PHARMACIST STEVE

Multiple times a week I get a email/text/phone call from pts asking the same or similar question(s) about being denied care by some part of the healthcare system.  I am going to put this post on the RESOURCE TAB on my blog so that I can just forward that link to pts in the future.

There are a lot of moving parts between the pt and getting appropriate care. Insurance companies, Prescription Benefit Managers (PBM), Hospitals and their employed prescribers,  prescribers in private practice, bureaucrats/politicians.

If at all possible, it is advisable to do a audio/video recording of what the healthcare provider said as to what he/she was going to do or not do and, if possible, the reasons for his/her decisions. Prevents in the future the healthcare professional developing amnesia of what was said and/or denying what they said.

Likewise there are numerous potential legal issues that may apply to a individual pt:

Americans with disability act discrimination – which is considered a civil rights violation. https://www.justice.gov/crt/how-file-complaint  there could be a ADA law also at the state level.

patient abandonment is involved  What is Patient Abandonment?

Medical Battery

PT/Senior Abuse – denial of care and/or throwing pt into cold turkey withdrawal

Failure to meet standard of care and best practices (Malpractice)

The CDC opiate dosing guidelines that were published in March 2016 have become de-facto standard of care and best practices. Some prescribers are claiming that they are following these guidelines, when in fact they are following the MOST STRICT portions of the guidelines that are suppose to only apply to pt with ACUTE PAIN.

Here is four quotes from the CDC opiates guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

Core function of the practice of medicine:  Exam pt, diagnose, treat/cure/maintain/prescribe medication 

Prescribing encompasses the starting, changing, stopping a pt medication.  It is ILLEGAL for a prescriber to prescribe medication for a pt that they have not done a in person physical exam. If a insurance company/PBM tells you that they won’t pay for your medication or especially if they stop paying for your medication.. that is the practice of medicine and they don’t have a license to practice medicine.

If your insurance is Medicare/Medicaid/Medicare Advantage:

You need to file a GRIEVANCE with www.cms.gov (800-MEDICARE) against anyone involved with you being denied care.

Don’t let a insurance company/PBM tell you that their policies/limits are in CONCRETE… everything with health insurance can be APPEALED… They don’t have to tell you about this… unless you ASK… then they have to provide you in WRITING what their appeal process is..  Never take NO for a answer from your Insurance company.  With Medicare/Medicaid/Medicare Advantage… there is an appeal process outside of the insurance company’s… once you exhaust the insurance company’s appeal process you have to appeal to a Administrative Law Judge… > 50% of pts that goes this far will get approved.

If your insurance is thru an employer…. you need to find out if the employer is self-insured (ERISA). The employer pays all the bills, the “insurance company” just adjudicates the claims. Contact whoever is in charge at the employer and see if they will intervene… the employer can tell the insurance company to pay/cover whatever you need.

If you h ave single/family insurance policy… then your options may be limited to state’s Insurance Commissioner, Medical Licensing Board, Pharmacy Board, Accreditation Agency – like Joint Commission

Legal action, in our legal system the “value of life” of a individual who is handicapped/disabled, elderly, unemployable has LITTLE VALUE and it is unlikely that a law firm with take a case on a contingency basis because there is little financial upside for the law firm.

As more and more large entities – bureaucrats/politicians, corporations, insurance companies/PBM’s are getting into the business of dictating the practice of medicine. The interest of the class action law firms may change, since the decisions of a corporation with deep pockets that has caused harm to tens of thousands of pts by their actions… means that the class action law firms could see a financial upside in suing a law corporation.

 

 

 

 

Filed under: General Problems