Paul's Heart

It Should Not Have To Be This Hard To Get Cured

I get countless stories across my feed, about patients being denied procedures, treatments, or prescriptions, and not just in the world of cancer. Two recent articles referenced an adult dealing with severe kidney disease and a young child needing medication to prevent flare ups of a chronic illness, which would risk death. Both were being denied what was being decided by their respective doctors by a pen pusher in an insurance company, driven by only profit for shareholders and what is best for them.

It was not always like this. In the 1970’s and early 1980’s, I can recall my mother writing a $25 check to the doctor directly. There was no insurance, just him and his nurse. There was no one dictating to him how to care for his patients. But that all changed once insurance got involved. Then care became about being “managed” with at least some concern about preventative medicine. But still, there were no warning signs that care was going to be sacrificed for shareholder profits as we see today. Today, the insurance industry is out of control with its interference with patient care, resulting in one tragedy after another. And leaving other patients with only one option, to fight the almight insurance company with everything you have, just so that you can get done what your doctor knows is best for you.

First, let’s understand the basics. Only doctors know what is best for their patients for one simple reason. They are the one hands on, in the room with the patient, hearing the patient, with the entire history at their fingertips. Next, insurance companies are like casinos in that, like casinos, also known as “the house”, they both have the advantage, and they only make money if the customers/patients do not win and get paid. So now you understand the odds are against you as a patient. The insurance company cares only about making money for its shareholders, and that means only one thing, deny paying out as many claims as possible, and worse, denying care and treatments.

If you are one of the fortunate, who are either healthy or have what is called a “cadillac plan,” one that covers everything without restrictions, then you have likely never had to deal with a pen pusher denying a claim or treatment. But for those of us that have had this happen to us, we know things have gradually gotten worse, way worse, and people are dying because of it. So I am writing this post, to do my part, to help, at least provide some directions and information, how to do the seemingly impossible, fight the big bad giant insurance company. It sucks that for so many, fighting for their very lives, they have to spend any energy they have to fight for their medical care on top of it, and the odds are against them, and so is time.

Dealing with an insurance denial can feel infuriating because we know our doctors are only trying to help us, but not the shareholders. So there is that constant conflict. And sadly, it is going to take more than one attempt to defeat the insurance company, by putting the right kind of pressure on the insurance company, you can improve your chances. But it takes strategy and focus, all while you are sick, possibly fight for your life against time.

Get the denial in writing and read it carefully. Ask for the exact reason for the denial and pay attention to the policy language they are using as to the denial. Was it:

• not medically necessary
• experimental/investigational
• out of network
• preauthorization missing
• coding error

Often times, denials are procedural in nature, and can be fixed. A pain in the butt when time matters, but it is what it is. Coding errors are becoming more and more common and can be fixed by the doctors administration staff (remember earlier how I mentioned only a doctor and nurse handling everything, administration staffing is a major reason for health care costs skyrocketing, and mistakes being made).

File a formal appeal immediately. Insurance companies expect you, expect most people to give up. DON’T!!!! But this is where you now have to ask your doctor to advocate for you and file this appeal for you (actually they will likely have an admin staff member do it). This is not a big ask of the doctor and is really quite common. It is in their patient’s best interest to do this, and do so immediately. The appeal needs to include:

• a letter of medical necessity
• supporting medical records
• peer reviewed studies if applicable
• a clear explanation of why other options will not work or have failed

If the appeal fails, or time is that crucial, request a Peer-to-Peer Review. This is where your doctor can speak directly with the insurance company’s reviewing physician. But don’t be fooled by the “peer to peer” as anyone knows, there are differences between doctors and specialists. And you do not know the specifically if your doctor is speaking to an actual peer of their standing (as in oncologist to oncologist, neurologist to neurologist or cardiologist to podiatrist or pulmonologist to orthopedist). There is good and bad to this, but hopefully, as long as the conversation is keep professional, if not dealing with an actual peer, the insurance doctor can trust what your doctor is trying to convey. But if true peer to peer, then there should be mutual understanding of what needs to be done. A direct conversation is the best chance to clarify any complexity.

Even then, sometimes those appeals or reviews are not good enough. This is where you really need to advocate for yourself, because your life literally depends on it. It should not be this hard, but you need to do what you can. You have the right to request an independent external review under federal law (the Affordable Care Act). This external reviewer is not employed by the insurance company, and makes binding decisions in many cases. State-specific instructions how to do this are usually found under your state’s Department Of Insurance on the internet.

Depending on your coverage, as in if private insurance, you also have the option to file a complaint with your State Insurance Commisioner. If you are dealing with Medicare, contact the Centers For Medicare & Medicaid Services. And if it is employer-based insurance, you may have to involve the US Department of Labor (ERISA plans). Regulatory complaints often trigger faster re-reviews.

Double-check if it could have been a coding issue. It happens more than you know, especially with insurance companies dictating what appointments should be, versus what the doctor actually does, and contradicts what the insurance company expected. With my complicated health history, this happens all of the time. So, if it was the wrong billing code submitted, or the diagnosis code is wrong or does not justify the test or treatment, or even the provider forgot any pre authorization needed. It is not a big deal to have the doctor’s office double-check the CPT and ICD-10 codes.

If the denial says “experimental,” ask your doctor to be sure to include specialty guidelines, standard-of-care publications, and consensus statements. Insurance companies may relent and reverse when shown what the doctor wants to do is standard practice.

Of course, if the situation is Urgent or Cancer-related, and delay will seriously jeopardize the health of the patient, reqeust an expedited appeal. Response must be faster, hopefully within 72 hours or less. A simple accompanying statement from the doctor, “delay may materially affect the prognosis,” should carry weight.

And if all else fails, there are some other options such as negotiating a cash price (which is often times less than billed rates), speak to a case worker or social worker about financial assistance programs, and if necessary, a legal consultation (especially if the denial contradicts policy language). Your doctor is going to do all they can for you, or at least they should, but understand, like the comparison to the casino, the insurance company only succeeds if they deny, deny, deny, and not pay out claims. They do not care about patients, only profits for the shareholders.

But what the insurance companies do not count on, is persistance. Like really, who does not want to survive what they are dealing with, that you have to fight even harder and waste more time. But keep this psychological strategy in mind. Insurance companies operate on time pressure, administrative fatigue (they count on you giving up), or they may even just get tired of the fight. Some times, persistence is one of the strongest tools in this fight.

Of course, this all circles around to my constant fight for universal health care. Those who oppose it, come up with one excuse after another, and even after it is proven to be the advantage, at the end of the day, it is the mere fact, that some simply do not want the government in charge of the insurance. These people are willing to pay over $20,000 a year, for a private entity to deny them health coverage as opposed to what is already taken out of paychecks, called a FICA tax, which contributes to Social Security and Medicare, an amount of 15.3% total, split in half between the two, so 7.65% to Medicare, already being paid along with whatever your pay towards private insurance. Medicare has a much lower, if any denial rate compared to private insurance, and more importantly there are stronger mechanisms for Medicare to fight any delays or denials. But then the argument falls back on “I don’t want government controlling my health care” or “wait times” (which already exist), or “can’t see who you want” (with a private option, yes you can), or whatever excuse those who oppose want to throw out. It is against your best interest to oppose universal health coverage which is why EVERY other industrialized country has it except for us, because in the US, health insurance is not about patient care, it is about profit over patient. And because of that, good luck with your appeals.