MDI is freedom from physician and insurance oversight and manipulation


#42

I don’t even let my physician download my meter or cgm and certainly wouldn’t if I had a pump either… I’m often perplexed by how different peoples relationships with their doctors sound than my experience. They ask for my meter and cgm, I say “no, thanks” then the appointment moves on…

I’m the one paying the physician. I dictate the course of the appointment. If they get off on a track I feel isn’t what I’m paying them for I simply hold my hand up and redirect the appointment back to where I want it to be. I am not intimidated by my doctor, nobody should be.


#43

But Sam, how would changes ever happen on your pump if your endo didn’t do it for you? You know that they can look at it for 30 seconds and know much better what changes to make than you can.


#44

I don’t know. This is why I am not smart enough to run a pump.


#45

Eddie and @Sam19 -

ROFL


#46

You need a different Doctor.
This is an awful way to live. Its dangerous.


#47

Okay…Don’t shoot the messenger!!!:slightly_frowning_face:

I understand and totally agree with WHY you do it BUT you ask if it is wrong and so I have to give you the honest answer that none of you are going to like.

Morally, for the reasons you do it, I personally agree with everyone else that has commented- that it is not wrong. It is however illegal.

To “inflate” the amount of insulin you use is actually insurance fraud. Health insurance fraud is described as “an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.”

That is why your doctors my be reluctant to write “inflated” prescriptions. To do so knowingly is fraud. The doctors that DO do it most likely have no clue that it is considered insurance fraud because the vast majority of doctors are not legal experts and it has probably never dawned on them that doing so is illegal.

Also, don’t be fooled into thinking that no one knows. Your insurance company clocks your refills so, unless you are refilling it on time each time vs. there being a slight lapse in when you fill it, your insurance company is most likely telling you doctor that “this person isn’t filling their prescriptions in a timely manner. There is a possible concern for adherence.”

Don’t get me wrong. Your reasons are valid and I totally get it but I have to give you the truthful answer.

Now that I have been the bad guy, some possible solutions:

  1. Have your prescriber: “Uses up to ‘X’ units q d with meals based on sliding scale (x 3 meals a day- or whatever)”
    You can’t overestimate it too much but, doing it this way, the prescriber could honestly give you a little cushion. It says: “You may use that much but you may not it all depends on your glucose, food, etc”

  2. Have them count the priming units. Example: “Uses up to 20 units subcutaneously q with meals (x 3 meals a day) with an additional two units each time to prime the pen/syringe.” If you take your rapid acting insulin and prime the pen each time that is about 2 units wasted every time you give yourself an injection). Granted, it is not giving you wiggly room but it also not short changing you either.

  3. As far as denying your rapid insulin, I’d have to understand WHY they are denying it. Is because it is “refill to soon”? (According to their calculations) Is because it is now non-formulary? Do they want vials instead of pens (or vs. versa)? Are you on a vial and they think (based on your usage it should be lasting you more than 30 days but you have to dispose of it after 28 days (though some insulins are longer)- sometimes you have to point that out to them)

  4. Regarding your long acting insulin, I have a sneaking suspicion that it has more to do with your insurance company than your pharmacy. A favorite game of the insurance company that has been growing the last few years is if what will get you to 30 days actually exceeds 30 days than they’ll undercut you. So if you two boxes of insulin pens would last you say 36 days, if your insurance is a stinker then they may only allow you to get one box for 18 days and then you have to get the next box in 18 days. There aren’t many ways around it but, if this IS the cause of your issues with your long acting you may try calling your insurance and seeing if they can do some sort of override. For example (still using the above scenario) Tell them that the insulin comes in a box of 5 pens (may be less depending on which insulin you are using) and that two boxes last you x amount of days and that by only getting one box at a time it is putting you at risk because you are having to make sure you can get to the pharmacy every two weeks to get your insulin. The box is sealed and you can’t break up a box. (Technically you can but most pharmacies won’t because they don’t have a way of keeping loose pens at the pharmacy…fridge space is limited).

  5. Another solution is to set up your insulin through the insurance mail order (if you have one) and then set it up on automatic refill. (Typically I HATE automatic refill which I’ll explain in another post). When you do automatic refill through the mail order pharmacy they tend to fill 3 months every two months so you can build a nice little stock pile.


