Corrections added Jan 10 as noted. See sections marked “Update 1/10”. See also my comment tonight on today’s disgusting experience of trying to sort this out, and our ultimate rescue.
Two months ago I posted Let Patients Help, Cost-Cutting Edition, part 1: a bill:
I often hear about how patients are a major part of the cost problem – their “non-compliance,” their wanting everything they can get, wanting it for free, etc. So, let’s see what happens when a patient who wants to help cut costs gives it a try. …
In that case I tried to fathom a so-called “Explanation” of Benefits, which was in fact unfathomable. (The FTC forced cigarette makers to be truthful in labeling; can’t they force insurers to stop using “explanation” on something nobody understands?)
This time my wife and I are shopping for vaccines. Specifically, shingles. And trying to be a responsible consumer turned out not to be easy.
Shingles (herpes zoster, aka chicken pox) is a nasty condition that develops sometimes in elders who had chicken pox as a kid. (Wikipedia: “The immune system eventually eliminates the virus from most locations, but it remains dormant… in the ganglia adjacent to the spinal cord … or the ganglion semilunare … in the base of the skull.”) When it awakes, it is nasty painful – my mom had it for months this summer – and there’s not much of anything you can do. You just suffer, until it’s damn good and ready to go away.
And I mean suffer. It’s debilitating. Mom’s cropped up as she was recovering successfully from otherwise-uneventful hip replacement surgery(!) … apparently it’s not uncommon for this to happen when one’s system is challenged, e.g. by surgery.
There’s a vaccine, and it’s recommended for everyone over 60. So my wife and I decided to get it. (Nothing like a close family member with a recent horror story to get you in gear.)
But guess what: the vaccine is wicked expensive – at least $200 – and Medicare doesn’t cover it! Update 1/10: Medicare “Part D” (the D-for-Drug/prescription supplement) does cover it, but a lot of people don’t know that – including people who work for Medicare! See my comment tonight. Nor does AARP’s supplemental insurance. That’s Medicare “Plan N.” On the other hand, my private insurance – the New Hampshire high risk pool – does cover all immunizations … but there’s bureaucracy. Here’s what we found – a collection of anecdotes:
- My mom said a local grocery store’s clinic offered a deep discount if you fill out a long questionnaire. Not available here.
- My uncle in Atlanta got a verbal approval from his insurance before he & wife got it – then the claim was denied anyway, saying “Well, what that agent told you was wrong.”
- I called my plan, NHHP, and got a verbal okay. I called again, got a different agent, got a verbal okay. Called two weeks later, got another one. Went to Walgreen’s yesterday,which advertises it, and they said “Your insurance doesn’t cover it.”
- Called the insurance company today (they’re not open weekends), and learned they cover it but only at the provider’s office, not at a pharmacy (What??) I’ve found a really good guy at the insurance company to discuss things with, and I told him I again want to do some comparison shopping.
- I said “You still won’t cover it at the pharmacy, even if it’s more expensive at the doctor?” They said yes but only if I pay for it and submit the paperwork. How long will it take to get reimbursed? They don’t know – “It might not be very fast.”
- In an earlier episode I’d learned they don’t keep info on which providers offer the best price for various things. I suggested they offer it – chances are pretty good they do have some historical data, and should publish it!
- I called Walgreen’s and asked the price: $220.
- Called my hospital (Beth Israel Deaconess) to inquire about their price.
- Main switchboard didn’t know what a shingles vaccine is or where to get prices; referred me to my provider’s office. (No problem.)
- They referred me to the travel clinic.
- Travel clinic said they don’t do it anymore – it’s now in Infectious Diseases.
- Infectious Disease clinic charges $298. Or, $209 if you pay in full at time of service. And btw, they only offer shingles vaccine on Tuesdays. (What??)
- I’ve been excited that Dartmouth-Hitchcock, a great quality organization, is opening a new facility near me next week. So I called them, and their price is … hold your breath… $360 plus $44 “to stick the needle in your arm.” Yes, $404. (She said they make Medicare patients sign a special waiver saying they realize it won’t be covered.)
