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PostPosted: Sat Jan 30, 2016 4:09 pm 
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Ive been taking Suboxone for around a year and 1/2 , been going to the same Dr I pay out of pocket each visit, and he never had my medicaid information, never had any problems with paying the Dr's office 150$ each month then medicaid would cover my prescription at the pharmacy. When I first started I did all that "Prior auth" crap to have them cover the script. Long story short one day a couple months ago I take new sub script to my pharmacy and they tell me Medicaid wont cover it anymore , I asked why and only thing they tell me is some bs that my Dr's office's "Dea Numbers aren't good" All of a sudden. I asked my Dr and they told me they stopped participating in medicaid and they never accepted it in the first place everyone had to pay for each visit there, I remember asking if they accepted it in the first place and they did not.

I guess my question is since Ive always paid at the drs office the full amount and medicaid was never involved, how come I cant have my prescription covered at the pharmacy anymore? It worked for 8 months or so , and now even though I pay out of pocket and never included dr with my insurance they wont cover it at the pharmacy?

Any help is greatly appreciated, Ive been paying around 700$ a month at pharmacy and now the sub discount card only works 4 times I cant afford my prescription. A side note the drs office tried to drop me and didnt want to let me back since I have medicaid , but they always knew. Im still at the same dr but had to sign a stupid medicaid thingy .


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PostPosted: Sun Jan 31, 2016 12:48 am 
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I can explain it, but most people are going to be bored to death by all of this. But if you read it, you will get a small sense of why docs complain about medicine, and why there are so few doctors going into the non-procedure specialties like psychiatry.

For the writer of the post, I'm not why this is happening now, and not about 10 months ago when the policy changed... but part of 'obamacare' requires that medicaid only cover medications if doctors are registered with medicaid. Understand that medicaid pays very low rates for psychiatry visits--- literally less (a lot less) then you would pay for a plumber to come to your house and spend an hour fixing a leaking faucet, and less then you would spend for someone to sharpen your lawn mower blades. I'm trying to think of all of the other things out there that cost more than $37 bucks... I don't mean any disrespect to plumbers or blade-sharpeners, but if they had to run their businesses by setting aside appointments for people to bring in their blades, and were forbidden to charge the people who didn't show up on time with those blades (as medicaid forbids docs from charging for missed appointments), they would have a hard time staying in business.

So many docs don't sign up with medicaid. Up until recently, medicaid agencies would still cover the scripts those docs wrote. But one of the many little features of obamacare, that nobody took time to read about before signing it into law, was the requirement that by 2015 medicaid agencies had to stop covering scripts by doctor who didn't join up with medicaid. Understand that when a doc participates with any insurer, including medicaid, that doctor agrees to accept whatever the insurer pays as full payment, and is not allowed to bill the patient for the rest (which is called 'balance billing'). So if your doctor signs with medicaid, he/she has to accept their fee schedule-- something he/she has no ability to negotiate over-- as 'full payment.'

The 'affordable care act', to use the official, silly name, essentially played chicken with doctors--- except it was patients who were used as the bargaining chip. The law made the bet that doctors like yours would HAVE to give in, and join medicaid-- because if they didn't, their patients would be abandoned. But doctors with large numbers of medicaid patients-- like addiction docs-- just can't keep their doors open with medicaid payments. I know of a couple practices in Milwaukee who make it work by setting up assembly-line practices, where nurses do all of the work, and the doctor basically says 'hello' to 20 people per hour. It can also work in multi-specialty group practices, where the larger payments for cardiac catheterizations or knee surgeries can subsidize the income for the non-procedure docs. But for single psychiatrists or groups of psychiatrists, the numbers just don't work.

In Wisconsin, the medicaid agencies were smart enough to see what was happening, and they created a way for doctors to join medicaid, meeting the requirements of the ACA, without participating in reimbursement contracts.

I don't know where you live-- but doctors have been able, in the past, to belong to medicaid in one practice location, and not-belong in another practice area. Or they could choose to just not belong at all. It's all different now-- and your doc needs to contact the medicaid agencies in his state and see if he can join up so that they cover his scripts, without needing to sign agreements to accept medicaid as full coverage.

