Her name was Helen and she had breast cancer. Because of the advanced state of her disease, it was recommended that she undergo a course of treatment that involved a bone marrow transplant. At the time, this expensive procedure was considered experimental so her insurance company refused to approve it. Knowing that an appeal process could take months or even a year or more – time that she may not have – she took matters in her own hands. They mortgaged their home and paid for the treatment in cash (over 0,000). This quick and financially-painful decision did save her life.
She then got a good attorney, did her research, and took the insurance company to court. She won. Not only was she reimbursed for her treatment expenses, she was awarded additional damages.
My teenage patient going to Scout Camp. He reluctantly told me that he was still wetting the bed; wearing pull-ups at night. He did not know how he was going to manage this and keep his secret during his one week camping trip. The answer was a medication called desmopressin – a hormone that could quickly control this nighttime wetting. His insurance company refused. It took me about an hour or so on the phone arguing with the medical director, but in the end, I was able to get this medication approved in time for his trip. The medicine miraculously worked and he was dry for the first time in his life. There are many things in life (most things, in fact) more important than money. His self-esteem was one of them.
If you are denied coverage, there are steps you can take with your insurance company to appeal the decision. Say you go to the pharmacy, pick up your prescription and are informed that the drug prescribed is “not covered” by your insurance, so you will have to pay out-of-pocket. You are told the price and nearly faint in disbelief. What are your options?
- You can get out your credit card and pay for it.
- You can choose not to get it filled.
- You can call your doctor’s office and complain; hoping there is a less-expensive alternative medicine that can be prescribed
- You can call your insurance company to complain.
Calling your insurance company may be frustrating and is often futile. The first level of people that you may get on the phone are just following algorithm instructions on the computer screen. No matter what argument that you present, the answer is:
“No, this medication is not covered. Please call your doctor.”
Most insurance companies will have a formal appeals process that can be equally as frustrating, but those carefully written benefit policies are often iron-clad. If your insurance company does not cover “X”, there may be little recourse, or at least, it may be a long, bumpy road to fight the denial – independent review, arbitration or even court. If a person needs an expensive cancer drug, this will be worth it. For an expensive antibiotic, where there may have an alternative choice, it is unlikely that patients will climb the “appeals ladder”.
The pharmacy may fax us a TAR – or “Treatment Authorization Request”. The medical provider must answer a series of questions to justify our decision to use a particular drug that was not in their preferred formulary (usually a cheaper alternative). The form is faxed to the company to be reviewed by someone; often a pharmacist or medical director. They may or may not approve it. All the while, the patient is going without the recommended prescription.
Granted, there are less-expensive alternatives in many cases that your medical provider could have chosen, but sometimes, there are no other choices. Your medical provider may simply ignore the TAR or not fill it out correctly. Many will even refuse to modify their prescription or treatment plan and will leave you in a quandary. You are caught in the middle between a cost-containing insurance company, and expensive pharmacy, and a medical provider that refuses to bend and play the game.
Pick your battles. If you choose to fight a health care claim denial, you will need to be very organized and persistent. Read your insurance policy like an attorney. Unless you know what cards you hold in your hands, you cannot possibly win the game.
You should also try to be nice, regardless of the reasons not to be. You should always be assertive, but not hostile. Taking it out on those minimum-wage, first-tier people that answer the phone does little to achieve your goal.
Write down everything during phone conversations, especially names or employee numbers of your contacts. Enlist the help of your doctor or medical provider to support your case.
You may win some. You may lose some, but that doesn’t mean you should just take NO for the answer.