- 1/10 update:
- When we got the bill from Beth Israel Deaconess today, we saw that the $298 is $235 for the vaccine and $65 to stick the needle in your arm.
- Meanwhile today on a concall I heard (just grapevine) that Dossia.org is offering client companies information about, for instance, the prices for all the local MRI shops. That is a wild idea – offer us comparison shopping data. Woot.
All in all, my wife is assessing whether it’s worth the cash. Like everyone in this economy, we have plenty of concerns about cash.
- Update 1/10: I convinced her she’s worth it – and then today we found out that Part D does cover it. (How many people skip the vaccine because they were told it’s not covered??)
Whether it’s worth the cash was Mom’s concern, too, as she postponed it for years, until it was too late.
- Update 1/10:
- But now, it appears she could have had it four years ago: Part D plans covered it starting in 2007 (see this post on the AAFP site).
- Now this is pissing me off: this screw-up cost my mom months of agony, lost sleep, pain, exhaustion, a ton of family work caring for her, and pain, and suffering. All because this industry is such a disgusting, disorganized, misinformed mess that needed information doesn’t reach the people for whom it was created. For years!
Here’s what I want: Let Patients Help, and that includes controlling costs. Don’t you dare say we don’t care about healthcare costs, if you make it hard for us to shop. Please – help us help! Give us the information!
And please, insurance, when we find something cheaper, accept it…??? Let’s put an end to this malarkey of “Gosh, costs went up – we had to raise our premiums.”
p.s. Flu vaccines:
- Walgreens: $32
- Beth Israel Deaconess: free, in your provider’s office
- Dartmouth-Hitchcock: $46-$56, plus $44 to stick the needle in your arm
will check prices of flu vaccine and herpes vaccine and will revert.
Here is what is valid (unless healthcare budget cuts change it):
-preventive medicine including vaccines for children and grown-ups (e.g vaccine for HPV is available to females of 11 to 26 years of age,it costs approx. 500euro each of the 3 shots if obtained outside the public healthcare system).
-vaccines for children are here too reimbursed by social insurance if made by the doctor in his practice
– there is a list of the official mandatory vaccines and one of the electives
-some vaccines are available through Institut Pasteur in Athens others are imported, those imported are also available at pharmacies. One may chose he/she does not want to go to the public hospital, then he might buy the vaccine on the market (not reimbursed) and have the injection made by a doc (doubt that a doctor here would charge less than 50euro)..
Unfortunately, you won’t know whether or not it is actually cheaper … because the $220 that Walgreens quotes you and the $298 the infectious disease clinic quoted you are the amount that they charge the insurance company … not necessarily the amount that the insurance company will pay …
Yeah, Lisa, since I’m not a client at Dartmouth-Hitchcock, they gave me the billing codes they use so I could ask the insurance company for the actual numbers.
And that starts to touch on something that’s so irritating I don’t even want to get into it – the uninsured (who already have enough problems) get charged WAY more than the prices negotiated by the insurance companies. I don’t object to a company negotiating a better price – but something has gone seriously immoral when the net effect of anything is that the (many) people who are already in trouble get squashed more severely.
When I left my job two years ago, in the 3 days before COBRA cut in, I went to get a cheap prescription refilled. Its price had always been $4. They said “That’s $11.” I said what?? They said now that I didn’t have insurance, my price had almost tripled. That’s obscene.
Of course I came back in a couple of days when COBRA had cut in.
Grrrr…. and we keep seeing news articles about the many families who don’t fill their prescriptions, and the high cost of care that results. When will policy people get it through their skulls that prevention is cost-effective and shouldn’t be discouraged?
Dave, you may have explored this option, but:
Medicare Part D plans are obliged to cover the shingles vaccine (see p. 4 of linked PDF): https://www.cms.gov/partnerships/downloads/11315-P.pdf
Generally Medicare eligible people can only make MA PD elections each fall for the following calendar year – but it can’t hurt to check the list of special qualifying situations: http://www.medicare.gov/navigation/medicare-basics/sign-up-part-c-and-part-d.aspx#otherspecial
The price of the shingles vaccine may or may not exceed the annual premium amount for your Part D coverage – MA PD premium rates vary from region to region.
