I had that problem a few years ago. I needed a special eye exam because I'm borderline glaucoma. My insurance denied it saying it wasn't needed. My eye doctor was livid over this. Who are they (the insurance people) to deny a test. they are not doctors. Well, in the long run, it got approved and I think the person who denied this was fired. Good for her.

Last year I experienced much pain in my right jaw and ear. I went to ENT. I was given a script for antibiotic and was told to return if that did not work. That was in May. Most of the pain was gone, but I still had some swelling in my salivary gland. Two visits for xrays to the in-house oral maxillofacial surgeon, a CT scan and an fMRI of the head and neck (had to wait 2 weeks for authorization from insurance on that one). My November there was still pain and the doc asked the insurance for an fMRI of my jaw only. It took 6 weeks for permission and then the testing.

The conclusion: arthritis of the right TMJ and a stone in the salivary gland. Nothing ENT folks could do for me. So, between May and December 31, I went to the clinic a total of 12 times to be told that there was nothing they could do.

Just yesterday my salivary gland started hurting again! Rats!

Some denials are automatic based on what the doc listed as symptoms; however, would expect a BC neurologist to know what to write. Also they deny knowing not everyone will appeal the decision.

Remember, bottom line - insurance companies are in business to make money. It is their fiduciary responsibility to shareholders. The more they pay for, the less money they make.

I wonder if there's any legal recourse if a test is denied to find out later there's a major issue that could have been caught earlier and treated if it was approved. I don't think it's the case with me (hopefully not!) but it just seems dangerous to deny tests like this that are ordered by specialists.

"wait while wondering if there's something wrong with you"--AMEN!

I guess you could act preemptively and send a complaint to the state attorney's office IF they deny the supporting letter? I can't see that they would, but it's a thought. I was in insurance for a score of years before heading over to the other side of healthcare, and so, I am basing it on what I've seen happen. I'll be thinking of you!

Thirty years ago my OBGYN was already complaining about how insurance companies were dictating or trying to dictate how she practiced medicine.

I swtiched insurance companies in December, not the usual Jan 1, due to retirement. As luck would have it I had several medical issues at the same time. The new co kept insisting I was still insured by the old co. I was getting notices for unpaid bills, etc.., I was on the phone with them several times a week for months, on top of having to deal with the health stuff....not fun!

I hope you get things resolved. You may have to just keep bugging the insurance company, calling every day if necessary.

I too have problems with my insurance company. One hospital is close to my home. 10 minutes But I can only go there in an emergency and stay overnight. Then I can transfer to another hospital in my plan that is further away from my home or have to fight the traffic in the area to get there. Yesterday I had to go to a urologist in my plan. Took over 4 hours to find one and who would see me NOW. All my doctors that are taking care of me and have done all the paperwork to keep me as a patient. And have won. I hope you are feeling better soon or at least an appointment for your MRI. I think there are a lot of people having problems with insurance companies today Good luck to you.

Some of what we are experiencing with insurance companies is pendulum swing. When I began practicing in the ER, many yrs ago, tests were routinely over ordered (that still happens) and many unnecessary hospitalizations took place. Costs were lower then. Now as technology has advanced, costs have increased and a couple extra tests really adds up.

Remember insurance companies are not saying you cannot have the test, they are saying they will not pay for it. In SOME cases I think that's appropriate. Parents often bring their children into the ER after a minor head bump and want a CT scan. It takes time to explain the real risks of unnecessary exposure to radiation, not to mention the financial costs.

Unfortunately, too often, people with real problems needing appropriate diagnostics and referrals suffer the consequences.

I definitely agree that tests are ordered more than necessary, both because of patient insistence and malpractice concerns. It just strikes me as odd that a specialist recommending a relevant test can be denied. An MRI after experiencing neurological symptoms (and being referred to a neurologist after an ENT examination) seems reasonable.

