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And your doctor will have to fight with the insurance company over the phone for an hour to do a pre-auth. When my doctor wants to perform something or give a certain treatment not covered, he assures me he will make this long and stressful call. I really wonder what they are discussing and what goes on in these conversations...
What doctor has time to do that? I'm in Canada and I can never trust my doctor to have any conversation with anyone, at any time longer than five minutes at a time for anything.
The best tactic I've found if you want to get anything done for yourself or someone close to you is for you to do the legwork and make calls, contacts and literally hound people to do their job. If no one is there to push things along, no one is going to magically appear to help you ... that is a fantasy that seldom and rarely happens, even in our publicly funded system.
You or someone who is capable should advocate for you every step of the way, otherwise you will just get lost and forgotten in the system ... whether you are in the US or Canada.
I’m in Canada and I can never trust my doctor to have any conversation with anyone, at any time longer than five minutes at a time for anything
The best tactic I’ve found if you want to get anything done for yourself or someone close to you is for you to do the legwork and make calls, contacts and literally hound people to do their job.
This is my experience in the US as well. Also nobody knows anything about anything.
Doctor A puts you on a medication, doctor B doesn't know until you tell them and then he says "he put you on that!? You shouldn't be on that, I'm taking you off it."
You go to have a surgery and say "hey guys, did you know that I'm difficult to intubate? Because I could die if you don't take that into account", they didn't know.
"Hey guys, I have reason to believe that the insurance card I was issued in the mail isn't completely correct, can anyone help me with this?", 4 different people at the company that issued the card have no idea what's going on, don't even know about the policy tied to the card in question and think you must have accidentally called the wrong company (you didn't).
"Hey guys how much is this going to cost?" it is literally impossible to say.
I have a doctor that actually cares. If I had one that didn't, I would not stop until I found one that did. It's mostly getting the insurance to cover medications that they don't. The doctor usually spends the last hour of his day doing this, for me and other patients. You have to find a local doctor outside of a major city with less client base so they DO have the time. I am in the US. My deductible is very high but the medication I take is life sustaining and I can never pay for it. I have to do this every 6mo to a year: make an appointment and hope the doctor gets their way. Once they didn't and that is why I am at my current doctor. There is not much negotiating a patient can do calling the insurance themselves. They will just look and see you don't know what you are talking about. No matter how you complain about the symptoms, your financial burden, your family, or the fact of it being life-sustaining. Best to have a medical professional advocate. I have even tried with doctor letters and emails forwarded before calling. That is why I wonder what the doctor actually says that gets through.
What you are saying is generally true. The only real oversight in ensuring things are moving forward is us ourselves as patients. It's our responsibility as patients to take charge of our health.
That being said, P2P is sadly a standard aspect of American medical practice. Essentially anyone in a direct patient contact position position has done them. In the clinic or hospital, it may be your primary clinician handling it but it doesn't necessarily have to be. It can be handled by other clinical staff or a group of nonclinical doctors also.
You dont have to worry about P2P since it will get taken care of (whether the service will be covered by insurance is another story). Instead I'd focus on keeping disconnected parts of the system abreast of your medical conditions and current list of medications. Because health information is protected there really isn't a great solution for centralizing this data yet so if you go to a clinic that's on a different EMR, they're not going to have all of the necessary information available to them.
When I was a clinic assistant in a cancer-focused plastic surgery clinic, it was my job to fight with the insurance companies. I did prior authorizations for every surgery and they would do shit like approve the removal of a melanoma without requiring prior authorization, but performing the skin graft to repair the 10cm diameter hole required a prior authorization because the procedure code falls under the "Plastic Surgery" heading and they wanted to make sure you're not getting skin grafts for cosmetic reasons.
I've had doctors lead me to make certain statements so they can more readily justify a given treatment that they know I need.
It's a bit of a wink-and-a-nod situation.
It's even worse if you're part of an HMO, because the doctors are beholden to the business side, unlike independent doctors who don't have a management overhead telling them how many times a year they can prescribe a treatment, becuase they're doing it more frequently than other doctors in the system.
This demonstrates the major issue with socialized care, because it's also managed this way. I've been in both HMO and PPO systems - overall they both cost about the same despite HMOs acting like they cover more day-to-day stuff. It's just with PPO (independent doctors), I get care that's more tailored to me and my wishes, I don't get pushback from corporate, because there's no corporate involved. I may have to discuss with my doctor how to present things so my insurance won't push back, but at least the insurance company doesn't directly control my doctor's salary, bonus, etc.
All this crap started in the 80's as business management orgs started taking over healthcare organizations and consolidating them, and turning them into profit centers.