Thanks, Greg – get this – the hospital submitted to Part D while we were there, and Part D rejected it! I called and they said Part A covers it. Called the hospital back; they said no, D. I said so what do I do?? They said I don’t know. I said I’d call the president’s office, and suddenly new help was possible: she found that CDC page that says it’s covered.
Then Part D called back (Hooray! They’d investigated after we hung up!) and said they want to clear it up so they got Medicare Coordination of Benefits on the line. SHE said part D does NOT cover it! I told her it’s right on the CDC site, and she said “It is??”
Unbelievable. Anyway, turns out the system somewhere still has my old COBRA info from last year and thinks THAT will pay for it so plan D should reject. Next step will be to clear that up.
I’d like to say “This system costs too much but at least it’s run well.” No.
Unblievable.
Agree – Unbelievable!!
Dave, you should pull a “do you know who I AM!!1!?” on them
:^D
While Medicare D plans ARE obliged to cover the vaccine, I’m not all that surprised by the reply you’ve received. Another tack is to casually suggest that your congresspersons will be interested to learn of your insurer’s creative interpretation of the governing statutes and regulations. Insurers quake at the thought anyone at the federal level might invade the stranglehold they have over how they conduct business in the friendlier confines of state oversight.
Greg,
> pull a “do you know who I AM!!1!?” on them
Yeah, but: a) that’s not my style, and b) like the doctor who recently refused to pull rank, I don’t want distorted coverage – I want to see what the real experience is like for the ordinary schmuck with no name. So that’s what I act as.
> Medicare Part D plans ARE obliged to cover the shingles vaccine
Greg,
I’ve heard from several people now that they were given the okay before, but then the claim was DENIED and they were out the money. I’m starting to wonder if this is a widespread scam, or what. Any idea where I can find the explicit policy that requires this, so denied people can shove it up the company’s nose?
For comment subscribers: tonight I added substantial updates to the post above. Here’s what else happened today, when we went in for the vaccines – we got quite an education.
First, getting the vaccine was no problem, though I forgot to ask why they only offer it on Tuesdays in this little basement clinic.
As expected, my own vaccine was covered by my NHHP high-risk plan.
For my wife’s we had decided to pay in full, to get the $209. But then as we left for the other building for the scan Ginny was getting, she mentioned that she’d paid $298 out of house account, nearly draining it. “What???” I said. “They said it was $209 at time of service.” She said the desk said Medicare DOES cover it, so they’re charging the full amount; but it had been rejected for some reason, so we needed to go home and download a form and submit it and wait.
Ginny got out her three different Medicare cards (main one – Parts A and B; “Plan N” supplemental through AARP (“Medigap”); and Part D, MedicareRx, also through AARP, administered by UnitedHealthcare). I called Plan N, and Eileen(?) told me it’s covered by plan D.
I called Plan D and Christina told me no, if it’s done in the hospital, it should be covered by Part A, Hospital; Plan D only covers it if it’s a prescription.
I called the Infectious Disease dept back (the ones who’d done it), and the desk woman said no, Part A and B don’t cover it, Part D does it. I said “Well they just said you’re wrong, and you’re saying they’re wrong – what am I supposed to do??” “…I don’t know.”
There was no way in hell I was going to get jerked around like the many people I’ve heard about – I didn’t expect her to know everything but I sure wasn’t going to get bureaucratted up the wazoo. So I said “Never mind, I’ll call the president’s office and see what I’m supposed to do to sort this out.” And: “Is there any policy I can at least quote to the Plan D people to tell them they’re wrong??”
She realized: “The yellow sheet we gave you about the vaccine – do you have that?” And there it is, at the bottom of the page – URL: http://www.cdc.gov/vaccines/vpd-vac/shingles/vacc-need-know.htm, saying: “All Medicare Part D plans cover the shingles vaccine. The amount of cost-sharing (money you have to pay) for vaccination varies.”
Armed with this, I planned to call Part D back. But they called me first – amazingly, Christina had followed up to chase down the problem (!), and a Frank Wagner called us. He’d determined that the real reason for rejection was that the system thinks Ginny’s on MY Part D. I said I’m not old enough for Medicare – I can’t have a Part D!