The MRI place was telling me about a patient who needed an MRI because of a suspected tear somewhere, I can't remember exactly what she said the problem was. But insurance refused saying they didn't think the patient had that issue and they wouldn't cover it. So he ended up paying cash for the MRI only to find that he did in fact have the problem. That would infuriate me.

I hope they don't insist you have a CT scan first. I'm told that's pretty common--because CT scans are less expensive than MRIs. Insurance companies don't think about things like excessive radiation, apparently.

Yeah I don't do CT's anymore unless it's life threatening. I've had too many from my kidney stones before I knew better and I'm concerned about long-term radiation damage.

I have an update, actually. I got a call from the MRI place saying that my doctor called insurance and they have approved the brain MRI but not the spinal. I'm going in tomorrow to have it done. It's a start - the brain is the one I was the most concerned about, but I have a follow up with my doctor in a month and we'll discuss and see if we should push more for the spinal.

Good luck!

Best of luck Chi. It is very frustrating, the whole situation. I agree with mdln, I think most doctors probably order too many tests because they are afraid of getting sued. (I know there are some doctors and hospitals that flat out defraud the insurance companies for tests/procedures they never did.) So the insurance b!tches about how many tests are ordered and refuses to pay them. Dr's get slammed with frivolous lawsuits that drive their malpractice insurance up. You will always find a lawyer ready to take your case. It's a vicious circle.

Jim- since you have issues with salivary stones you might try actively sucking on hard candies. My mom had parotid stones and they recommended that she try sucking on hard things, it can help the stone dislodge.

Some things I was going to say are moot now so I won't go into that.

That said, insurance isn't there to give you what you want. People aren't entitled to demand every potential treatment. Insurance is there to keep costs under control for everyone as best they can. Frustrating though it may be, they can't just pay for everything under our system of care.

It's not really depriving you of something so, legal recourse? I guess you can always sue with or without cause but I'm skeptical of cause in this case. If you feel you need something, you can always have it done. Insurance isn't stopping you from the procedure, they're just not going to pay for it.

And anyone NOT frustrated with insurance? I'll raise my hand. I'm shocked with how happy I am with my insurance and not just their coverage but their dealings with me. I call and talk to a person, one who speaks clearly. One who is concerned that I've been answered. In the past 5-7 years (I don't recall offhand) I've had 2 issues: one, the company declined an ER visit which was appealed (on advice of the customer service person no less who told me how to do it) and subsequently paid and I got a complimentary letter when they approved the appeal. The other was an issue of not approving a drug choice. I just didn't take it - I had other options. And I found out afterward how to have dealt with it but it really wasn't a big deal. So no, I'm not frustrated with them. I understand why they're there.

I don't expect insurance to cover everything I want. But when a specialist tells me I need an MRI to rule out some very serious issues like MS, I expect my insurance, which I pay a lot of money for, to cover it. I don't think that's unreasonable. This isn't Botox or some other elective medical procedure.

We have Blue Cross PPO health insurance. We've paid over $1,400 per month for the premiums for many years. A $500 annual deductible for each of us, except for "preventive" stuff, such as an annual exam, mammogram, etc.

My mother died (45 years ago today, as a matter of fact) from metastasized breast cancer. Her only sibling, my aunt, also died from metastasized breast cancer. I have had two (thankfully benign) lumps removed - one from each breast. And my insurance company is refusing to pay for the mammogram I had done in April. Why? Because the imaging center did a 3D mammogram, rather than a "regular" mammogram. The imaging center is now doing 3D mammograms for all mammograms. But Blue Cross said they need a valid reason for doing a 3D mammogram. How much did the imaging center bill Blue Cross? A whopping $61.

That's terrible, Lindsey. With your family history, I would think you would be completely covered for advanced screening. I'm glad the cost difference isn't significant though.

We don't pay as much as you do a month but we do pay over $500 a month premiums. The whole point of insurance is insuring against the risk of needing it. It's not like we get our premiums refunded if we're healthy and don't file any claims for a year. We pay into it in case we need it. That's why it's so frustrating when they disagree with doctors about what a patient needs.

