*Dealing With Insurance Companies**

Unfortunately, the days of going to see a health care professional and knowing that your insurance company will cover the costs are long gone. Likewise, the days of getting medications and knowing that your medicine will be covered by your insurance company are a thing of the past. Individuals with chronic medical illnesses quickly find themselves thrown into the insanity of the managed health care system. Trying to get the treatment that you need can be VERY difficult now. However, with some knowledge, determination, and willingness to fight for what you need you should be able to get most medical costs covered in some way. The key to this is not giving up immediately.
To begin, you need to know the type of health care insurance you have. Many people do not know this, and frequently just give me the name of the insurance company. YOU MUST KNOW THIS in order to figure out how you are going to approach the problems that you will inevitably have. Generally, there are three types of health care insurance, and then there is Medicare and Medicaid. Click on the link below and read the descriptions to discover which type of health care insurance you have.

Yeah, let me read about this

Well-Known Secrets

I assume that you now know the type of health insurance that you have. Obviously, there are pros and cons to each of the insurance types. At this point in time, most people have an HMO/EPP or PPO policy.
Here are the well-known secrets:

Managed health care insurance companies are motivated to save money.
Managed health care insurance policies have very strict rules so getting health care that is out of the ordinary is very difficult (and this is the type of health care most people with chronic illnesses need).
Many managed health care insurance companies will put up obstacles to deter having to pay for health care, but these obstacles can be overcome.
The astronomical rise in health care costs is a result of managed health care:

Many health care professionals will only be paid as little as 20% of their usual fee for health care services.
Medical testing and procedures will be billed at an enormous price, but it is understood that the reimbursement from the insurance company will only be around 50%. Thus, the hospitals or medical testing facility "writes off" what was not paid.
If an individual has a FFS or no health insurance, he or she is going to pay alot for health care because the health care professionals or hospitals can bill at that enormous price and the person is going to have to pay it.

Pharmacy policies:

Again, costs for medication have skyrocketed for the same reasons as health care costs.
Every insurance company has two medication lists: "formulary" and "non-formulary." The translation of these lists:

"Formulary" = medications that will be covered
"Non-Formulary" = medications that are not automatically covered and the physician is going to have to justify why the medication is needed.

If a medication is on the "non-formulary" list, a call from the physician does not guarantee that the insurance company will cover it.
Oftentimes, medications on the "formulary" list will still require what is called "pre-authorization" by the physician (translation: the doctor is still going to have to call the insurance company and justify why you need to continue taking the medication).
Much of this goes on "behind the scenes", and people with chronic medical illnesses are unaware that all of this is taking place.

However, as insurance companies become stricter with the medication policies, people with chronic illnesses NEED to become active and involved in this process -- we can't expect physicians to keep up on 150 patients' pharmacy policies and what needs to be called in when.

Secret Tips

After reading through the last section, you may be somewhat worked-up right now. Although the secrets I shared are considered "well-known", many people are not aware of these things. Also, many people do not realize that an insurance company may automatically decline coverage of a health care service, but with a little perseverance on your part, the insurance company will cover it. Here are some things that I have found useful in dealing with HMO/PPO insurance companies:

If you are anticipating having any procedure, testing, or referral to any specialist, CALL THE INSURANCE COMPANY before you see your primary care physician and find out what needs to be done.

Write down what the insurance company tells you and then share this with your primary care physician.

If you find out that the primary care physician wants to refer you to another specialist or have testing performed, have the PCP write out the referral form, but CALL THE INSURANCE COMPANY before you actually see the specialist or have the test performed to make sure that the referral is correct.
If you have a pharmacy plan, start taking an active role and call the insurance company to get the following information:

Which medications you are taking that require "preauthorization" and how long the insurance company has authorized coverage of the medication (this does NOT mean that when the authorization period is up, the insurance company will no longer pay; your doctor will need to phone the insurance company or send a letter justifying continued use of the medication).
Call to see if a new medication prescribed is on the insurance company's "formulary list." If not, find out what the physician needs to do.
Form a good relationship with your pharmacist

Find a pharmacy that you like that has a pharmacist you believe is good
Pharmacists can pull some strings for you in the likely event that there will be problems with the insurance company covering medication costs

Do NOT give up if the insurance company initially denies coverage of health care. Oftentimes, these companies will automatically deny coverage at first, but a call to the insurance company to find out how to get them to cover the costs will reveal that a call from the PCP will take care of the problem.

Remember, insurance companies are motivated to save money, so they will put up obstacles with the hope that you won't pursue the issue further and you will just pay for the costs yourself.

If you frequently see a specialist besides your PCP, MAKE SURE you keep yourself up-to-date on how many appointments are left with the current referral.

If you see a specialist and really do not see your PCP, it is worth your while to make occasional appointments with your PCP. Having a good relationship with your PCP and the individual who handles referrals can make life much easier for you.

Realize that insurance companies ARE REQUIRED to pay for health care services provided by individuals outside of the "network" if there is no one in the "network" to provide the service. I have had several experiences where my insurance company told me I "could not see" specialists because they were not in the network, yet the insurance company did not have any of these specialists in their "network." Remind the person that you are speaking to that this would be illegal, and if you do not get a positive response, then you ask to speak to the supervisor.

* This web page is designed to provide information and does not constitute development of a professional relationship. You are strongly encouraged to speak to the health care professional(s) who are treating your chronic illness to obtain a suitable referral.