Health Insurance: Need It, Love It, Hate It
The cost of getting healthy
We’ve all been there, right? You go to the doctor not quite knowing how much the appointment is going to cost because you didn’t pay attention to the finer details of your insurance policy. Is it a $20 copay? Wait, is this doctor a specialist? That might be $50. Ugh. No! This is a routine visit that should be fully covered. I think. Oh crap, I haven’t met my deductible yet; it’s going to cost $4,389,250.76.
Imagine having this conversation going on in your head several times a week — because that’s how often you go to a medical office. Imagine getting a bill every week and having to research your insurance policy (which, by the way, you pay an astronomical amount for each month) to check to see if the bill is accurate. You do this because, as you’ve learned, there are many billing errors because of a variety of things: erroneous medical codes used by the medical office, the insurance company mishandling the claim, the dates are off; the insurance sent a last-minute denial of services, and the list goes on.
My daughter, Emily, went to medical doctors, therapists, had multiple prescriptions, endured many procedures, and used medical equipment throughout her childhood. You want her to go to physical, occupational, and speech therapy every week? She needs seven prescriptions a month? She needs to go to the hospital every week for chemotherapy? Yes, yes, yes — anything to keep her alive, here, and with us functioning to the best of her ability. This was the reality of a brain tumor diagnosis. You go broke paying for it all and spend countless hours a week on the phone with your insurance company.
Not too long ago Emily was put on a medication that needed to come from a specialty pharmacy (i.e., I can’t just go to CVS and have it filled). The doctor put in the prescription to a specialty pharmacy that I had used previously, and I waited for the call to tell me when this medication would be shipped. The next day I received the call, but the pharmacist said insurance denied the claim.
This was puzzling because by this time my daughter not only had group insurance that my husband had through his work but also secondary insurance to help cover the costs our primary insurance didn’t cover.
I got off the phone and called the insurance company. After navigating to the appropriate person (a lovely process), I was told the claim was denied because the insurance company has their own specialty pharmacy and I need to use them.
Easy enough, I thought. I called the doctor’s office and asked them to send the prescription to the insurance company’s specialty pharmacy.
The next day I received the phone call from the insurance company’s specialty pharmacy. “The medication will be shipped today. It will be $690.75, how would you like to pay for that?”
“With my insurance,” I replied, utterly confused.
“That’s after insurance,” the rep calmly stated.
“Is that just one month’s supply?” I asked, still trying to wrap my brain around this number.
“Yes.”
“Did you bill our secondary insurance?” I finally asked with relief, realizing they probably hadn’t.
“No. We’re not set up to bill secondary insurance.”
“But I have secondary insurance that would help cover the cost. What am I supposed to do?” I asked.
“You’d have to use a different pharmacy to fill this prescription. One that bills secondary insurance.” The insurance representative matter-of-factly stated.
“I tried using a different pharmacy to fill this order. You denied it, saying I had to use this pharmacy!”
“I’m not sure, ma’am. Would you like to use a credit card?”
“No! I would not like to add two car payments a month to my credit card for a prescription I could get filled elsewhere and have the insurance cover it.”
I went in circles with the insurance company around this. I finally, after two weeks of daily calls to various levels of supervisors, got the approval to use a pharmacy that would bill both our primary and secondary insurance. And every month the pharmacist called me to say it was denied by our insurance company. And every month I had to call the insurance company and remind them of our situation.
Every month.
This was just one of our struggles. Imagine being sick, being the one who needed this medicine, and having to fight this fight? I was always grateful I was healthy enough to endure this battle and that my daughter did not need to have this worry.
I learned a few tricks along the way, which helped navigate my insurance questions and issues. I enlisted the help of the Human Resources department through work where we had group insurance. They not only helped me tease out the intricacies of my plan benefits, but they also helped negotiate the health insurance plans being offered. In one case, I had several conversations with one of my HR reps at work detailing how much I spent a month on medical costs and the result was eye-opening for my representative. She took that information to negotiate a better monthly premium rate for the next year.
The biggest ally in my monthly battles with insurance companies, though, was my State Insurance Commissioner. Each state has one and its job is to keep insurance competitive, fight fraud, and educate consumers about insurance-related issues. When the battle got big enough, I enlisted my Insurance Commissioner for assistance.
I will gladly continue to pay for insurance every month; thankful I don’t have to pay out-of-pocket costs for medical expenses. But that also means I gladly yell at every insurance rep who tells me something was denied or cost more than it should (sorry insurance reps — I know it’s not you making the policies, but you’re much easier to get ahold of than the policymakers).