Avoiding the "forbidden" confrontation

bsc,

reading this last update (specifically, insurance related stuff) really made my blood boil... Knowing the hell you went through to get your wife to her current state of functioning, it is maddening to hear that all that might be in jeopardy simply because some insurance bureaucrat cannot grasp the need for injectable Risperdal. I had similar reaction couple of days ago reading someone's post on schizophrenia forum - that person apparently had a moment of insight and wanted to see someone ASAP only to be bounced from one doctor to another and finally left to wait for an appointment, which may come too late.

And on the other side here I am with quite enough financial resources to cover treatment, ready to suck it up and stay with my husband if only he made an attempt to see someone and consider treatment. Not going to happen. It sounds melodramatic but is true in his case: he would rather lose everything he has left, including his life, than admit he is ill and needs treatment.

It is also heart-wrenching to hear about your daughter's problems. Hopefully, she will be able to see them for what they are and deal with it. This will sound weird to many people, but in a way I am grateful that my children are on autistic spectrum. While I know their lives will be more challenging because of it, it is something I can understand and deal with and it is certainly not something that shatters my hopes and dreams for them. Quite the opposite with my husband - it is terrible thing to say but I don't think he'll ever again be able to find his peace in this life...

Tara - thank you.

I just did a quick calc. I think I owe the hosp about $11,000 to 12,000. Each shot at the hosp cost between 650 and 750 every 2 weeks. Been about 8 months now.

The actual med cost about 450. The rest is the "labor" charge since it is done in outpatient nursing. They take her BP, temperature, and other health niceties, as well as keep the records for her Dr (psych). It's like getting your car fixed at the dealer. It will cost more than the local mechanic.

First question is why do the meds cost so much. Taking the equivalent pills is about a tenth the cost.

Using the hospital has been the key to keeping her on these meds. She goes there willingly. Two years ago when she was going to the social service rehab center with druggies, alcoholics, and other degenerates, she refused to go and talked her dr into changing her over to the pills, which she then refused to take. The control was out of my hands.

I guess peace of mind has a price.

that sure is a lot of money. I'm sorry about your predicament.

Is the issue that the pills don't work as well as the shots, or just that she cannot be trusted to take them regularly?

qwerty,

bsc posted some of the reasons she is using injectable form of Risperdal in this thread:

http://psychforums.com/viewtopic.php?t=22762

bsc,

this is very likely old news to you, but Janssen (maker of Risperdal) has a web site with resources on reimbursement support specifically for Risperdal Consta:

http://constantresource.com/risperdalco ... ex_bs.html

If you haven't already done so, you might be able to contact their helpline and get them to work with your insurance to get this covered...

Thanks Tara - I didn't know about it but I will investigate.

I finally got a letter from the insurance company acknowledging that I even appealed. They said they denied the claim for something, but it was not clear (to me) what they were denying the claim for. They must write in some some special insurance doublespeak. I will send a copy of the letter to the hospital to see if it makes sense to them. I have just a little sense that the wrong codes were used, but I am not sure.

I called the website number at Janssen. Talked to a very knowledgeable lady who also remembers my wifes case with the social service place several years before. (they never got paid either). It seems the issue with the insurance company is use of wrong codes. She suggested that the nursing "service" be billed to the regular med insurance, the meds themselves to the pharmacy benefit, and none to the mental health insurance company. Our plan is complicated - the employer uses a separate mental health insurance company.

Friday morn went to the hosp billing office armed with a few actual bills from them, and some informational notices from them, and EOBs from the insurance company. The billing clerk looked everything up to see where it all stood. BTW , the hosp did get the copies of appeal letters I sent them, so they were up to date with everything. The clerk told me not to worry, that they were still investigating, and had not yet come to a decision as to how they were going to handle it. She did not indicate whether they had a dialog going with the insurance company.

So I guess I will sit tight, not rock the boat, and see what happens. I don't trust either the hosp or the insurance company.

Our wonderful health non-care system! I assume you are in US.

Yes, it is US

bsc, I am glad Janssen helpline was of some use.

Interestingly enough, we also have mental health insurance which is separate from our regular health insurance through an HMO. More interestingly, it was our regular health insurance who picked up whole involuntary commitment bill for us although based on everything I read it should have been done by mental health insurance (in which case I would be worse off since they would cover 90% of charges leaving me with couple of thousand dollars to be paid out of my own pocket). I never questioned this - apparently, hospital called regular insurance HMO to preapprove charges, they did and that was it. So, it seems that we essentially have some duplication of benefits which is probably a good thing.

So, what the Janssen lady recommended makes some sense to me...

On a similar note, I am still dealing with final couple of hundred $ payment to county hospital psych ER. Our insurance paid it to the hospital couple of months ago but hospital apparently transfered the account to county collection agency at about the same time and payment still hasn't trickled all the way through. At this point I am pretty much sick of talking to automated voice systems...

bsc,

so glad to hear you seem to be making headway. I've moved around a lot (& switched jobs a lot) so I've had numerous insurance companies over the years. For the most part, their goal is to wear you down until you feel like it's easier to give up & pay, just to relieve the hassle. Essentially, they behave like bullies. That's the most efficient way for them to make money! I've found that if you can stand your ground & keep mailing/calling/etc, eventually things can get straightened out. It takes a lot of effort and patience, plus it's adding insult to injury to have to deal with this on top of an illness. Make copies of everything you send. Every time you speak to someone, write down their name, date & time so you can reference it. It seems to make a difference when you get into a disagreement if you can say, "I talked to so & so at your company on Dec 12th & she said...". I'm sure I'm probably not telling you anything you don't already know, but good luck.

Here is a long overdue update. It has been a little over a year since my wife's 4th hospital stay. She has been on the resperdal shots all this time and she is doing ok, we are doing ok. I stil feel that underneath there lurks a monster that the meds cover up. Her personality is very subdued, she sleeps a lot, gained weight, not very active compared to when she was overactive manic. She leads a low key life.

But we are getting along - I love her this way much better then when she was totaly unlovable.

She recently visited her psych to get the meds prescription updated for another year. One of our insurance companies finally started paying for these shots from April on. I don't know what the hosp wil do with the bills from last July07 thru April08.