#48

I read your first paragraph but you’re so blatantly wrong I could not even continue. Yes it’s illegal to fraudulently claim you use more than you do. To ask your doctor to prescribe more than your absolute bare life sustaining minimum is not that same thing. Period.

Again I suggest explaining to your doctor exactly how much you are using, and asking them to prescribe an appropriate amount in reasonable excess of that. That is perfectly legal, and anything less of that is idiotic.


#49

I disagree.

I have significant experience with Fraud. This is not Fraud.

It is not shooting the messenger, it is replying to a post.

That is 100% False.

Not happening. We have one of the larger insurance companies in the USA. This does not happen. It is possible but not with our very large insurance company.

These are your beliefs and your opinions. It neither makes you the bad guy nor makes your opinions to be factual.

Again - My response is not a personal bash but it is not reasonable to post misinformation and not expect to receive corrections. That would be doing extreme disservice to any other poster who may read this thread.

In a public forum such as this, one of the ways one can decide what is accurate and what is not is based on responses to posts.

Therefore, IMHO, a post such as this REQUIRES a response.


#50

You are making some pretty wild assumptions. Some of us do not know even close to how much insulin we will require within the next 90 days. I am on call to my headquarters in China and India and never know how long I will be in those offices. I dose MDI according to my CGM which works very well. In Asia, where I have very little idea of how many carbs are put in front of me at each meal, I go through 65-80 units of insulin a day. In the US, where I have a pretty good idea of daily carbs, and mostly avoid them require between 8-20 units per day.

If your insulin is delivered by mail, then also need to make sure that it does not arrive a few days after leaving for an extended trip or you run out unless backup stock is kept. There are a whole bunch of issues that can affect 90 day requirements.

When I used insurance for almost 30 years, they never gave me an issue for being over prescribed, not once. In the past couple of years I have purchased my insulin OTC (no insurance involved) outside US as it is 90% less than US list price and get over prescribed even more so that I do not have to make additional trips to Canada.


#51

Lauri,
I have had T1 for 25 years and if there is one thing I have learned it’s that you need to take care of yourself because the insurnace companies will not. I do not think there is anything wrong with telling your dr that you use more insulin in order to have some extra on hand. You never know when you are going to need more, have an emergency, or have you insulin to carb ratio manically change.

Also, if you use any insulin pens or use a pump (I am on MDI and use Tresiba and humalog pens, but have also used the pump) you have to account for priming and malfunctions ( such as air going in the insulin pump tube and having to unexpectedly prime again or the pump getting ripped off by accident) Priming can “waste” a lot of units of insulin, with my Tresiba pen I prime 1 unit a day (that’s 30 units of insulin a month and I only take 15 units per day so that’s two days worth of insulin) and with my pump I’d prime anywhere from 8-12 units every time I changed my infusion set ( I changed every 2 days due to skin sensitivity so take 12 x 15 that’s 180 units of insulin to “prime”, I used about 18-20 units of humalog per day do at the very least that is 5 days worth of insulin , gone. If I am doing my math correctly). I also have tonprime my humalog pen by 1 unit every time I use it and I eat anywhere from 3-6 times a day- so let’s say I waste 6 units a day priming , again 180 units of unused insulin.

Here’s my suggestion. Think about a day where you used more insulin than normal, add in what you”wasted priming” and say that is the number of units you use per day. This should give you plenty since you probably aren’t eating the way you did on the day you used more insulin than normal.

Why should you live in fear and in the state of anxiety. I’d ask your dr how they’d feel if they ran out of medicine or couldn’t deviate what they ate du to fear of not having enough insulin. Or better yet ask them how they’d feel if this was happen to their child or family member.
This is not lying or immoral, in my opinion it’s just being smart.

Your dr. Sounds awful. If they can’t have empathy and consideration for you then they don’t deserve to be getting paid to see you. I recommend getting a new one!


#52

That is a ludicrous comment for her to make. I’ve gotten large (500+/mo.) rx’s for strips for decades, thru no less than 4 different endos. I suggest looking for someone who cares about their patients welfare.


#53

I’d rather have enough supplies on hand by fudging somewhat, then running out. I’m an honest person who has never cheated on his taxes, but I’ll be d*mned if I’m going to ask for exactly the amount that I use, BECAUSE THERE ARE TIMES WHEN I NEED MORE. More strips, more insulin, more sets. Your attitude is a bit holier-than-tho for me. Anytime you want to get off of your high horse, I’ll applaud you.

