Now I understand..an insurance rant FINAL UPDATE

[cabanafrau]

Your provincial insurance paid for it in January, you had to pay again now to use it, and yet your insurance now says it's not covered, but it will be in another month or two? I'm missing something, but it sounds like you were double billed?

Not to mention there's no way I'm believing they simply provided the meds to another patient without billing them.

 

[kimblebee]

Your provincial insurance paid for it in January, you had to pay again now to use it, and yet your insurance now says it's not covered, but it will be in another month or two? I'm missing something, but it sounds like you were double billed?

Not to mention there's no way I'm believing they simply provided the meds to another patient without billing them.

Ok, I'll use names to maybe clear it up.

In January, Pharmacare (provincial insurance for those who don't have other insurance) paid for my meds. I didn't use them so they were put in a fridge at the hospital. In March another patient needed the same med so mine was used for them. There was no need to write a prescription or pay for it again so it was simply pulled out of the fridge and used by someone else. There is no charges here for using a nurse or needing a special clinic to use the meds.

Yesterday, I was told that my original prescription was gone so I had to get more. The pharmacy was called and I was told I had a new Pharmacare deductible (the year resets on April 1 so I had a new deductible). The deductible was $1500 so it was paid with the understanding that Empire (my husbands insurance through work) would reimburse the $1500.

I called Empire today and was told the claim would be denied because they don't cover drugs that need to be administered by a health professional.

I was able to call the drug manufacturer and have them reimburse me for the $1500.

I am waiting to hear from my nurse to find out why my January drug (already paid for) was given to someone else.

Hopefully that clears it up. There was no double billing. Two prescriptions were paid for - January by my provincial insurance, April oop to be reimbursed by the drug manufacturer.
The new patient was able to skip billing and insurance altogether.

 

[kimblebee]

So, final update.

I talked to my nurse and she explained that when the drug was ordered back in January it wasn't with a prescription, so it wasn't attached to me. They knew people would need it so they ordered it and paid the $$$ up front. Then, when the other patient used it it was put on her prescription and her insurance.

I can start breathing again.

 

[Heidict]

Ok, I'll use names to maybe clear it up.

In January, Pharmacare (provincial insurance for those who don't have other insurance) paid for my meds. I didn't use them so they were put in a fridge at the hospital. In March another patient needed the same med so mine was used for them. There was no need to write a prescription or pay for it again so it was simply pulled out of the fridge and used by someone else. There is no charges here for using a nurse or needing a special clinic to use the meds.

Yesterday, I was told that my original prescription was gone so I had to get more. The pharmacy was called and I was told I had a new Pharmacare deductible (the year resets on April 1 so I had a new deductible). The deductible was $1500 so it was paid with the understanding that Empire (my husbands insurance through work) would reimburse the $1500.

I called Empire today and was told the claim would be denied because they don't cover drugs that need to be administered by a health professional.

I was able to call the drug manufacturer and have them reimburse me for the $1500.

I am waiting to hear from my nurse to find out why my January drug (already paid for) was given to someone else.

Hopefully that clears it up. There was no double billing. Two prescriptions were paid for - January by my provincial insurance, April oop to be reimbursed by the drug manufacturer.
The new patient was able to skip billing and insurance altogether.

But it is still fraud. They billed your insurance for a medication and used it on another person and not you. They can't receive payment from YOUR insurance for a medication that is being used on someone else.

Glad it all worked out, but I would be seriously ticked off at the clinic, or whomever, helped themselves to your medication. That is just all kinds of wrong.

 

[DisneyHardin]

You are so much calmer than I would be. If I had 90K worth of meds sitting in a fridge at a clinic waiting for my appointment and I found out the clinic just gave them away to another patient and expected me to pay again to get them, I would have flipped my lid at the people at that clinic.

 

[usd2bmd]

Ok, I'll use names to maybe clear it up.

In January, Pharmacare (provincial insurance for those who don't have other insurance) paid for my meds. I didn't use them so they were put in a fridge at the hospital. In March another patient needed the same med so mine was used for them. There was no need to write a prescription or pay for it again so it was simply pulled out of the fridge and used by someone else. There is no charges here for using a nurse or needing a special clinic to use the meds.

Yesterday, I was told that my original prescription was gone so I had to get more. The pharmacy was called and I was told I had a new Pharmacare deductible (the year resets on April 1 so I had a new deductible). The deductible was $1500 so it was paid with the understanding that Empire (my husbands insurance through work) would reimburse the $1500.

I called Empire today and was told the claim would be denied because they don't cover drugs that need to be administered by a health professional.

I was able to call the drug manufacturer and have them reimburse me for the $1500.

I am waiting to hear from my nurse to find out why my January drug (already paid for) was given to someone else.

Hopefully that clears it up. There was no double billing. Two prescriptions were paid for - January by my provincial insurance, April oop to be reimbursed by the drug manufacturer.
The new patient was able to skip billing and insurance altogether.

I would be especially angry that medicine in my name was used for another patient. I would think that there was a law being broken in there somewhere. The clinic is who I would have wanted the money from.

I am glad that you are being reimbursed, but is that $1500 the full cost of the medicine? Will you be able to get it for $1500 now that it is no longer covered by your insurance?

 

[amberpi]

I've gone through hell with insurance companies - like when I was at a speciality hospital to get off my trache and had to be admitted to another ICU for a week to figure out a bleed, my insurance is saying that hospital was non-emergency and out of network. It sucks, but I'll keep fighting about it, its like an $111k bill and my doctor didn't want me to die (again) and I almost did in the ICU when my blood pressure bottomed out. I would have died (again) had I not been in the ICU where they were monitoring me like a hawk. Its not a big deal, but man is a HUGE aggravation dealing with insurance companies. It sounds like its been worked out and I'm happy for you! I will be keeping you in my thoughts and wishing you the best!