Argh another irritation! On Tuesday I went to my pharmacy to pick up my monthly prescriptions. Today (2 days later) I came in for another months worth since I am going on a long vacation. The price rang up 7x as much as it was on Tuesday. The pharmacist was confused and called Cigna.

Apparently cigna decided that unless I switch to mail order medications, I have to pay this higher price. This requires getting a new prescription and signing up. Not a huge deal except that they didn't tell me!! And instead held my medications hostage to either pay the higher amount or leave without it. Since I need them, I ended up having to pay the retail price of 4x because I don't have time to sign up for the mail order before I leave. So very annoying.

Our insurance, too, has a mail order service. But, we can pick up three months' worth at a time from the local pharmacy, or have it mailed to us. The pharmacy is close, so we just pick up our prescriptions. Beats having them sit in a hot mailbox all afternoon.

Yeah I prefer picking them up too but not at 7x the price! I'm going to call them and see what my options are.

I had my MRI last night. It was a little different than one I had about 6 years ago. They just had me lie down with my regular clothes on, which I found strange since my bra has metal in it. But everything went fine. Just waiting for results.

Yes, check to see if the pharmacy can just call your doctor to get the OK to dispense three months' worth at a time, without having to bother getting an entirely new prescription. In any event, your doctor's office should be able to electronically submit a new prescription to the pharmacy if it turns out that you need a new one.

I avoid mail order at all cost when I can; luckily our insurance will allow for 90 days through the local pharmacy as well. But when they first asked us to use mail order, I didn't know that and one time I had to have a specific non generic potassium pill because the generic they were using made me ill. First our mail order sent the generic because the prescription just said potassium as opposed to the specific name brand. That was a couple of dollars down the tube but whatever. So the doctor wrote a new script and sent it in. However, after that was submitted, they sent the prescription of 90 potassium pills along with an invoice of almost $100.00! I knew it would be more expensive, but not $90.00 more expensive! And no one even called to confirm the charge would be ok and then they wouldn't take it back. I was so sick and upset over it. A $100.00 wasted; never again. The drug stores have saving programs for prescriptions too and now between that and the 90 day program, we are for the most part mail order free.

So you may want to try to get a quote on pricing before you submit something new or different so you don't get blindsided.

For our insurance company, some brand name meds are ok, but others are not. It depends on whether there is a generic available or not. And, not all generics are the same. There are "generic equivalents" and "generic substitutes." A generic equivalent must be bioequivalent to the name brand drug. A generic substitute is simply a generic drug that is taken instead of the prescribed brand name drug. It isn't necessarily the same medication.

And when we are given generics, our insurance allows us to specify which pharmaceutical company's generic we want to take. For example, one of my blood pressure medications is (brand name) Toprol XL 100mg. For years, I was allowed to get the brand name drug because there wasn't a generic. When generics became available, the mail-order pharmacy was still sending the exact same pills. Then the insurance company changed master pharmacies, and the new pharmacy sent me generics that I didn't want --- I wanted the same pills I had been taking all along. I had found out that the company that makes the brand name drug also manufactures the generic equivalent that is sold under a different pharmaceutical company's name. So, I told the local pharmacy that that is the generic I wanted, and that's what I've been getting ever since.

@lindsay, did you mean generic "alternative" instead of substitute?

When we write scripts for generic substitute it means the pharmacist. can substitute a generic equivalent of the same drug. If I write a script for "Toprol generic substitute" the pharmacist can dispense metoprolol, but not atenolol (a different beta-blocker).

A generic alternative would be a different drug but with similar action (e.g., atenolol for metoprolo - both beta-blockers, but different drugsl; naproxen for ibuprofen - both NSAIDS, but different drugs).

Mdln, perhaps generic "alternative" is more correct, but with the insurance we have, we can go online to find out if a drug is covered, how much it will cost, etc. If we type in a name brand, we are given the option to look at generics, to see how much they will cost, etc.

