In the last couple of posts we
have been exploring ways to effectively appeal a medical insurance claim that
has been denied. I will offer one more
scenario and then some general advice.
Payment of pharmacy
benefits—prescription drugs—typically represents the largest benefits
expenditure by insurance companies. So,
of course, they will take whatever steps they can to limit their exposure. This will almost always take two forms: imposition
of a formulary (a list of approved drugs they will pay for) and step therapy.
Formularies are not new. Hospitals use them, too, to limit the drugs
stocked in their in-house pharmacy and which doctors may order for inpatients. The formulary is not arbitrary, being
composed by, and subject to review by, a committee of doctors and pharmacists
to ensure all therapeutic categories are adequately covered with a range of
drugs but without unnecessary duplication or inclusion of unproven medicines.
It can be easy to run afoul of an
insurance company’s formulary and have your prescription drug denied (or
covered but with a huge co-pay from you) as not being on the formulary; or if
it is on the formulary then it may not be covered until you try alternative
medications first—the so-called “step therapy” approach. In this scenario, the insurance company may
cover the particular drug your doctor ordered but only after older (and
cheaper) alternatives were tried and proved to be ineffective.
If this is the first time you
will have used the drug (e.g. for a new diagnosis), you should consult with
your doctor about the insurance coverage and see if she will prescribe one of
the alternatives that is on the formulary. This can benefit you since the alternative
will not only be cheaper for the insurance company but for you. If the
alternative(s) are not acceptable to her, then the burden should shift to her
to justify to the insurance company why it should be covered. This would ordinarily involve providing some
clinical documentation to the insurer to demonstrate why the non-formulary drug
is superior to the cheaper alternatives. Don’t expect success here. That information was likely already reviewed
when the formulary was composed and was deemed inadequate to justify inclusion
on the formulary. In that case, you are
left with having to try the cheaper drugs first. It’s not necessarily a bad thing.
But suppose the cheaper drugs
don’t work. Or suppose you have been on
this prescribed, non-formulary medicine for years and it’s just that you have a
new insurance company you are dealing with that insists you go through step
therapy. Here is where you may have some
success. You need to give the insurer an
account of your having tried the cheaper alternatives and their failure to cure
or control the condition for which they were prescribed. Your doctor can assist with this, and it is
usually adequate to get the initial rejection from the insurance company
overturned.
I’ve been on the other side of
the fence, having worked for an insurance company (although they like to use
terms that don’t carry a negative connotation—like “managed care organization”),
and despite the perceptions to the contrary, there are people working at these
places that really do care about the health of their customers. Don’t get me wrong; there are “cost
containment” people there, too, that are trying to find every reason they can
to limit payments or deny claims. But
customer service reps, provider service reps, case managers, and nurses
employed by the insurers are of a different mindset and are often frustrated by
the cost controls that they see as interfering with care or confusing the
customers. In my experience (on both
sides of the fence) they will do whatever they can to assist a customer to get
appropriate care and claims paid.
I read an article this week about
customer service reps at Cigna protesting their work conditions, lack of
training, no raises, etc. This kind of
dissatisfaction and lack of training can come across during their interactions
with customers as their not caring about helping resolve complaints. But believe me, lack of training is a killer
of good customer service, even if the employee has the desire to help. I’ve worked with Cigna as my insurer, and
what I had to do is what I recommend YOU do whenever you contact your insurer:
take precise notes of when you called, to whom you spoke, what they committed
to do, and any case or call reference numbers they give you. Get a commitment of when the situation will
be resolved, and if they miss that deadline, call again and have all those
notes handy.
As I’ve said before, one of the
keys in appealing is demonstrating how an adverse decision from the insurance company
will actually cost them more money in the long-run than just paying the claim,
etc. But an equally important best
practice: BE NICE. I’m afraid civility
is becoming a rarer commodity these days; but if you talk calmly and don’t
shout, treat the insurance rep respectively, and make a reasonable and coherent
case for your request, you will stand out in the crowd, believe me. And this should make the other party more willing
to help. No guarantee here; some people
only respond to threats, unfortunately.
But for the conscientious ones—and they do exist—this is a great tool. Plus, it keeps your blood pressure down,
which might keep you from having to visit the doctor, which in turn keeps you
from having to submit another claim to the insurer that might get denied and
which you’ll have to appeal.
For help with Medicare claims,
you may contact your state health insurance assistance program (find it at www.shiptacenter.org) or
Medicare Rights Center, an advocacy group for Medicare beneficiaries, at
800-333-4114. For commercial insurance,
be acquainted with your insurer’s various levels of appeal, but also know that
you can take your complaint to the insurance commissioner or other regulatory
body in your state.
Until next time,
Roger
“The right word at the right
time is like precious gold set in silver.” Proverbs 25:11 CEV
“A kind answer soothes angry
feelings, but harsh words stir them up.” Proverbs 15:1 CEV
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