(Are you insane yet? I was.)
So Frank got the Medicare Coordination of Benefits department on the line, and we were just going through authorizing me to talk for Ginny (she feels that I, ahem, argue more effectively) when Ginny got called in for her scan. So, Frank and I continued with this woman, without getting into HIPAA-compliance areas.
I understand that this woman’s job is to defeat fraud, but she was no star at customer service. It wasn’t just that she was suspicious; she plainly thought I was a geezer who couldn’t think straight.
First, she said (I’m not making this up), “Part D doesn’t cover the shingles vaccine.” I said “It does; I have the URL for the page on the CDC website.” Disbelief: “It does??… Well, that’s not my business, I’m just doing coordination of benefits.” Fine.
Frank had said he’d found the problem (the system thinks Ginny’s on my Part D). I repeated that I’m not old enough for Medicare – I can’t have a Part D! A couple minutes later that came up again and I repeated it. Finally, toward the end of the call she said, “Well, you CAN’T have a Plan D, because you’re not old enough.”
By now my mood had shifted from insane to disgusted.
She left the call. Frank and I continued, realizing that though I don’t have Part D, it’s probably my COBRA, which expired in August. Frank agreed to call us back at our convenience later, get Ginny’s okay, and complete the clean-up. He did, exactly at the promised minute, and the correction was completed in 15 minutes, well under the 30 he’d promised.
Frank Wagner was one heck of guy today, professional, capable, punctual, effective. This would be a different healthcare industry if everything – everyone I spoke to – acted anything like him. And I almost fell off my chair when he first called and said that Christina had followed up after our frustrating first call. Do you know how many people I’ve seen in health insurance who follow up after a problem? Zero, until now.
So, big props to UnitedHealthcare, and thanks to the desk woman for thinking of the CDC page to use as evidence against the many people who don’t realize that Part D has covered the shingles vaccine since 2007.
Next step: In the morning, when I call back to have them submit the charge again, we’ll see whether it goes through.
If crooks had designed a shell game where it was impossible to track down what’s happening because people are prevented from knowing the rules, and all the players and cops have given up, it would look a lot like this. Except for people like Frank.
re: “Frank had said he’d found the problem (the system thinks Ginny’s on my Part D)”
For reference, Medicare coverage is entirely individual. There is no “dependent” coverage status. So you can’t be “on” your wife’s Part D coverage, or vice versa.
Also, you’re right – Frank’s da man (tho I don’t know him & have never talked to him). There ARE more like Frank, just not enough more.
re: “If crooks had designed a shell game where it was impossible to track down what’s happening because people are prevented from knowing the rules, and all the players and cops have given up, it would look a lot like this.”
You’ve really captured it here, Dave. May I quote you?
Yeah, blogs are not exactly confidential. :-) Simple: “As e-Patient Dave said on his blog the other day [link link link], ‘If ….'”
Twitter buddy @Health311 adds this short PDF. It’s a three page memo from May 2006 (5-1/2 years ago!) with this opening sentence:
Then @Kari_On added: “Medicare RX plans must cover all commercially-available vax (i.e. shingles vax) http://1.usa.gov/zndUdu,” which includes this:
So now we come down to: whose word must the insurer accept regarding “medically necessary”?
Dave,
As the plan communications writer for the Medco Medicare Prescription Plan, I can assure you that certain vaccines are covered–and have been covered–by Medicare Part D. What may be confusing many people is that up until 2008, the administration fee associated with these vaccines was covered by Part B (so Part D covered the cost of the actual vaccine and Part B covered the doctor’s fee to administer it.) Here is an excerpt from a communication I wrote for physicians regarding the CMS guidelines:
I recently blogged about a study by the U.S. Government Accountability Office (GOA) that shows most Medicare beneficiaries have not received routinely recommended vaccinations covered by the Medicare Part D program. The GOA reports that a relatively low percentage of doctors and pharmacies stock the shingles vaccine due to factors such as purchasing costs, storage requirements, and challenges with obtaining reimbursement from Part D plans. Since doctors can’t add the vaccine charges to their bills under Part B, seniors have to pay out of pocket for the vaccine and await reimbursement from their Part D plan or use a pharmacist who can administer the vaccine and bill the Part D plan for both costs.