Although the system seems to have been updated so that now it will only show generic equivalents, several years ago it would show both generic equivalents and generic "alternatives," but it showed the "alternatives" labeled as "substitutes." After all, a generic, by its very nature, is a substitute (for a name brand drug).

Unfortunately many people think there is a difference between generic and brand name drugs. When first developed drugs are given a generic name and then a brand name, which is usually easier to pronounce and remember. Because drugs are initially and heavily marketed by the original manufacturer, the brand name tends to stick.

However, aspirin is aspirin whether it is sold by Bayer, Walgreens or St. Joseph and acetaminophen is acetaminophen whether sold by McNeal as Tylenol or made by Equate and sold at Walmart.

Due to usually significant cost savings when the patent runs out and generics are available hospitals quickly switch to them. If they were not just as effective hospitals would quickly notice that and not use them. Interestingly, for a long time McNeal sold Tylenol to hospitals for less than the cost of generics, so they could advertise "hospitals use Tylenol more than...." Pharmaceutical companies are very profitable and spend more money on marketing - than research and development. So when people pay more for a brand name drug know you are helping to pay for those TV ads, glossy color advertising pages in medical journals, and until very recently freebies including trips and dinners for physicians, and lunch for doctors office employees.

http://www.washingtonpost.com/news/wonkblog/wp/2015/02/11/big-pharmaceutical-companies-are-spending-far-more-on-marketing-than-research/

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/QuestionsAnswers/ucm100100.htm

A generic drug is identical -- or bioequivalent -- to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically sold at substantial discounts from the branded price. According to the Congressional Budget Office, generic drugs save consumers an estimated $8 to $10 billion a year at retail pharmacies. Even more billions are saved when hospitals use generics.

I have been going in for lots of medical tests lately. I had 2 neurologists say I needed a Datscan to confirm Parkinsons. I went to a second one as a second opinion. Aetna insurance said it was approval verbally over the phone. Even the neurologist and Stanford Hospital got the OK from the insurance, again verbably. I went ahead with the test which cost $10,000. They denied the claim and we got a bill. We had nothing in writing. We fought them for 8 weeks and got the neurologist and hospital resubmit the claim. Turned out the paper work was filed wrong, had the wrong information and was FAXed to the wrong department. Don't give up. Talk to your insurance company, find out what is going on. Maybe just need the neurologist office to resubmitt the claim. I was getting my test done so I could have DBS (Deep Brain Stimulation) done but after the battle over the test I am afraid that they wouldn't cover the surgery and have one HE!!

Sorry hit the wrong keys - do that all the time with the tremors. I was going to say, have one H---L of a bill. Can you imagine how much brain surgery costs?

Generics are supposed to be "bioequivalent", but that is not the same as identical. The active ingredient is supposed to be the same, but the rest may not be. I was using brand-name prescription eye drops and they were helping a lot. Then a generic version came out, and when I tried it, my eyes burned like crazy upon using it. I asked the pharmacist, and he said one of the inactive ingredients was irritating my eyes, and I wasn't the only one who had that happen.

I had a similar thing happen with birth control pills. Brand name worked fine; a generic came out so I switched to it, and my body reacted like I had switched to a completely different pill. That's now one area where I insist on taking the exact version of the pill that's been working for me - no changes.

Other generics have been perfectly fine for me, so I'm not saying they're all bad or anything. But I think it's important to keep in mind that there are some instances where the fact that they're not strictly identical can make a difference.

SilverComet1 -- my husband has glaucoma, and for years had a prescription for Xalatan, at a cost of $10 for a three-month supply. Then the patent expired and generic latanoprost became available. Because there is a generic, our insurance will only cover the brand name drops if we are willing to pay $75 for a three-month prescription -- as opposed to $5 for a three-month prescription for the generic. Hubby's ophthalmologist told us that some folks experience a burning sensation with the generic and said to let him know immediately if that happened. Hubs hasn't experienced any bad side effects, so he is still using the generic, and his eye pressure is really good.