Furthermore, EVERY endo I’ve had has written my rx’s for enough to keep well stocked with any and all diabetic supplies.


#54

I appreciate your response and in no way to I consider it a personal bash. I rather read your response and know how my words are being interpreted so that maybe I can explain better. I find the hardest thing about the written word particularly between strangers is that we are missing the human element. In spoken word you can say the same thing and give it different intent or meaning by changing the inflection for your voice or your facial expressions or gestures. In the written word you don’t have those elements so the way it is read may not be the “voice” in which it was written. Knowing this that is why I preface my post with “Don’t shoot the messenger.”

That being said, my post was not simply my opinion though, in hindsight, I didn’t give you any foundation to understand where I was coming from.

My opinion is there should be nothing wrong with it and it is wrong for insurance companies to be cutting patients so close. You have no idea how much this irritates me (and that whole we rather cut you short vs. give you a few days over 30 days, OR charging you two copays because the prescription lasts you 40 days vs. 30 days- That’s a Medicare favorite). Every time we talk about disaster preparedness, we always hear how we should have ample supply of our medications on hand. How do they expect us to do this when they cut us so close?

My actual opinion on whether it constitutes fraud is actually very conflicted. My personal beliefs is no, not for the reason given. However, I am a paralegal by training and that part of me is at war with my personal beliefs. Years ago I had this exact matter come up when a pharmacy questioned a prescription’s directions because the person wasn’t filling their prescription in time with how the directions were written. (Personally, I get it and the doctor didn’t care if the person was giving themselves extra cushion. The doctor wants people to have extra cushion.) That was the first time I was told it was insurance fraud. Having the legal background, I wanted to know if that was accurate and, more importantly, how could we do what we needed to do so that it wasn’t fraud but the patients could still get the extra cushion they needed. Since I am not an attorney, part of the research I did included speaking with our legal advisors. This is how it was explained to me To write a prescription: “Inject 25 units subcutaneously at bedtime” when the person is only doing 10 units is a false statement. “A misrepresentation to gain ‘extra’ benefit from the insurance company.” Even though this is not then intent behind overstating insulin usage, the laws don’t take that into consideration. A provider is committing insurance fraud for writing it that way and the pharmacy is committing insurance fraud for filling it that way. The same is true if a person misrepresents what they are using (and the doctors and pharmacies are no less culpable just because they didn’t know. They are expected to know because the pharmacy can see how often they are filling it and the prescriber should know how often they are having to write the prescription.)

What I said that it may be why doctors are reluctant to write “inflated” prescriptions part of that was my opinion. The part about doing so knowingly being fraud, again that was what I was told by our legal advisors.
The part about doctors not be legal experts and things not dawning on them, that is my opinion based on experience.

With regards to clocking your refills. I can assure you that it is definitely happening and not just on prescriptions. They monitor whether you have had a recent diabetic eye exam, a recent hemoglobin A1c, blood pressure check, whether you are on a statin, whether you’ve had your kidney function checked. I can’t say that every single plan across the US does this but the big players typically do. Sometimes they want a response and sometimes it’s an FYI to the doctor, kind of like…“are you doing your job? This person hasn’t done this yet.” Then you have the yearly “quality measures” and “risk management” where they want a complete copy of people’s labs, proof of diabetic eye exams, there is a whole list of things. (This is not on everyone, I’m not quite sure who gets picked. Medicare patients, if they are on a MedAdvantage plan, definitely. The plan has to justify to Medicare what they’ve paid out on Medicare beneficiaries. But it isn’t just Medicare).
Before you ask, your privacy protect doesn’t extend to those paying the bills. That being said they are limited only to physical documentation of the time period that they are providing you with insurance coverage.)

My “favorite” is when the insurance companies send: “Your patient didn’t fill their prescription for “X” between the months of 01/01/2018-02/28/2018 (example dates)” Well duh, person gets a 90 day prescription and didn’t need to fill between those dates. (They did finally stretch their dates out after a year+ of this).

As I said above, when I was told it was insurance fraud part of what I wanted to know was how could we do it so that it wasn’t insurance fraud. The solution is actually very simple: “Don’t make a blanket statement.” Don’t say: “Inject 25 units subcutaneously a day” Use the phrase “Up to” then you are indicating that the person may be using that much but they may be using less. It varies. You can’t grossly overestimate it like saying uses up to 75 units a day" because then the whole “fraud” question comes into play again.