One important issue-- the quickest way for a doctor to go to jail is by accepting money from medicaid or medicare, and ALSO balance-bill the patient. With MediCARE, a doc who participates, but doesn't 'accept assignment' (this garbage is so messed up!), can bill patients a very small amount--- an amount around $5-$6). When a doc 'accepts assignment', they agree to be paid about 10% less than the already-low rates, in exchange for getting paid directly by the government. If a doc chooses NOT to 'accept assignment', they can bill a few bucks more than what the government pays. But in that case, the government pays the money for the appointment to the PATIENT, and the doctor has to collect it from the patient. If the patient just decides to pocket the money, the doc is left getting nothing for the visit-- which is why most docs just take one more 10% cut off the top, and accept assignment.

Where was I... If a doctor is paid anything at all from medicaid or medicare, and then charges patients the remainder of his regular fee (called 'balance billing'), that doc can and usually will be prosecuted very aggressively. That is why the person writing this post's doctor makes the patient sign a form, saying that the patient is aware that the doc is not accepting medicare or medicaid, and agreeing NOT to submit a claim to his or her insurance on their own.

Choices for the person writing the post: 1. have your doc register with medicaid, without signing a participation agreement, so that the meds get covered again, or 2. have the doc prescribe plain buprenorphine, which is much more reasonably priced. In Wisconsin, 30 of the 8 mg tabs cost about $75-- and 8 mg per day is plenty if you take it carefully.

My negative attitudes about the ACA probably 'leak' into my responses... and this is one reason why I don't like the law. I also don't like the fact that all the surveys that claim 'premiums aren't rising as fast' do not take into account the fact that people now pay much, much higher deductibles than they used to. Also, I now run into cases very often-- at least several times each day-- where the drug that I know is the best choice is not covered by the insurer. A couple classics include Abilify, the best augmenting agent for depression by far (insurers demand substitution with zyprexa or geodon-- meds that have never been shown to even work for depression!), or Vyvanse, a great stimulant for ADD that insurers now demand to be substituted with Adderall.

Good luck to the person who posted the question-- if you're still awake!


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PostPosted: Sun Jan 31, 2016 5:11 am 
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Very interesting Dr. Junig! Part of a country's soul is embedded within its laws. Thanks for the explanation, lol I didn't fall asleep. I'm sure you have plenty more forum participants who find this kind of stuff worth their time, I always appreciate it when you go into the laws especially since they're from a doctor's perspective.

The ACA (I know what a dumb name!) actually came at a very opportune time in my life for me as I was an unemployed college grad. Until it came into effect I was on HIRSP which was the inly insurance people like me qualified for. Due to having too many preexisting health conditions private insurance companies could reject me. If I had been in another state I might have not even qualified for any health insurance at all. So basically if I had been living in that kind of state no matter how much money I had I would not have been able to buy ANY insurance. But luckily in WI the state had set up HIRSP which was government run insurance for high risk people like me. However, it was extremely expensive. The monthly premium was $200 and then the deductible like $3500 so really for someone already unemployed it was the equivalent to not having insurance -more like disaster insurance. Hey but better than nothing! For that I am grateful for. I am a firm believer that in America to walk around without having your life medically insured is like driving without a seat belt. When the number one or two reason for debt is health care related costs... that tells you something lol.

Finally when the ACA kicked in and I was still unemployed I had access to all the services I needed (think psychologist) and my medications didn't cost an arm and a leg. Then until I got a "real" job white awesome health insurance I was working at a grocery store. Well getting full time there was virtually impossible since they knew I had a college degree they didn't think I would last there long. So in order to keep my Medicaid I had to be making less than $715 or something like that per month. So I calculated the number of hours I could work at my grocery job based off the $715 figure, that way I would be qualified as low-income and still eligible for Medicaid. Otherwise, if I worked the number of hours I actually wanted to (which the grocery store only let you work about 30 hours before they had to worry about the health insurance thing themselves) I would be making about the Medicaid low-income number. Then I would have to buy private insurance which would basically make working those extra hours pointless. So better to save up on time looking for a "real" job than waste it on working extra and having that income go towards my insurance.