"Generics are supposed to be "bioequivalent", but that is not the same as identical." Very true. I think the FDA allows a range between 80% and 125% for a generic to be considered bioequivalent.

MDLN said, "Unfortunately many people think there is a difference between generic and brand name drugs." Well, that could be because some insurance companies will only authorize a specific generic which is NOT the same as the brand name drug. My husband's doctor (an internist, not the ophthalmologist) prescribed a specific brand name medication for my husband. That medication is still under patent with no generic. The insurance company won't cover it. They will cover a specific generic, but the generic doesn't even contain any of the same ingredients - it's a generic for another brand name medication that my husband is already taking. It's very frustrating.

@lindsey, where did you get the idea the FDA allows a range of 80 and 125%? How can a drug be 125% identical?

In 2014, pharmaceutical companies paid $3.53 Billion to 681,432 physicians. Do you think that influences prescribing? If your physician prescribes a brand name medication, I encourage you look him/her up to see if they received $ from that drug company.

https://projects.propublica.org/docdollars/

mdln- thanks for that site! Found some doctors on there that I'm sad to say I wasn't surprised. Saw that my most trusted doctors weren't listed thankfully.

Interesting site! All of my doctors except my primary care have received money.

mdlin, the information on the Propublica site is misleading and I think you know it.

All of us want our doctors to be current. They go to seminars and conventions to do so. At any professional gathering (in any industry), vendors sponsor events. If after class your doctor stopped by a cocktail reception with peers to discuss the new material covered that day, they had to sign in because the "event" was sponsored by a vendor. The value of each attendee's food and drink is reported. If they later went to the convention's scheduled dinner to eat and listen to the featured speaker, that event was also sponsored by a vendor and they had to sign in. That was reported.

If your doctor is particularly clever and invented a medical device or other item that others can use to treat patients, they will be paid a royalty for that. That's reported. Or, if they sold the patent rights to a company, that's reported.

And yes, if your doctor is an orthopedist, s/he may get a payment from a device company for using a particular brand of hip replacement hardware, for example. Perhaps all the providers do that. After choosing which s/he likes to use for a particular case, should s/he decline the payment (which would be similarly offered from a different choice anyway) ?

Et cetera. Know what you're reading, don't jump to conclusions.

Yes, Snidely, we stay current by attending national meetings where speakers (myself included) have to disclose verbally and in writing any conflicts of interest.

The problem is after hours activities, dinners and presentations (sponsored by pharmaceutical companies) can and do influence prescribing decisions. I have traveled out of state, received salary/compensation, dinners at expensive restaurants, and attended closed museum events and cruises thanks to pharmaceutical companies. The ACA is now requiring public disclosure. Many are unhappy about this. However, I believe if a patient is prescribed a brand name medication (esp. when a generic is available), that patient has a right to know if the physician is receiving compensation from that drug company.

https://www.cms.gov/openpayments/

Snidely, If I like to use brand X endotracheal tubes, why should I get payment from the manufacturer - when the patient/insurance is already paying for the equipment and for me to do the procedure? Do you really want your healthcare provider getting kickbacks? What if I really liked brand X, but brand Z will pay me 10x as much to use their tubes?

Great video demonstrating truth in a humorous way, the end is especially funny. http://www.businessinsider.com/john-oliver-takes-down-prescription-drug-industry-2015-2

That video was hilarious!!

I have mixed feelings about this. I frankly don't think most people understand what's involved and most who do, don't much care.

I know a lot of docs who have have a "personal entitlement" attitude when it comes to money. Some don't. Incentive-type payments from drug and device companies can always be declined, yet few do so unless they have no choice for other reasons. With fewer physicians practicing independently and more in large groups, what sounds like something you consider to be a matter of ethics perhaps should be regulated by the employing groups? I recall hearing that some medical schools (wasn't UPenn one of the first?) have imposed stricter policies in recent years.

