Fun with Rx

Only six weeks into the new year, and we've nearly set things up appropriately with our new annual insurance policy. Though we have a doctor we have no intention of abandoning, we have both also had to acquire an in-network "primary care provider" who has authority to issue a hall-pass for any specialists we may need to see. The PCP already has done yeoman's service getting me clearance to have my right-eye cataract dealt with by an out-of-network surgeon. I thought, for the left eye, we might try to pre-clear with the insurance company and avoid the fire-drill and drama.

No dice. The PCP's office can't start the approval/exception process until I schedule the surgery. OK, sez I, I'll schedule the surgery and then find out if insurance will pay for it, though it seems a bit odd. By the way, for the right eye, the surgeon sent me to a local doc for post-op care, which was very convenient, but she wasn't on the list of out-of-network exceptions, so could you add her to the list this time, see what the HMO says? Oh, good heavens, is the reply, why do you have to see her instead of driving an hour to go back to the surgeon's office? Well, obviously, because it's nice not to have to drive an hour to go back to the surgeon's office. Well, why can't you see someone else in network for the follow-up? I can, but their in-network people are an hour in the other direction.

More guff about the theory of managed care and why they run the network the way they do--at which point I gently interrupt to point out that this is a financial arrangement, not a medical one. I'm not turning over the management of my medical care to an insurance company with whom I'm likely to have a maximum of one-year contact. May I humbly request that you simply ask the HMO if the local follow-up care can be added to the list of exceptions, secure in the knowledge that if the answer is "no," I'll cheerfully go to the local doc anyway and pay her fee out of pocket, in order to avoid the two-hour round-trip?

This precipitates another several rounds of concerned explanation that the insurance company may say "no," and the PCP won't know what to answer if the insurance company asks "why," and managed care means . . . . I gently interrupt again to repeat that I'll accept a "no," and will still do it my way, but I'd appreciate it if they'd just ask. If the HMO asks why, the simple truth is best: the surgeon is an hour away and trusts this local doc to do the follow-up, and the patient prefers to avoid the round-trip. If that's not convincing, fine. It's "no."  I'll live.  But isn't it worth asking?  They may say "yes."

I swear: another round of "but they may say no, and managed care means . . . ." And yet, I also swear, I did not (for once) erupt in a tirade about Obamacare. I'm making a real effort not to offend these people, even though I realize that every time I go out of network, they pick up the message that I lack confidence in professionals who would agree to be in the network. There's some justice in that, but on the other hand some of the doctors we chose independently are in network, which we try to emphasize in order to avoid the unpleasant implication. We've also emphasized that there are some kinds of doctor--such as long-time dermatologists and gynecologists--that we're unlikely to be willing to change every year just because we have to go with a new insurer. Nothing personal against you guys or anyone else who's agreed to be in this year's network.

It sure takes a lot of negotiation and discussion.