So far for my situation the ACA has been a lifesaver however I'm definitely aware that there are plenty of stupid and potentially life-denying laws which the media addressed but which affect us (and if my living situation changes or employment could affect me too!) I can't think of any right now but I think one of them involved that the pharmaceutical industry could price medications however they wanted to... I think that was one of the big agreements between the pharmaceutical lobbyists and the government. I know there are some major kinks in there.

Also I can't believe how little psychiatrists get reimbursed by Medicaid! In the pre obamacare days I used to see this shady doc who took a lot of Medicaid patients (I'm sure Dr. Junig you've heard about Dr. Isrealstam) and I would only see him for 5-10 minutes... Just enough to cover his legal tush to make sure the meds he was prescribing me weren't killing me. There'd be all these sketchy looking young men waiting in his waiting room. And yet the walls of his office were covered in children's paintings thanking the good doc for his work, omg the guy turned out to be a child molester and is in jail now. Super weirdo. Anyways not to bash another doctor but for real the guy wasn't even a doctor, only on paper.

So that's my rant lol. Hope it made some sense! I could even go on.... Lol


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PostPosted: Sun Jan 31, 2016 12:17 pm 
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The ACA is certainly a mixed bag. My sister-in-law and her husband were paying for very high deductible plans plus $800 a month for healthcare that didn't allow them to receive preventative care, or regular basic care if they had the flu, for example. They had to go to urgent care for that because it was cheaper. They are basically retired without any health benefits, but not old enough to get on Medicare. Under the ACA they were able to have insurance that costs them a couple hundred dollars a month without a high deductible, and are able to get preventative and wellness care. I have a feeling that neither of them voted for Obama, but they certainly appreciate the outcome of the ACA.

At the same time I hate what Medicaid does to doctors under the ACA! I wouldn't know anything about it if Dr. Junig were not patient enough to explain. But I have to wonder what insurance would look like under a plan from the other side. I have a feeling that the poor would be losing more and more benefits. People would still be denied insurance because of pre-existing conditions. And for all the talk about supporting our military, our soldiers and veterans would still be needing food stamps to make ends meet. For every story on Fox News about food stamp recipients dining on lobster, I'm sure there are thousands of food stamp recipients who are trying to feed their families nutritiously. Recovering addicts among them. I don't think we can count on churches and other charities to take care of the poor. I think we need a government safety net.

My friend who is getting her degree in health care administration, and manages clinics in low income areas, sees the ACA as a mixed bag too. She points out that even though our health care costs are rising, society has already been absorbing those costs in different areas. For example, the ACA has made it so that lower income people don't have to use the emergency room for primary healthcare. We were paying those higher costs from the ER in different ways, but we were still paying them. I don't think it's too much to ask that we all have healthcare. Typically the news agencies, politicians, and talking heads who represent the wealthiest people in our midst want to convince regular people that the folks who need services are people of low character and low work ethic. That is sometimes true, but these are the same folks who would say, "Let the addicts all OD and then we will be rid of them. They are people who make bad choices and hurt the rest of society!". As if it is that simple.

I don't know. I certainly don't know all of the answers. But I do know that there are plenty of people looking down on addicts. And they are the same people who look down on the poor, the mentally ill, the homeless, etc. They want to think that the same circumstances couldn't happen to them, when in reality they are only a job loss, a medical bill, or a condition requiring pain medication away from being there themselves.

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PostPosted: Sun Jan 31, 2016 1:36 pm 
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I realize that the ACA has done some good things. I'm sure, by now, people know that I'm not a fan of the law overall-- but I realize that the medical system was screwed up long before the ACA.