#55

I’m sorry if you had read further maybe you would have understood. To write a prescription such as: “Inject 25 units subcutaneously at bedtime” when you usually are using 10-15 is a false statement. HOWEVER, if you use the phrase “UP TO” (For example Inject up to 25 units subcutaneously at bedtime." That is NOT a false statement and then you are getting what you need. It is such a simple solution. I also added some other ways to get ahead. Though I did forget one so I’ll add it here.

Another way to get ahead is to refill your prescriptions “early.” Most insurance companies (at least in our jurisdiction) allow you to refill your medication (at a retail pharmacy) several days early (could be as many as 7 days). Just keeping filling your prescriptions as early as you can for several months and you should have a good little stock pile.


#56

Many pharmacies do not allow “up to” prescriptions. Cvs Caremark insists that prescriptions be written “inject x units daily”

Your “up to” idea makes sense, but it doesn’t work that way.

This is no more fraud than a doctor prescribing pain pills with the directions “take 2 daily.” Is it fraud if the patient only ends up taking 10 of the pills in a month instead of 60? Of course not.


#57

I have two years first-hand experience with US Federal Fraud cases of many different varieties.

Writing a prescription for more insulin than is actually used according to one’s pump…

*** IS 100% NOT FRAUD ***

That is a fact. If one feels otherwise, it will take an actual CONVICTION which was NOT overturned on appeal to convince me otherwise.

Fraud absolutely exists and is a big part of the reason for many of the insurance hoops that are required to jump through. Without those hoops, there is not a shred of doubt in my mind that people (who actually do not even have an illness) would be taking advantage and sucking Millions of Dollars out of insurance companies. The cost of that is then borne back by the entire insured population.

However, any attempt to compare actual fraud cases which really are prosecuted and where people really do go to jail with writing a prescript for more insulin than your pump says is used on a given day is not even in the same ballpark. Not even close.

If you @MOOBM do not want to have a prescription written for anything over what your pump logs as being used in a given day - that is 100% your right and your choice.

But in any way to state that anybody else is committing ACTUAL FRAUD (based on how many units written on a valid script for something who is actually using insulin) is absolutely and 100% a falsehood.


#58

I’m sorry Dave44 you did not read my post the way intend it and I’m sorry it came across holier-than-thou. I don’t know if you got as far as the solutions, maybe I should have led with that. Lauri asked if to inflate the amount of insulin she uses and, actually as I type this I think I could have done a better job explaining. As I said in my other responses: For a prescription to be written as such: “Inject 25 units subcutaneously at bedtime” when some one is only taking 10-15 units is a false statement. It is a misrepresentation. BUT If you use the phrase “up to”(I.E. Inject up to 25 units subcutaneously at bedtime) this is NOT a false statement or a misrepresentation. In Lauri’s case she isn’t telling her endocrinologist because, from the sounds of it, her endocrinologist is either not thinking or not being reasonable. If she tells her doctor that she is using “x” amount and he/she writes it that way then unfortunately, yes, the provider has made a false statement and misrepresented things and the pharmacy has filled it as such. Just because they didn’t know doesn’t change things. They are supposed to know. Pharmacies in particularly based on a person’s fill history.

My intent wasn’t to call into question anyone’s character. I have dealt with this matter personally though and I cannot, in good conscious, tell you something that false. I guess I could stay silent but I don’t find that right either.

That being said you are 100% correct in everything you said in the first sentence. The solutions I gave are ones I use all the time to make sure insurance work for us and not the other way around.


#59

I have a prescription shampoo that says to use every day. But in reality I only use it once a week. Is that also fraud? Where can I turn myself in?

Nobody is suggesting anyone make any false statements. As I’ve said repeatedly, you discuss with your doctor how much insulin you use. They determine what an appropriate prescription is, which is absolutely more than your useage, and they direct the pharmacy to fill it that way. Many pharmacies can’t or won’t fill prescriptions as “up to x amount”


#60

You are talking about pumps. This was never about pumps. It is about MDI and the solution is so simple. Instead of making a “blanket statement” of Inject 25 units. Say “Inject up to 25 units” and the whole problem is solved. Now if you are fudging to the provider because the provider is being hard nose about it as Lauri said. Then you just need a new provider.


#61

@Sam19 - I strongly suggest you avoid the 9th Circuit Court. I just don’t see that being a good fit for you.