Doctors are a barrier to testing

[Rufous McKinney]

Also if your health insurance adds extra barriers that can get very messy.

I think alot of this is tied to the medical insurance industry driving health care in the US. Maybe its different elsewhere.

Insurance companies are who deny the tests, and deny covering medications. My GP has no interest in insurance companies. Nothing he recommends is tied to what the insurer will in fact authorize. And I have a Medicare Advantage type plan/ so Medicare itself is also denying tests, off label uses of Rxs, etc. And you can't argue with them because the data is hiding in expensive subscription only data bases. Where it says in Medicare that I can't have Provigil...is on some page in a public document you can't read.

things get clearer when I go talk to the woman who runs his office. She is who then understands- oh yeah they won't pay for any of that.

I've yet to push them hard via a formal appeal. But that day may come.

Back with the GP, one Friday afternoon after 5 pm, my GP called the insurance provider and I witnessed what happens there. He was transfered 5 times. He had to explain it all to 5 diffferent people, five times. He is asking them to authorize the Provigil (I think). The last transfer, he then talked to the equivalent of an actual doctor at the insurer. He reported on a whole litany of drugs I had never taken, suggesting I had tried them and they all failed. (Like Lyrica). (and what does this have to do with Provigil?).

so in between this 35 minutes of 5 transfers, this horrible MUSAC is coming out of the phone, I'm standing there having an ME/CFS overload siezure, and ultimatelhy whomever that was denied us.

So why would any doctor in their right mind, subject themselves to such an ordeal. So I saw what happens, and its real ugly.

 

[valentinelynx]

So why would any doctor in their right mind, subject themselves to such an ordeal. So I saw what happens, and its real ugly.

Indeed, few doctors have the time to deal with the prior authorization process. Not to mention its effect on their mental health. Imagine being constantly undermined in your clinical decision making by some untrained nurse of pharmacy technician (working for the insurance company). It gets old really fast.

 

[Sledgehammer]

Discouraging doctors from ordering tests might border on illegality. It's probably a murky area, where the big money can't be convicted, and the doctors are caught between useless honesty and losing their practice. I think it's just one of those unpleasant facts of life that we just have to accept that it exists, and try to work around it. Yes, we should stand up against such things, but I expect that there are well-funded organizations that are trying to fight it and failing.

I agree. I see it as a mechanism to wear you down, make you give up, or take what's on offfer which do nothing to help with the problem at hand. We have one good Doc in a practice of 10. He's OK and tries, but I know he's up against the machine and can't deviate from the script for fear of beeing pushed out.

 

[Learner1]

Sometimes they'll deny testing for no substantive reason other than their preference. Often times getting their office staff to process the paperwork is a nightmare.

If something doesn't fit into their narrow way of doing things, they reject it.

Anyone else running into this problem?

Are there any solutions that you've worked out?

Sorry that's happening. As some of the other posters have shared, finding a different doctor can help. I've found having more than one doctor is helpful because if it's out of the expertise or comfort zone of one, then it might be better suited to another, who will order it for me.

With a new and esoteric test, I try to make it easy. I find the source of the test, lab draw instructions or kit, and the requisition form or contact info for the doctor to sign up to be able to order it. And, any literature/research that backs up the usefulness and validity of the test and share it with my doctor.

Physicians who work for HMOs and government agencies frequently are discouraged from ordering "unnecessary tests" to keep the cost of providing patient care down. They may be subject to penalties for ordering "too many labs".

I have heard this from a few doctors. And, cost savings from unnecessary tests are a well known issue.

https://www.choosingwisely.org/our-mission/

https://www.npr.org/sections/health...th-care-costs-undermine-public-trust-in-medic

Discouraging doctors from ordering tests might border on illegality.

No, it's seen as being a wise use of limited resources.

An additional issue I've run into is that, for a test to be paid for by insurance or s government, a doctor has to put an ICD10 code, or diagnosis code, on the order form that corresponds with the test being run. For example, my doctor ran a KIT genetic test for mast cell diseases, and my insurance bounced it. I appealed, saying I had mast cell activation and was on 3 drugs for it and they wrote back, saying "Oh, mast cell activation, yes, that test is valid with that diagnosis."

Having had that happen a few times and had to fight it, I keep a list of ICD10 codes that apply to me, research the tests and my insurance company's policy for what ICD10 codes go with each test, and make sure the doctor notes the correct ICD10 when ordering the test, so it's seen as "medically necessary." And, just a note, here, ME/CFS as a diagnosis doesn't seem to qualify us for most tests. It's better for the doctor to suspect another diagnosis...which most of us also have.

I hope I have gotten better at winnowing out the self-satisfied jerks, asking better questions at the outset and then moving on quickly if the person treats me like I am a problem. I basically ask them if they are willing to play ball: I tell them I don't expect them to be an expert, but ask if they will work with me to look at and investigate various testing and treatment based on what I bring them.

I use a similar approach. Some doctors are great about it, and others aren't worth arguing with, because they'll fire you as a patient in the end or just refuse to help. I've also found that doctors working for large medical systems are more conservative about coloring outside the lines in case anyone slaps their hands, and that independent practitioners in smaller practices are freer to do what they think is best.

 

[gbells]

I've found that a good primary care MD will be open to running a test provided you have a good reason to do it. Perhaps it's a communication issue. The worst MDs I've found regarding ME are the infectious disease MDs. My last one refused a course of doxycycline for a suspected unknown pathogen based on repeated positive for Rocky Mountain Spotted Fever unspecified until I discussed it with him and he relented. But he refused to extend treatment to six weeks which was required because I'm on immunosuppressants. I had to go back to my primary care MD and he was willing to be rational and extend to six weeks. The inf disease MD basically thought the treatment was unnecesssary which is why he refused. The treatment really helped me by curing chronic daily headaches so I suspect I was co-infected by a new bacteria from a past flea bite.

It comes down to whether the MD trusts your judgement and the strength of your argument to justify a test. Many patients don't have a medical background so it is hard for them to evaluate whether or not a test is worth the cost. MDs don't want patients or insurance companies wasting hundreds of dollars on unnecessary tests.

 

[dyllanmurphy]

I was able to find a doc I previously worked with in another state using telemedicine (which is more widely available due to covid), and he ordered the tests I wanted.

It's a good option to have, worth checking out if you run into the problem in my OP.

 

[gbells]

In many states there are places where you can self order and pay for a blood test on your own and they do the blood draw in house.

https://www.anylabtestnow.com/

https://questdirect.questdiagnostics.com/

 

[Sledgehammer]

In many states there are places where you can request and pay for a blood test on your own and they do the blood draw in house.

https://www.anylabtestnow.com/

I used to see them in London but that was 23 years ago. Would like to see them on every High St.