The main problem I have with it is that it seems to have contributed to a change in attitude toward health insurance and 'shared risk'. When I was a teenager and then a young adult, my parents used to talk about how importance it was to be insured. They would say that if insurance lapsed for one day, and you broke your leg that day, you might never get insured for anything related to that injury. I remember going on a trip to help build a church in Mexico when I was about 18 (I wasn't a missionary-- I just wanted to go to Mexico!). I bought a short-term health insurance policy, because my current policy didn't cover me if I was out of the country. The point is that we knew what insurance consisted of-- it was there to cover RISK. There were hassles of course--- like if you changed policies, the new policy would not cover pre-existing conditions for the first 12 months. But that type of system lowered costs for everyone, because there was a huge pool of healthy people who paid premiums.

At some point, people stopped being as prepared for the future as they used to be. Maybe I'm just imagining that whole concept-- but that's how it seems to me. As I write this I wonder-- maybe I just moved from a part of the country where people seemed to be aware of the risk of being uninsured, to an area where nobody could afford insurance. I try to keep my mind open to the idea that this is all just my perception, and not reality. I did not grow up in a wealthy home; my dad was a lawyer, but he worked in Beloit, a very poor city, representing car thieves and petty criminals who didn't have much money to pay legal bills. Our home was 1200 square feet, and I shared a bedroom with my two brothers... just saying that I don't think my perception was based on growing up in some rich environment.

But at some point in the 1990s or so there was an increase in uninsured people. Some couldn't get coverage because they were unemployed, or employed in jobs that didn't provide insurance-- and they couldn't afford to buy their own policies. Some of the uninsured just didn't do the 'right thing'-- i.e. pay for insurance in case they got sick. I don't have as much sympathy for those people, because most of them knew the deal-- that they were supposed to insure themselves against risk-- but they chose not to protect themselves. Then when they got sick, it was too late to get insurance.

But there were also people who ended up in trouble through no fault of their own-- people who lost insurance after losing a job, but then couldn't get covered again because of a pre-existing condition. There were laws enacted that helped with many of those problems-- for example, a person who was covered by insurance, lost that coverage, then got re-insured could not be required a 'waiting period', as long as there was no gap in coverage. Also COBRA required employers to offer insurance for people who lost their jobs (as long as the ex-employee paid for it). There were still problems.... sometimes a child would be born with severe health needs, and the parents made too much money to qualify for medicaid, leaving the child uncovered.

The ACA fixed some of those things-- at a very large expense. If we had taken the 15 million uninsured people and given each a check for $100,000 dollars to buy their own policies, we could have spent less money than the cost of the ACA. The ACA will have to be rewritten soon-- in the next few years-- or it will not survive. The numbers just don't add up--- and if anyone wants to know why, just google 'aca death spiral' and read about it.

But the thing that bothers me the most about the ACA is that it encourages less personal responsibility. The concept of 'shared risk' is gone now. In fact, young people don't even know what that was all about-- and once it is gone, it can never be brought back. I see young people make the calculation with their current medical bills and prescriptions, and the fine for going without insurance, all on one side of the balance sheet... and the cost of a policy on the other side. They then choose NOT to be covered, completely forgetting about coverage for RISK. Of course the risk is much lower now, because people can just get covered AFTER they get sick.... although I'm always pointing out to people that if they have an emergency, they will end up with a huge bill that will follow them for life! Yet people CHOOSE to not be covered-- which dramatically raises the costs for those of us with insurance.

None of us need be too worked up about the ACA, either pro or con, because the law will need to be rewritten-- soon-- because of the death spiral. The fine for no insurance must be raised to a much higher level, for example. They had to keep it low when the law was written, because the law would have never passed if it had been written in a way that actually made the numbers work. But since the law was passed with absolutely no discussion or consideration for Republicans or their constituents, how do they expect to fix it? I assume that they thought that the public would like the ACA, and that there would be political pressure to fix it... but it hasn't worked out that way. So the next President, whether Democrat or Republican, will have a massive challenge on his/her hands to deal with the collapse of the ACA. As much as I didn't like the law, I'm not looking forward to that happening.

