Anyone familiar with 'in-network' insurance

[madmax]

I have Aetna Health Insurance. I must use doctors that are 'in-network' and I need to get a referral from my GP for any specialists.

This is the first time I've had to go through all this bullshit with my health insurance. I've had rheumatoid arthritis for 10 years and was diagnosed with cancer last year.

These doctors practically make me beg for an Rx or a referral to a specialist.

My question is do these bastids get some freaking bonus points or what for keeping Rx's and referrals low? It's total bullshit already.

I have a pelvic fracture that I need x-rayed and my RA dr. who also specializes in osteoporosis passed the buck and told me to ask my GP or my Oncologist (she does that all the time). WTF........She's the bone lady! My appointment was today so I also asked her to refill an inhaler that my other RA dr. (moved to Ohio) prescribed for me when I get a cold because my chest gets congested and it won't go away for months... no - she said, I didn't need it. I could barely breath last night. Slept sitting up. I've tried to find another RA dr. but, it's slim pickens here for one that is "in-network".

Anyone know anything about this 'in-network scam. Or am I nuts.

[virgogal]

1. =Read the fine print. I have dental insurance like that. I can go outside the

network but the coverage is much less.

[madmax]

3. Yes, they allowed me to use a radiologist

who does osteoplasty. It's crazy glue injected into fractures. I had 3 pevlic fractures and couldn't walk. The only reason I found out that I had them was I demand to see all test reports because these batards almost killed me once. I can't read the films but, I can read the report findings and summary. I had to act as my own dr. and research what could be done for the fractures because the pain was unbearable and I was sitting in a wheelchair for 3 months.

After the 3 fractures were glued I started physical therapy and now I can walk and even climb stairs. There is still just one more that needs a glue job ;)

[virgogal]

5. Ouch ! I wish you well,I truly do.

[madmax]

8. Thank you, friend

:hug:

[liberal N proud]

2. In network is very normal

Most allow provisions for you to use out of network doctors but it just cost you more. We use an out of network Dentist because Delta Dental in network Dentist suck in our area. It cost us 50% more than if we used in network.

[madmax]

4. I was just wondering if they are in the network because

they agree to hold off on tests, Rx's and the like. I've tried to get an appointment with another RA dr. but, she refuses to deal with Aetna.

[abluelady]

6. I Don't Think So

From my experience certain providers are more prominent in certain areas/regions. The more subscribers they have, the more money they make. I haven't seen them doing less tests, etc.

[madmax]

7. I need to get my

:tinfoilhat: Ever since the major screw up last year. I see stupidity and conspiracy everywhere. And this was at Duke, no less. I've learned my lesson, be your own advocate or you will be S.O.L.

I'm so grateful for the inter-tubes and the googles. I'm able to question those few Doctors who think they're God and try to blow us mere mortals off.

[uppityperson]

11. Just because a doc is associated with someplace doesn't mean they listen or are good

endocrinologists I had trouble with were at UW Med center (university of wa med center, a VERY good place, lots of research, etc). They were incapable of listening. Seriously. I saw 2 different docs there and they had made up their minds without hearing what I had to say. Pissed me off so I refuse to go back there.

Why go to a doc that tells you something stupid simply because they are "in network"?

My problem was I was reacting to different fillers in thyroid pills, depending on manufacturer I would have allergic reactions or none. The learned endocrinologist told me I was having "reoccurring eye infections" that just coincidentally happened when I got a new rx refill from a particular manufacturer. "No one EVER reacts to the fillers". Oh bs. I been in the business long enough that you NEVER say things like that. ALWAYS qualify "hmm, I've never heard of that before. I don't think it is possible" is different from what he said.

Turns out it was the fillers, got onto a brand that doesn't cause problems. Argh.

You have to be your own advocate and sometimes that sucks. Edited to add, beware though of the internets and the google. People have a tendency to write online about stuff they are not happy with, leading one to think perhaps no one is happy with a particular treatment, medicine, etc. But those who are happy don't usually go only to complain. If that makes sense.

[madmax]

13. Wish you lived closer we'd kick some butt ;)

My dr. in NJ knew about the fillers because one of the drugs I take for RA in generic form didn't work so he argued with the ins. co. for me to get the name brand.

