals and would check on it and give me a call. She never called. Since the current authorization ended on July 3rd, I called her again on June 30th to find out the status of the request. This time I got a different nurse who was filling in for her and she would leave a message for me. On Monday, July 3rd, I received a message from the nurse. She had checked with Rebecca who informed her that my request had to come from the hospital, meaning nothing had been done.
At this point, my blood pressure was reaching the boiling point. Authorizations have to come from the prescribing doctor. I called the office and told the receptionist that I needed to speak to Rebecca or whoever was handling authorizations and referrals. She put me on hold. Elevator music. Finally a soft voice belonging to someone named Dawn came on the line. First she told me that they couldn’t take requests for prescriptions. I explained what Xolair was and how and where it was administered. Then she checked for authorizations. She found the one for my orthopedic care and voila, she found the authorization, good until July 3rd. In a very surprisingly calm voice, I asked her to look at her calendar for that day’s date. July 3rd. Oops. At that point she became very apologetic. Told me not to worry, she had a contact at Tricare Prime and she would fax the request and get me an authorization immediately. Yeah, right. I’ve dealt with Tricare Prime for years. They have to muddle over it and beat it with a stick. Then, and only then, they’ll take a look at it.
At this point I was ready to give up. It was the day before a federal holiday, which means no one would be at work and if they were, no work would be done. And forget about the day after the Fourth – I really didn’t expect to hear anything until the end of the week. I was wrong. On the afternoon of July 5th, Dawn called me. She had just received a fax of the authorization and telling me how good she was until she looked at it. Tricare Prime in all of their extreme intelligence had authorized ONE visit. This is for a treatment that keeps me out of the emergency room, has cut down on the number of asthma medications and has improved my quality of life. This is a treatment that I will probably have to have for the rest of my life. And, they authorized ONE visit.
When I pointed this out to Dawn, she got all hot and bothered. How could they do this? What were they thinking? So now she is all fired up and is submitting another authorization request so that I don’t have to go through this game in four weeks. I wish her luck.
And why do I, or any other customer of Tricare Prime, have to go through this anger-raising, horrific game of countless phone calls, voice messages, time consuming aggravation. I pay my quarterly premiums on time, every time. I’m paying for service and not getting it. Just because I live in an area that is out of network, and Tricare Standard doesn’t cover my needs and I’m not old enough for Tricare for Life, doesn’t make it right or acceptable.
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Last Updated on Thursday, 10 September 2009 10:48 |
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