Appreciate your comments on this. It was time for my 3 month Eligard ADT injection on June 24 +/- a few days. Since I had left Kaiser (to some degree due to comments here about avoiding an Advantage plan), I scheduled and had an appointment with a Compass Oncology clinic here. The MO who could see me on short notice ordered the injection. Now, almost 2 weeks later, the clinic will still not do the injection because " they have not received Medicare approval". I thought pre-authorizations for SOC treatment could be avoided by avoiding Advantage plans and using traditional Medicare instead? That clinic did not mention any need for Medicare approval for the MO consult?
Does Medicare EVER deny coverage for a SOC ADT injection????
Had I been with Kaiser, I could have had the injection within 24 hours after the Doc ordered it!!
Written by
maley2711
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Makes no sense. Someone doesn't know what they are doing.
(1) I would go visit them. Ask to speak to their supervisor, and escalate it up. If they are not available, sit down and say you will wait as long as it takes.
(2) While waiting set up some appointments at medical provider offices that know what they are doing.
An incompetent back office can kill just as surely as an incompetent doctor.
(3) I think maybe make an appointment with your Doctor there to ask him about what's going on.
And " if this treatment requires pre-approval, let's get a 1 month shot of a substitute that doesn't require pre-approval."
"And while we are at it can the two of us together call this person, or better her boss's boss and ask him who hired and trained this person? And what are we going to about it?"
Thank you. Fortunately, my T is down to something like 2...or 0.2 ? So, assume the delay is not impacting the RT +ADT eventual long-term outcome ? I have been exchanging messages with the MO's nurse team. Unfortu ately, here in Portland, the other 3 major cancer treatment systems would not see me without a referral from Kaiser.....coverage there ended June 30, and July 1 standard Medicare A +B coverage began. Kaiser refused to provide a referral!!!!
Feeling like the medical system has some type of vendetta against me!!! Compass Oncologywas my last remaining option, and all good until this Medicare delay. My latest question to them was " Has Medicare EVER refused to make payment to Compass for ADT/Eligard PCa patient? " I haven't asked yet, but I wonder if this is because I am new at Compass and they want to confirm my Medicare enrollment before proceeding? I gave them a copy of the coverage letter Medicare sent to me when I enrolled....they won't accept that letter as proof of coverage?
You need to get out of there. There is something wrong with them. Do to another city if you have to.
"Kaiser refused to provide a referral" That sounds like the problem.
Its not whether medicare is approving this treatment. It's whether they are approving you as being covered. If that's the problem, its going to be a problems wherever you go.
I suspect the morons at your provider didn't explain that to you clearly. Most likely because they themselves don't understand it clearly.
In most states you can't ever leave an advantage plan.
In states where you can, you have to do it right. Whatever that means in that state. And the advantage plans, they can't be relied upon to do what they are required to do. Ever.
There is probably an appeal process for this. I would start on that right away. If there is some kind of ombudsman someplace use that as well. There should be someone with your state insurance department of something that can also help.
Don't delay hoping for something to happen. The more delay the more difficult it will be to fix.
Talk to the folks at your provider and make sure you understand what is going on. I suspect it is the above. But you need to know for certain.
I don't recall if you said how long you'd been on Eligard, but speaking only from my own experience, I doubt that a couple of weeks will make any difference with a 3-month injection. I had my last one in January, and now 9 months later my PSA and testosterone are still undetectable. I always assumed that the 3-month duration was a conservative estimate of how long the drug takes to dissipate below therapeutic level, but whether due to slow dissipation or just how long it takes the 'nads to wake back up, mine is still working at least 6 months past the expected duration.
Never heard about Medicare denying coverage for an ADT injection. Maybe call them yourself - they are very responsive. Any reason you're not going to OSHU?
They said they are not accepting patients like me without referral.......and as I said, Kaiser MDs refused to provide referral . Other oncology centers, other than Compass, said the same. One private urology clinic would see me...in 7 weeks!! Incredibly frustrated wth our Fing medical system. Everyone says SOC treatments are always approved with Medicare......so what is the logic in delaying my treatment at this clinic????
Thanks. Good idea. But I don't yet have Part D...will start January 1. Kaiser RO refused my inqury re Orgovyx...no idea if this MO at Compass would agree? I've learned I can assume nothing about how I will be treated by our fing mediical system......only interested in the $$$???
You tried to hop from one treatment system directly to another at the same level. Hence the latter wants a referral from the former. You may have to hook up with a new PCP who will refer you to a new urologist who will refer you to a new oncology team...
Your whole situation reminds all of us that it is best to stick with the horse you started with. If they should decide to not accept new Medicare patients, hopefully you will be grandfathered.
Any new clinic would have all my past records and see that I am Gleason 4+5 and am completing my treatment plan which was RT + 18 months of ADT...still 13 months t go as oof today. Many here proclaim one oof the great things about Medicare is that you can see most providers and don't need a referral!! Also that very few providers aren't accepting Medicare patients!!?? Compass Oncology was very helpful in agreeing to see me just one week after I called....later I was told that they always keep a few slots open for "urgent" needs such as mine....ie timely injection!! Then, the Doc orders the injection...told will be called in approx 3 days to set a date& time...but now this delay foor Medicare approval???
I love the USA, I love the people, I love the scenery but I’m so thankful I live in Australia when it comes to easily and inexpensively accessing high quality medical care.
When my husband was getting Eligard shots there was never a pre-approval required. I can't imagine why the new provider would require a referral from Kaiser. Are you still on Medicare Advantage? Is it some sort of Medicare Advantage requirement? I can understand the new provider wanting your medical records. Did Kaiser transfer your records?
" Appreciate your comments on this. It was time for my 3 month Eligard ADT injection on June 24 +/- a few days. Since I had left Kaiser (to some degree due to comments here about avoiding an Advantage plan), I scheduled and had an appointment with a Compass Oncology clinic here. The MO who could see me on short notice ordered the injection. Now, almost 2 weeks later, the clinic will still not do the injection because " they have not received Medicare approval". I thought pre-authorizations for SOC treatment could be avoided by avoiding Advantage plans and using traditional Medicare instead? That clinic did not mention any need for Medicare approval for the MO consult?
Does Medicare EVER deny coverage for a SOC ADT injection????
Had I been with Kaiser, I could have had the injection within 24 hours after the Doc ordered it!! "
I don't believe you can switch from Kaiser Medicare Advantage to regular Medicare outside of the Open enrollment period that starts on Oct 15 and runs until Dec 7. As far as Medicare is concerned, you must pay for any services not authorized by Kaiser out of pocket.
" Appreciate your comments on this. It was time for my 3 month Eligard ADT injection on June 24 +/- a few days. Since I had left Kaiser (to some degree due to comments here about avoiding an Advantage plan), I scheduled and had an appointment with a Compass Oncology clinic here. The MO who could see me on short notice ordered the injection. Now, almost 2 weeks later, the clinic will still not do the injection because " they have not received Medicare approval". I thought pre-authorizations for SOC treatment could be avoided by avoiding Advantage plans and using traditional Medicare instead? That clinic did not mention any need for Medicare approval for the MO consult?
Does Medicare EVER deny coverage for a SOC ADT injection????
Had I been with Kaiser, I could have had the injection within 24 hours after the Doc ordered it!! "
I thought it was clear that I DID NOT enroll inANY Advantage plan and went with regular Medicare instead....on advice of maany folks here.
In my eight years of Medicare Advantage, now in the latter days of my ninth year with PCA I never had any problems scheduling or receiving any kind of treatment medicine.
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