Incidently, one of my readers told me that after reading my blog she went to CVS to inquire about the shingles vaccine. The pharmacist told her, “Medicare doesn’t cover it.” So clearly we do need to get the message out loud and clear — I’m going to blog on this topic again and make this a priority.
Awesome awesome awesome! (I took the liberty of “blockquoting” that excerpt you posted.)
Yes, if something has been a regulation since 2006 and a CVS pharmacist still doesn’t know about it, we have a *massive* fail going on!
One place for our outreach will be *to* CVS etc, to train their pharmacists – because if the pharmacist is turning down business I’m sure the company won’t like that.
(Otoh, I wonder how many times that pharmacist has had a claim rejected by an insurer! This whole thing smells like a messy cesspool that will take some time to unclog.)
well…as Peggy’s post notes, pharmacies, and pharmacists, face some of the same issues as MDs re: Rx inventories, etc – so CVS (or any chain, or independent, or mail-order – pharmacy) may not be all that upset about the situation…. But they probably would want to revisit how they handle this vaccine if they continue to get this kind of unwanted public smackdown… ;^)
Dave — I recently got a very similar run-around from Golden Rule. I’d talked to them 2-3 times to confirm they’d cover the shingles shot and the answer always was “yes.” I had the same issue with providers; my PCP doesn’t give the shots. That left the local pharmacies and, for some reason I never understood, Golden Rule would not allow them to bill directly for the service. So I got the shot and filed the claim with Golden Rule myself and, of course, they turned it down. Arrgh! But I called to appeal and was lucky to get a very diligent service rep who agreed that it should have been paid, took it up the chain to her supervisor and I was finally reimbursed.
I just wonder how many people simply give up on trying to get reimbursement, even though they probably are entitled to it. And if the insurance companies count on that!
Today I called Beth Israel Deaconess back and said “The problem at United Healthcare is fixed – can you resubmit?” “No. You’ve already paid – go to their site and get the claim form and submit it.”
> I just wonder how many people simply give up on trying to get reimbursement,
> even though they probably are entitled to it.
A lot, I bet. The tone in the voice of the Medicare employee yesterday suggested a significant disrespect for her customer (wife & me), and I imagine that’s not limited to that one location.
> And if the insurance companies count on that!
I don’t know if it’s the insurance companies or what, but the rules sure aren’t clear.
Are you willing to go back to Golden Rule with the documents I linked above, in earlier comments today, and talk to a supervisor to request that they fix the misinformation?
So Dave, you’ve inspired me to work harder on getting the message out that Part D does in fact cover the shingles vaccination. After getting several e-mails from readers and a few senior family members and neighbors, and then reading your post, I realized that if CMS is not going to take responsibility, the little people are going to have to speak out. So today I posted “Yes Virginia (and ePatientDave), the shinges vaccine really is covered under Medicare Part D”
http://themeddiva.com/category/vaccines-and-vaccinations/
I then did some further digging into the CMS document that has health literacy advocates like me pulling our hair out — the Evidence of Coverage (EOC) — and I am appalled at not only the lack of information provided about vaccinations, but also at all the doublespeak used to explain the coverage. (I have to work with the EOC every day, so I don’t even want to get started on how much I hate this document.) I’m going to discuss this in my next post and hopefully help some people better understand what they need to do in order to get their plan to cover the vaccine. (I knew I should have bought stock in a company that makes red tape!)
Dave —
A fascinating story. On a related #letpatientshelp note, One of the big three payors in Massachusetts is apparently kicking off a new program that will incentivize patients to find the lowest (we hope lowest reasonable) cost for diagnostic tests. See: http://visibli.com/E0cvgn Harvard Pilgrim Health Care says it will pay patients $10-$75 if they shop around and find a lower-cost diagnostic test, saving the insurer money.