 

[Magpie]

But it is still fraud. They billed your insurance for a medication and used it on another person and not you. They can't receive payment from YOUR insurance for a medication that is being used on someone else.

Glad it all worked out, but I would be seriously ticked off at the clinic, or whomever, helped themselves to your medication. That is just all kinds of wrong.

Possibly not, as Kimbledee just posted above that "when the drug was ordered back in January it wasn't with a prescription, so it wasn't attached to me. They knew people would need it so they ordered it and paid the $$$ up front. Then, when the other patient used it it was put on her prescription and her insurance."

It sounds more like a series of miscommunications. I'm glad it's all sorted now!

 

[MamaBelle4]

Possibly not, as Kimbledee just posted above that "when the drug was ordered back in January it wasn't with a prescription, so it wasn't attached to me. They knew people would need it so they ordered it and paid the $$$ up front. Then, when the other patient used it it was put on her prescription and her insurance."

It sounds more like a series of miscommunications. I'm glad it's all sorted now!

My confusion is she said it was covered by her insurance in January. If her insurance was billed and did have to cover the claim, then it is fraud. Does OP know that her insurance wasn't billed in January?

 

[kimblebee]

My confusion is she said it was covered by her insurance in January. If her insurance was billed and did have to cover the claim, then it is fraud. Does OP know that her insurance wasn't billed in January?

I talked to the nurse and she confirmed that my insurance wasn't billed. The drug was ordered without a prescription so
My name wasn't attached to it from the start. I was wrong in assuming it was ordered with my prescription.

 

[mi*vida*loca]

Makes sense. Glad it all worked out!

 

[kimblebee]

I would be especially angry that medicine in my name was used for another patient. I would think that there was a law being broken in there somewhere. The clinic is who I would have wanted the money from.

I am glad that you are being reimbursed, but is that $1500 the full cost of the medicine? Will you be able to get it for $1500 now that it is no longer covered by your insurance?

The total cost of the medicine is $98000(!!!) and my portion was $1500 to cover my deductible. It was paid yesterday by cc and the drug has now been ordered under my name and provincial insurance. I am getting the $1500 reimbursed by the drug company because, as my nurse put it, they want their $90K so $1500 is a drop in the bucket.

 

[kimblebee]

Makes sense. Glad it all worked out!

Me too, thank you.

 

[amberpi]

The total cost of the medicine is $98000(!!!) and my portion was $1500 to cover my deductible. It was paid yesterday by cc and the drug has now been ordered under my name and provincial insurance. I am getting the $1500 reimbursed by the drug company because, as my nurse put it, they want their $90K so $1500 is a drop in the bucket.

$1500 is a drop in a bucket compared to the total price of the medication; I'm glad the drug company is reimbursing you, so you get your medication without having to stress. Being unwell is stressful enough!

 

[cabanafrau]

Nope, the math doesn't work for me. The clinic got 98k of medicine in January without paying for it? Somebody paid for it. At the time you were the patient they brought it in for. You said your provincial insurance paid for it. Presumably for that kind of $$ amount they wanted to know who the patient was, so therefore a prescription was issued to bill it against. Presumably you were the patient identified, no matter how fast the clinic is backpedaling now.

 

[superme80]

Just

 

[kimblebee]

Nope, the math doesn't work for me. The clinic got 98k of medicine in January without paying for it? Somebody paid for it. At the time you were the patient they brought it in for. You said your provincial insurance paid for it. Presumably for that kind of $$ amount they wanted to know who the patient was, so therefore a prescription was issued to bill it against. Presumably you were the patient identified, no matter how fast the clinic is backpedaling now.

When it was ordered in January, the pharmacy ordered it on their dime. The pharmacy paid for it knowing at some point they would get reimbursed. Then, when the other patient had a prescription for it, their insurance was billed with the pharmacy being reimbursed. My name was not attached to it at all. This time, the pharmacy did have a prescription for it, and I was charged for it. The province covered the ~$97000 and I was responsible for the rest to fill my deductible. All drugs for the rest of the year are 'free' for me and my family because we have met the deductible.

If I was so inclined, I could call the provincial provider and ask if they paid for the drug in January. I trust my nurse and what she is telling me. I was wrong and made assumptions.

 

[MamaBelle4]

When it was ordered in January, the pharmacy ordered it on their dime. The pharmacy paid for it knowing at some point they would get reimbursed. Then, when the other patient had a prescription for it, their insurance was billed with the pharmacy being reimbursed. My name was not attached to it at all. This time, the pharmacy did have a prescription for it, and I was charged for it. The province covered the ~$97000 and I was responsible for the rest to fill my deductible. All drugs for the rest of the year are 'free' for me and my family because we have met the deductible.

If I was so inclined, I could call the provincial provider and ask if they paid for the drug in January. I trust my nurse and what she is telling me. I was wrong and made assumptions.

I might call anyway just to be 100% sure. I know your insurance is way different than stateside insurance, but you don't want them claiming you maxed out or questioning why you needed another prescription.

 

[kimblebee]

I might call anyway just to be 100% sure. I know your insurance is way different than stateside insurance, but you don't want them claiming you maxed out or questioning why you needed another prescription.

Maxing out won't raise a flag because I do every year. Last year, one prescription was $3000 a month so they know my history lol

If there would have been a problem, it would have been denied when the prescription was applied to my deductible.

Thank you for the thoughts though.

 

[Pea-n-Me]

Where I work the patient isn't billed for the drug until it is administered.

If there are issues again, ask to speak with a pharmacy supervisor. They are in charge of this type of thing, not so much the nursing or medical staff.