The manager of the General Judicial Mutuality (Mugeju) resolved in July 2013 that Asisa was obliged to reintegrate a mutual official The price of chemotherapy that had had to pay from your pocket after being denied for “economic drug reasons.” This is stated in an office that has had ABC access and in which it appears well, today owned by Atrys, as an oncological advisor of the insurer and responsible for the report that concluded that the drug recommended by the oncologist should not be authorized for economic reasons.
The official decided COST THE TREATMENT Knowing that his oncologist considered that denied therapy offered him greater possibilities of success against the disease. Previously, he had requested the treatment repeatedly without success. The therapy should consist of 15 sessions every 21 days, and the one corresponding to the month of May cost 7,611.74 euros to the mutualist.
Fortunately, the patient did not have to pay more because claimed against Mugeju demanding the return of that payment made and the coverage of the rest of the treatment. The National Mux and Asisa Commission analyzed the case on July 22 and the treatment was authorized that same day. “Asisa is obliged to reintegrate the amount of the amount of 7,611.74 euros corresponding to the Avastin treatment of the month of May and to pay the treatment of the following months until it completes the same,” collects the trade, dated the next day. “Asisa must reintegrate the amount of the amount of 7,611.74 euros corresponding to the treatment of Avastin of the month of May and to pay the treatment of the following months until it completes the same, since it is a prescription made by a doctor of the Asisa Services portfolio,” resolved the Mugeju manager.
Respect oncologist
The office to which ABC has had access includes the argument that led to that decision and that is very hard for well and for Asisa. «The medicine has been indicated by the company’s specialist to the mutualist without being covered by the entity exclusively to COST CRITERIA Effectiveness, since such a requirement is not contemplated in the concert ”, includes the legal valuation of the resolution. “Any indication of that character would be framed in his case, in the relationship between the entity and the prescriber doctor,” he adds.
From here, the trade emphasizes that “if the entity’s oncologist determines that the proper treatment in this patient is Bevacizumab (Avastin), this decision is binding for the company, especially if the oncologist performs the indication using the coverage of the RD 1015/2009 of June 19, which regulates the regulating the Availability of medications in special situations, which allows indicating a medication outside the authorized indications collected in the technical card of the medication ».
“They have mechanisms”
The trade also includes that after the first denial of treatment “the Discrepancies between the Asisa consultant (Bienzobas) and the oncologist regarding the origin or not of the prescribed treatment ». This crossing of arguments is what oncologists are denouncing as pressures they suffer to change their cheaper drug prescriptions although they are less suitable for patients according to the stage of their disease.
ABC contacted yesterday afternoon with Asisa to gather its version about this case. «This is a 2013 case and, with such a short time, we have not been able to locate the case and review it in depth. In any case, Asisa completely assumed the full payment of the treatment prescribed by the doctor chosen by the insured. On the other hand, it is clear that mutualists have effective mechanisms to solve any discrepancy that they can have with the insurers that serve them, ”the company officially said.
“In charge of the entity”
The trade also recalled that the health care concert for the beneficiaries of Mugeju should be provided according to the Service portfolio established in it. “It includes the set of techniques, technologies procedures, understanding by such each of the methods, activities and resources based on scientific knowledge, through which health benefits are effective,” he said. “The beneficiaries will have access to techniques and procedures, diagnoses or therapeutics included in the portfolio of services contained in this concert, provided that the corresponding indication is established by a doctor of the suppliers table,” he added.
And specifically on the denied treatment, he stated that “hospital use medicines for outpatient patients treatments will be in charge of the entity, The Bevacizumab (Avastin) medicine is a hospital medication, therefore in charge of the entity ».
The oncologists consulted about this case put the focus that not all mutualists have the ability to Cost cancer treatment Not even to advance payments. And that this is binding that the “shock” that causes them of the treatment often prevents them from fighting or resorting. “They have enough with the diagnosis,” they underline.
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