I was post chemo and desperate to get the vaccine because I’d learned people can get shingles from the stress of chemo. I wasn’t going to suffer from ANYTHING that could be prevented, after what I’d already been through. So I ran around looking for it and learned that, first, it is mysteriously unavailable for long periods of time. No place in my city had it for 6 months from when I started looking. Then all at once everyplace had it — Safeway, my doctor’s office, the hospital pharmacy. I rushed to get it. Because I was only 57, and my insurance only covered it if you are 60, I paid for it myself. Just wrote out a check for the $200+. I was not going to wait around for 3 years and trust the fates just to get out of the 200 bucks. Walking out of there after the shot I thought, Phew! Dodged one bullet, at least. Three months later my husband, who is two years younger than me, got shingles. I. could. not. believe. it. But he had been my caretaker during my cancer, which is real work, and he’d been just as scared as I was during it, which is plenty stressful. In fact, we had been warned from several quarters that the caretaker often comes down with some kind of illness once a crisis like mine is over. Yet in my shingles campaign, it had never once occurred to me that he would be the vulnerable one. So as they say, if you want to make the gods laugh, tell them your energetic plans.
I’m 50 and had a full blown case of shingles a year ago. You can bet I looked high and low for a relief to the pain and rash at my rib-line. I found a very effective solution in keeping a spray bottle of vinegar around. I would spray it on hourly or whatever was necessary – and wild as it sounds- it kept the symptoms effectively at bay until full remission a couple of days later. Don’t know why a vaccine would do any better…?
Mike, your experience not only bears no resemblance to the experience of people I know who had the disease, it makes no sense at all: spraying a pH-changer on the skin would affect a virus on the spinal cord? I don’t think so.
If it worked for you then I’m happy but I’m not going to let it look like I’d recommend it to anyone.
I removed the Shaklee URL from your signature. I presume that not all Shaklee reps would make such loony claims.
And if you really don’t know the difference between a vaccine and a treatment, well, good luck to you.
I WAS VERY LUCKY,I HAVE HUMANA GOLD AND GOT MY INJECTION LAST WEEK.PAYMENT WAS $80.00 FOR THE SHINGLES.THANK GOODNESS ,MY SISTER IN LAW GOT THE SHINGLES LAST MONTH,SHE SAID IT WAS A LOT OF PAIN,SO I WENT TO WALGREENS AND NOW I AM GLAD I DID.
From Dave: here again I’m pasting in a “de-linked” copy of this spam comment that arrived, as a teaching example for people who don’t know how comment spam is done. Losers like this think this is the best shot they have at making a living.
The distinguishing signs of spammers: off topic (shingles has nothing to do with melatonin), with a link to their site, and a bogus email address on the sign-in form.
In the past such comments would be totally random, but spam filters learned to ditch them automatically, so now the losers take the time to insert some wording from the post – in this case, “shingles lesions.” But spam is spam.
Here’s the specimen:
_____________
The lesions that you can get from shingles are of course annoying, itchy and can be quite painful at times. ;
Most recently released blog post straight from our blog
http://www.melatonin____/______/
Worked in a nursing home years ago providing care to a ‘Shingles’ infected elderly lady. Her rash (lesions) was so severe that she would scream whenever we tried to touch her, extreme pain and suffering. Come on Medicare – show you really CARE!! (providers of vaccine also)
Was shocked that Medicare and secondary insurance does not pay for shingle relief. To me this is a form of stealing from the suffering. Our government wastes so much of our tax dollars. Our senators have taken so many perks for themselves and refuse to have Medicare cover the shingles shot. It is too much money for the average american to spend for pain relief. Part B should cover this expense. The senior citizen did not get an increase in Social Security even though the cost of prescriptions and the cost of their day to day living expenses went up this year. The senate needs to understand what is going on in the life of the senior citizen. This is why I am writing with the hope that my cry will be heard by our leaders to lead more fairly.
Sincerely,
MryAnnTK@aol.com
I am disqusted that AARP hasn’t been able to get the shingle vaccine shot covered for older Americans . Medicare D coverage varies and my dear friend’s savings was $7.00 at a cost to him $217. & w/o coverage the price was $225.
Medicare D is not designed to help older Americans it is confusing and poorly organized by design. What is wrong with our Governent that they can’t or are unwilling to cover the necessary prescriptions . They took money away from Medicare to pay for Obama Care & this is the results….and it’s only the beginning!