Some dr's care, some don't. We just have to be brave and never think that because they have some letters at the end of their name that they know it all.

You sound like you can handle being your own advocate. Yes, it sucks sometimes but, what's the alternative. Let them mess around with our well being. Hell no.

Re: Google and the net - I research drugs and therapy, side affects, etc. I found out about the osteoplasty for fractures from a newspaper story. It's especially helpful for fractures in the sacrum or pelvis due to the fact that they are extremely painful,take long to heal because of body weight on those bones and movement.

Guess it was a human interest piece about a guy with scaral fractures who had this done and within a week - no more pain and he could walk. I too, had 2 sacral fractures and 2 pelvic fractures. I was cracked back to front ;)

It was a coicidence that the same radiologist who does my scans performs this osteoplasty. Called them and the rest is history.

[liberal N proud]

12. Doctors do join the networks because it means customers or patients

Greed once again is the driver behind the business decision.

Not about tests of even about treating people.

[madmax]

14. And who drives the greed.

You can't watch an hour of tv without being bombarded by pill pushing Big Pharma for everything from a limp pecker, PMS, PAD, and on and on. People get this crap in their head, 'oh, yea I have THAT!'. I want to put the least amount of chemicals in my body as I can.

I think we're becoming a nation of hypochondriacs. I wish I never had to take any meds. In my heart I believe the meds for the RA caused a lot of other problems including cancer. When I took immune suppressants for the RA the warnings were susceptible to TB and infections. If you listen to them now it includes a cancer warning.

[liberal N proud]

15. Indeed

[uppityperson]

9. In-network (some cases preferred providers) don't make more money

They agree to take whatever the insurance co pays, which is a lot less than what they charge people without insurance (which is another issue for later). They agree to take what the co pays, in return they are allowed to see/be paid for seeing people with this insurance.

You have to get referrals and jump through the right hoops to make sure providers will be paid and you won't be stuck with the bill. This, theoretically, is to make sure you aren't getting random unnecessary stuff done, but in actuality has turned out to be a time waster.

35 yrs ago, there was little overall oversight in what people got done or by whom, how long they stayed in the hospital, etc. Now it has gone too far the other way, leading to a new occupation of figuring out how to do the billing, referrals, all that. My doctor's office has 1 person who specializes in this, she does brilliantly and is wonderful. Other places may not have a good person who knows how to work the system.

I managed to get into the Aetna network as a provider recently (massage therapist) which means I now can get paid by Aetna. For 10 yrs they said there were enough on the list locally. Unfortunately, of the 5 local ones, one moved, 3 were only part time and the 4th was rarely available. I managed to get into network because someone on their list died. Due to the local economy I am now only rarely available, leading people with this insurance having to scramble to find anyone who can see them.

I am ready to go out of network for an endocrinologist as the ones available to me are awful. You sound like you need a new RA doc, one who won't pass you on. Paying for insurance, then not having a doc who is decent sucks. I would write a letter to the insurance company about this doctor, trying to be as objective as possible. If there is another RA doc around you'd like but isn't on the list, put her/his name in also, asking if it is possible to get him/her on the list or the visit paid for in any way.

[madmax]

10. Thanks for the suggestions and information.

I am at the end of my tether here with this RA doctor. We moved to NC 2 years ago from NJ. We had Aetna but, without all the bullshit. My husband now works for another company thus different policy. I'm also covered with Medicare due to the RA and now cancer.

I agree the pendulum has swung to far in the opposite direction and in addition to possibly saving money, it may also be costing lives. I'm not going to be a victim.

Since I first met this hematologist I had the gut feeling that she just wrote me off because I was diagnosed with cancer. Instead of ra drugs she had me on Dexamethasone which while keeping ra inflammation down creates a whole new set of side effects such as bone thinning, weight gain and general insanity. It's cortisone on steroids and I was taking a lot. I put my foot down and told her I wanted to be on the same ra regime and drugs I was given by my dr. in NJ. She gave in and I'm almost as good as 2 years ago.

Ok, I'm on a rant here but, thanks for the tips and your patience. I'm going to keep on pushing for what I need, no matter how hard they try to make it.