At each of her past few annual mammograms, Melissa Cogliati was told her breast cysts make it hard for the radiologist to interpret the film. Her gynecologist always insisted she schedule a follow-up ultrasound, which her insurance covered in full. So last year, with her doctor’s OK, Cogliati booked the two screening tests for the same day. “It made sense for me to get everything done while I was already there,” the Louisburg, North Carolina, resident recalls, but her insurer didn’t agree. For reasons that are still unclear, it paid for one procedure but not both, and Cogliati got stuck with a bill for $369.
You may think the national health care reform act has halted these seemingly arbitrary insurer-payment decisions (and if you think claim denial is rare, consider this: Up to a third of claims submitted for the first time are turned down). But while the new law does remove important obstacles to acquiring and keeping coverage, its changes unfold on a timetable: Right now many of its fixes apply only to people with new policies, and the rest of us must wait until 2014. (You have a “new policy” if you join a plan after changing jobs or carriers or if your current policy undergoes significant changes, such as in the benefits available or the size of the deductible.) Also, the legislation doesn’t end many of the more common claim-denying practices of insurers.
To help you get the coverage you’re entitled to, More has come up with this guide to resolving some familiar insurance snafus.
Your insurer says the treatment your doctor has prescribed is not medically necessary
Doctors and insurance companies are in a ferocious tug-of-war over who gets to define “necessary” treatments. Often called into question: treatments such as electric nerve stimulation for some overactive bladder problems.
Try this Sometimes the insurer rejects a claim because the treatment was improperly coded. If you’re really surprised by a turndown, ask your doctor’s office to phone your insurer and check the codes, says Donna Marshall, former business manager at the National Center for Advanced Pelvic Surgery at Washington Hospital Center in D.C. Always prevent after-the-fact rejection shock by getting the procedure precertified, if that’s required, or by calling the customer service number on the back of your insurance card before you schedule a treatment.
If all else fails If your doctor believes that you really need the treatment, formally appeal the decision (see “Dealing with Denial,” above). Your denial letter will tell you where to send the appeal. If your case is particularly outrageous, send a copy of your appeal letter to your state’s attorney general and insurance commissioner, suggests Mark Rukavina, executive director of the Access Project, a health care research and advocacy organization in Boston. Follow up with phone calls if you don’t get the help you seek.
You want a new kind of drug, but the insurance company says no
Insurers typically encourage patients, through high copays, to try cheaper medications before moving up to newer, pricier options. “It’s known as step therapy, and the insurance company will authorize only the least expensive alternatives prior to going to the more pricey options,” says Omaha dermatologist Joel Schlessinger, former president of the American Society of Cosmetic Dermatology and Aesthetic Surgery. This is probably your health insurer’s position on the new diabetes drug Byetta, the once-a-year osteoporosis treatment Reclast and the IV-administered arthritis medication Orencia.
Try this If your health won’t suffer, it’s easiest just to follow the required steps. Already tried the other meds? Send proof to your insurer in the form of old prescription labels or other documentation. Know that some insurers cover certain drugs only if you meet a clinical threshold. For example, they may limit the injection drug Reclast (which costs about $1,000 for a yearly dose) to women whose bone scans document osteoporosis, not its precursor, osteopenia. Mary Fujii, reimbursement manager at Hematology-Oncology of Knoxville, in Tennessee, says she regularly sees women come for the drug only to learn that their insurers don’t consider them candidates. “If you’re going to a specialist for a specific therapy, send him your records for evaluation beforehand,” Fujii advises. Also check if your insurer has special requirements for new, and therefore probably pricey, drugs.
If all else fails If you urgently need the newest Rx now, ask your doctor to arrange a “peer to peer” phone review, in which he’ll talk with an MD at the insurance company. (And be aware that if you do get a yes, you’ll be paying more out of pocket: Expensive new “fourth tier” medications can carry copays of about 25 percent.)
Your insurance company denies coverage of a cutting-edge procedure because it is experimental
Say your gynecologist wants to use robotic surgery to repair your prolapsed bladder. This procedure, newer than traditional surgery, permits a much smaller incision and faster post-op healing—yet your insurer may insist on the old-school operation on the grounds that while the patient’s experience is better with the robotic surgery, the medical outcome is the same.
Try this Ask your doctor to make his case by including in his written precertification request published journal articles and practice guidelines about the treatment. You’ll also improve your odds of succeeding if the physician can cite instances in which the procedure has saved insurers money. “After years of refusing payment for robotic surgery, some companies are finally giving it the green light because it substantially cuts the hospital stay,” Marshall says.
If all else fails It’s heartbreaking to think you may have to endure more pain and a longer recovery time than necessary. But if your doctor can’t convince your insurer, you may have to settle for an older (and fully paid for) procedure. A riskier option is to look for treatments that are usually free because they’re cutting edge: those performed in clinical trials conducted before FDA approval. Most often, the researchers pay for the experimental therapy or drug, which may be promising but is not yet officially deemed safe and effective. Find trials at clinicaltrials.gov.
You want to see that top out-of-network specialist—but your insurer will pay only a small fraction of the physician’s fee It’s most cost effective for you to see doctors in your insurer’s network, all of whom have usually agreed to accept a reduced fee. Out-of-network MDs can charge as much as they like, but your insurer will cover only a small amount, and you’ll be billed for the rest.
Try this You may be able to justify to your carrier that a particular specialist is crucial to your care. “If there are no qualified in-network experts in your geographical area, you could be in a strong position to get the fee covered,” Fujii says. You’ll have less success if you prefer that physician simply because of her top reputation.
If all else fails Ask the provider if she’ll reduce your fee. “It’s not uncommon for out-of-network doctors to lop off a percentage from what you owe,” says Cindy J. Holtzman, a medical advocate in Marietta, Georgia. And if you have a flexible spending account (FSA), in which your employer sets aside pretax dollars for you to spend on health care expenses that aren’t reimbursed by your insurance company, this is a great time to use that money. If not, here’s a good reason to sign up for an account next year.
Your policy doesn’t cover alternative medicine
Although there’s a lot of research that shows the effectiveness of alternative treatments (like acupuncture for chronic headaches), most insurers cover complementary and alternative medicine only if your employer adds a rider to its policy—and few do.
Try this Your FSA can help you here, too. The same applies if you have a tax-free high-deductible indemnity plan with a health savings account (HSA).
If all else fails Shop around for the best deal. Consider doctors who are schooled in alternative (or integrative) medicine as well as nonphysicians specially trained in the various techniques that interest you.