I'm writing because I have work to do, and I don't feel like getting to it--- and I realize I'm no expert on health law. These are just my thoughts on the topic, based on what I've been reading and watching over the past few years. I do encourage people to read about the aca death spiral, as it is real-- and you'll hear about it often at some point in the future. In Wisconsin, Blue Cross/Blue Shield dropped all ACA plans about 6 months ago, and United Healthcare has announced that they are probably leaving as well, because they are losing too much money on them. A storm is brewing.


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PostPosted: Sun Jan 31, 2016 1:54 pm 
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The law only could pass with no input from the Republicans because they had already pledged not to compromise or work with Obama in any way. So if they didn't have input they only have themselves to blame.

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PostPosted: Sun Jan 31, 2016 2:17 pm 
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Wow, very interesting Dr. Junig. I was not aware of the ACA death spiral -will check it out after writing this. It unnerves me when I hear friends (I"m 29) talk about how they don't need health insurance because they're healthy. We need more education or common sense!! Seriously? You're willing to compromise your financial future (because healthcare is so expensive in the USA getting even a broken leg could cost a low-income person a small fortune and that's assuming there aren't complications) for the sake of saving a grand (or two) a year?? Not to mention potentially compromising the quality of your care! I just don't get it... I would not feel OK walking around the streets of Wisconsin lol without insurance. I moved to Spain a few months ago and even though I don't need my insurance in WI anymore (Fastforward for you Wisconsinites) I STILL TO BE SAFE called Medicaid while in WI during Christmas break to make sure that I was still covered for the next few months. Even though I am insured here in Spain my life is still settling down here and who knows if something happens meanwhile, if i have to return to the US for whatever reason I want to make sure I will be fine. And then, once at the end of March by coverage ends i will STILL call them or the ACA to find out what will happen when I return to the US (just to be prepared). I mean this is all just a part of being an adult I think. Why is this so hard for people to get?

Sorry major rant lol. So ya if the young people aren't pitching (in which they are losing out majorily themselves by playing russian rullouete ) I can see how that's messing up the budget. Wow, Obamacare Death Spiral, need to check that out!

Here in Spain things are very differently. Not gonna say it's necessarily better because I don't know enough but it has to be pretty darn good because president Obama himself visited some healthcare establishments and talked with doctors here to get an idea of what a good model looks like for the ACA. Of course a MAJOR difference is that in Spain it is socialized, so if you work you pay, period. I should actually make a serperate post about my experience here and the addiction clinic I visit for my suboxone because they do things WAY differently.

For my suboxone I go to a special clinic where the only thing they do is addictionlogy. The entire building here in Madrid is dedicated to treating all kinds of addictions, "Centro de Drogadicciones" or something like that if you know Spanish lol. Even though I am a EU citizen (from another country though) I qualify for their state insurance here but even if I wasn't, they would STILL treat me. In other words, you don't have to even be a citizen of the EU to see this clinic. I have never paid a dime for seeing any of the doctors there. Which feels extremely weird. I do pay for my suboxone, which, comes in packs of 7 (each in their own bilster pak) and pay 7 Euros, so that's 1 Euro per 2mg pill. Expensive but now that I"m at 2.5mg a day it's a little better lol. I am working on getting my health card activated, and once it is, I will pay I think depending on how much I make like 40 percent of the cost. If someone is interested let me know, I can write more about it and my experiences at the clinic here in Spain.

Anyways, I wanted to add. Amy I really like how you connected how people view addicts with how they view people who supposedlt are the main ones who "suck up the system" (the low-income, lazies) <-sarcasm alert here lol. It is that Us VS Them mentality. But moreso it is this mentality of being above it all, when in fact they are just one job away, or one financial crisis away, from the same. SOrry not as eloquent here as you were lol. Can't believe that your relatives pre-AcA days paid 800$ a month premium per person? What the heck!


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PostPosted: Sun Jan 31, 2016 4:54 pm 
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I think it was $800 total for both of them.

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PostPosted: Mon Feb 01, 2016 4:31 pm 
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Thanks for letting me know Amy, ya still 400 a person is ridiculous.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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