Healthcare isn't like other businesses in some respects but it is in others. It is a business, after all. Maybe the public disclosure rules are about as far as it will go. They say that shining a light into previously dark places can work as a disinfectant for dirty dealing, although it hasn't done much to stop the influence of big money in national and local politics.

I will not live long enough to see a generic for Advair. The only question there is how much more they can get away charging for their monopoly on the two ingredients.

"I know a lot of docs who have have a 'personal entitlement' attitude when it comes to money" I'm glad I don't know any of that type!

I'd trade you chisue. I prefer symbicort and the pharmacy formulary doesn't cover it any more. I have to change. Yet again. And symbicort is on the verge of generic. So it's not doctors, hospitals, or even the drug company this time. It's my pharmacy coverage. I hate them (I would name them, but no thanks). I have to wonder if they're the ones in cahoots with drug entities.

@chisue, you are so right, the Advair situation on top of the albuterol reformulation a few years ago is unbelievable, when we have so many deaths from asthma.

@robb, nice article, what is your insurance covering if not Advair or Symbicort?

Why your asthma inhaler costs so much...

NYT - Cost of a simple breath

Advair & Insurance

I totally agree mdln! Why one and not the other? Cahoots?

ETA: my mom has the opposite problem. She uses Advair, but they won't let her have it, only Symbicort. UGH!

mdln asked me, "where did you get the idea the FDA allows a range of 80 and 125%? How can a drug be 125% identical?"

As a physician, I would imagine you are familiar with the FDA's "Orange Book." (Hint - bioequivalence.)

man, I read that wrong. They're covering the brand new Breo. Still cahoots. Nowhere near patent expiration.

https://www.cadth.ca/generic-drugs/similarities-and-differences-between-brand-name-and-generic-drugs

"Bioequivalent drug formulations have the same bioavailability; that is, the same rate and extent of ABSORPTION....

There is a common misperception that generic drug concentrations can be 80% to 125% of the brand name formulation; in other words, that the variance may be up to 45%. This is not true.

• One of the key parameters for bioequivalence is the area under the curve (AUC). The AUC is a mathematical calculation based on a graph of blood concentration versus time, and it correlates well with total drug exposure.
• The AUC of a generic formulation must be no less than 80% or no more than 125% of the brand name formulation. There is international consensus that differences within this range are not clinically significant.
• More importantly, the 90% confidence interval of the AUC must also fall within 80% to 125%. Recall that the confidence interval is a range of measurements within which we can be confident that the true result lies. So, for the entire confidence interval to fall within the 80% to 125% range, the variance is generally less than 5%."

When Advair was first introduced there was an alternative way to get the same medication. Advair has two active ingredients. You could buy each one separately and use the two inhalants in tandem. Soon, however, the manufacturer *bought out* the only company making one of the ingredients. They have a MONOPOLY -- and a phalanx of lawyers to make sure they keep it. None of the other inhalants helps me, so I have no alternative.

Retail on Advair is currently almost $4500/year for my 250/50 twice-daily dose. It is my only routine medication. Medicare requires me to buy Part D insurance -- which 'permits' me to buy Advair at a discount. My Part D costs almost $1000/year.

Millions of Americans have asthma. Advair has held this monopoly for at least a dozen years. Do you think they've recouped their R&D investment?

It's a ridiculous system -- paying for insurance to be able to afford inflated costs for medications. Let the government police pricing on at least widely used medications. Drop the Part D premiums. The pharmaceutical industry would still make money. Oh, wait, the Insurance Companies would NOT.

Single-payer system is the way to go but big pharma and insurance co.s (middle men) have a tight hold. No other country has such a system, that I know of.

I'm sorry for your situation, Chisue.

The health care system is broken in many ways. The predicament chisue faces is obscene in my book.

Congress has barred Medicare from negotiating drug prices. It's in a stalemate. Until that logjam is broken, those with Medicare coverage will face these situations.

USA Today editorial

Snidely -- Thanks for the commiseration!

Now...can Chi83 tell us if any of the tests have helped with a diagnosis? (Maybe she's off to visit Grandma and Grandpa?)