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Insurance Victories

Insurance Peace of Mind: A Patient’s Perspective on Making Insurance Work for You

March 2011

By: Jennifer Tahmoush
PH Patient

When diagnosed with PAH, who would have thought that the hardest part would not necessarily be the daily challenges that come with the disease, but instead the unexpected battlefront of insurance? Whereas the medications, the pumps and the labored breathing often become just a part of daily life that we hardly notice, it’s the unexpected denial of reimbursement or coverage for critical medications and tests that can derail what started out as a beautiful day.

I was diagnosed with pulmonary hypertension about seven years ago at age 25. I had open heart surgery a month after diagnosis and only six months before my wedding. Before that, however, I had been an active, healthy individual with little experience working with healthcare insurers. Luckily, I had purchased a great individual preferred provider organization (PPO) plan straight out of college; the majority of my diagnostic tests were covered and I had the luxury of going to the specialists I needed – and whom I credit with saving my life.

The first few months post-surgery remain fuzzy but my doctor’s team helped get my insurance to cover my Tracleer and other medications. Then came the Viagra. With the Viagra came the headaches, not as a side effect of the drug, but from trying to get it covered through insurance! Several years later I ran into similar issues when my insurance company tried to drop coverage of the Tracleer.

Seven years and nearly 10 prescription drugs later, I’ve been successful in getting all of my medications covered and have determined how to best deal with common coverage barriers:

Do it when you feel good. I know – who wants to ruin a day when you feel great by calling an insurance company? But choosing days when you feel healthy and strong will increase your ability to argue. It will also help you stay calm and focused when challenged.

Write down the names and dates of everyone you talk to. Call centers, faulty information in computers, disagreeable customer service representatives – they all have an impact on how quickly your issue gets resolved. By writing down the names and dates of those you speak to, you create a greater sense of responsibility on the other end, and you have reinforcement for future conversations.

Keep them on the phone until you have a resolution. Yes, it’s painful and challenging, especially when you work. Elevating the call to a manager and then their manager is one approach, while continuing to ask “what can you do for me?” is another. Any way you do it, by keeping an insurance company on the phone you are ensuring that someone is paying attention to your issue.

Keep an organized paper trail. This is especially important when it comes to medical bills. Write down names, dates and action items on a sticky note and attach to the disputed medical bill. Or, just write on the bill itself. And staple or clip your bills and explanation of benefits (EOBs) together with your notes. That way, when the second or third wave of inaccurate bills or insurance denials come in, you have all the facts right at your fingertips when calling the hospital, doctor’s office or insurance company.

You’ll also want to put memos on your checks or electronic payments so you know which dates of service (DOS) payments they were meant for. Often a hospital or doctor’s office will simply apply your latest payment to the most outstanding bill. This can be an organizational nightmare when you have one or more disputed payments pending. When new bills include DOS I know I’ve already paid for, I review the DOS notes in my online checking payments, make notes on the bill and then call the hospital or doctor’s office. By reviewing the dates and payments with the person in charge of billing at the hospital or doctor’s office, they can adjust how payments are applied in their system so your next bill will correctly reflect your intended payments.

Get your human resources (HR) department involved. If your insurance is through your workplace, your Human Resource department is another option for reinforcements. Like a doctor’s office, they have special contacts they can reach, and no one should know what your medical plan covers like your HR manager.

Consider secondary insurance. Secondary insurance (through work or a spouse’s workplace) can cover up to 90% of out-of-pocket costs left after primary insurance pays their piece. While the cost of an additional monthly premium may seem high, compare the cost of secondary insurance to the out-of-pocket amount you’re paying for doctor visits, medications and medical tests. You may be surprised at the result.

Ask for help. Some days, you just can’t do it anymore. It feels like the insurance companies have won and you just want to give up. Don’t! This is the time to ask for help. Whether it’s from a spouse who can contact their HR group, a parent, sibling, child or a doctor who can work out next steps with an insurance company, sometimes just a short break can give you the stamina to pick up the ball next time around.

Most importantly, maintain a close and open relationship with your doctor and his / her team. Your doctor is usually the biggest health advocate you have other than yourself. He / she has a vested interest in seeing you get the medication and treatments you need. Often a doctor or administrator can reach people an individual cannot. They also have the ability to approve or confirm things first hand. When you let them know where you stand on a certain issue, they can often help you identify the best way to break through to success.