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When the Insurance Company Says “NO”
This is an article about “advocacy”:
advocacy for yourself. It’s an article about committing yourself to
staying alive, and getting insurance companies and the government
to work with you to that end.
Let’s start at the beginning. No insurance company or government
agency can tell you which physicians you can see or what (legal)
procedures or drugs you may use. If you want to see Dr. “X”, one
of the leading PH specialists in the world, you may do so.
And if that doctor wants you to have an echocardiogram and then
take a daily dose of brand name calcium channel blocker you may
do so.
The issue is payment, isn’t it. You are “allowed” to get yourself
the best possible treatment. The only question is “who is going
to pay for it? ” That may seem obvious, yet I’ve lost count
of the number of times I’ve heard people say “My ‘primary’ won’t
let me see a PH specialist. He doesn’t have the power to take
that choice away.
Step number one in getting the best treatment is to decide that
you are going to have it. If your insurance gatekeeper says “NO”,
tell him that you’re making an appointment with the world famous
Dr. X because you have no intention of dying prematurely.
It’s hard to be that assertive with an authority figure, but you’re
going to do it. I’m telling you to !
It’s essential that YOU be willing to do anything it takes to get
yourself proper treatment, which in my experience means that you’ve
had a complete work-up by a PH specialist and that subsequent treatment
be administered or supervised by that specialist. If YOU have
any doubts about the necessity of such a set up, your insurer will
be very happy to give you what’s cheap.
Keep in mind that insurance companies have a very simple goal.
They need to take in more money from patients than they pay out
in benefits. They do not have your health as their goal, no matter
what the ads say. If you become “expensive”, the best thing you
can do from the company’s standpoint is disappear. That will
be accomplished if you die.
Now that you understand that YOU must obtain the best treatment,
the struggle boils down to money. First you do what you have to
do medically as quickly as possible. Then you attack the matter
of payment.
That’s when you jump all over the company that has refused to pay.
Lawyers may have to be consulted. The Press may be brought in. The
state Insurance Commissioner can be notified. If you’re alive
and as healthy as the best doctors can make you, you are in a good
position to battle over the money. And while I can’t guarantee that
you will always get reimbursed, you’ve got a reasonable chance.
Which brings me to the second part of this article: improving the
chances of getting necessary treatment paid for by your insurer.
Here we have to talk about the larger arena in which this action
is taking place. There is a battle for power between insurance companies
and patients. The amount of power each side has is determined by
laws passed by federal and state legislatures.
Right now, there’s a fight going on in congress among various
factions, each of which has a different view of who should have
the power to do what. The catch phrase for these proposals is “The
Patients’ Bill of Rights”.
Here are the questions that are addressed in these proposed bills
of rights. They may be addressed directly, or indirectly in language
that may not make it clear that someone is gaining the upper hand.
- Medical Necessity—This is the term that currently allows Insurers
to determine what kind of treatment the patient needs. You can’t
have an MRI because it isn’t “medically necessary”. A top
ranking specialist wants the procedure for you, but the insurance
company reviewer, a person with much less expertise than your
doctor, says it isn’t necessary. A good patient’s bill of rights
puts the determination of necessity in the hands of your doctor.
- Limits on Treatment—Many insurers impose limits on the amount
of a particular treatment a patient may receive in a given amount
of time. This is most obvious in mental health. The “28 day” treatment
for drug addiction has become standard practice not because that’s
how long it takes to cure the patient but because that's how many
days a number of insurers allow. Even in physical illness, hospital
stays are determined by insurance policy and not patient condition.
Take childbirth for example; many insurers know how long YOU need
to recover from giving birth, and the time isn’t generous.
- Right to Sue—As insurers have inserted themselves more and
more into the medical process, patients have been denied essential
treatments with sometimes disastrous results. Often vital information
is withheld from patients: a primary care physician outlines one
treatment plan, omitting an alternative and superior approach
which will be more expensive. If you suffer injury as a result
of treatment that does not put your best interests foremost should
you not be allowed to recover damages. Perhaps you feel
that our country is lawsuit-happy. Well, taking away this weapon
from the patient is not the place to start clearing the courts
of frivolous suits. There’s nothing frivolous about dying from
denial of treatment.
- Preference for generic drugs—In order to save money, insurers
often demand that a generic version of a drug be used when one
is available. Once again the company is interfering with your
doctor’s treatment program. Generics do not always act in exactly
the same manner as the brand name product.
- Treatment Reviews—In order to encourage treatment “drop-outs”,
insurers may institute review procedures that are so burdensome
that patients or doctors simply give up on a treatment. One large
company proudly referred to this as “The Sentinel Effect”, and
boasted that it could reduce the number of patients receiving
certain treatments by 25 percent. What do you suppose happened
to those people who didn’t get what they needed ?
- Specialist Equivalency—This is an issue of great importance
to PH patients. Many patients are told that the cardiologist or
pulmonologist on the insurers list of approved providers is able
to care for PH. Since there is seldom an official certification
in a specific disease, the insurer can claim equivalency between
any doctor with board certification in one of the organs central
to PH and a real specialist. Patients need a set of reasonable
criteria for demonstrating that the doctor whom they wish to see
cannot be matched by the company’s generic specialist.
- Specialist Fees—Insurance companies can effectively prevent
you from seeing specialists by setting their reimbursement rate
so low that only the youngest or most desperate doctors participate
in their program. I know doctors who have refused to sign on to
certain plans because the fee for their services is ridiculously
low. We all hear about “greedy” physicians, but I’ll tell you
that I don’t want to be operated on by a surgeon who’s getting
$150 to remove my gall bladder!
That’s a list of some of the criteria by which we should measure
any bill of rights. The question is, what are YOU going to do about
this. There are two things to do. First, you’re going to write to
your elected officials at both the state and federal level, from
the president on down. Use the points that I’ve made and any others
that your own research finds.
We’ve made it easy for you to get involved. Go to Action Central
on this site. You’ll find lots of information about writing to government
officials and expressing your opinions in the media. Need help formatting
your letter to Senator Foghorn ? How about his address. Or
maybe you’d like to know who’s running against him. It’s all there
on Action Central.
Second, there’s the little matter of elections. This year is the
biggie, the presidential. I’m going to vote on the basis of one
issue: Health Insurance. Sure I’ve got lots of other issues that
matter to me. But what matters most is my wife’s health. I don’t
want our insurer to decide that she has had “enough” flolan.
It’s a simple matter of priorities. I can cope with anyone, no
matter where he or she stands on the issues, or how close he is
to the big oil companies, or whether he was or wasn’t the father
of the internet, as long as he gives me the patients’ bill of rights
that I need. My first duty is to keep my loved ones alive, and make
no mistake about it, this is a matter of life and death.
Armond
Aserinsky, Ph.D.
President and Science Editor, PHCentral
September 20, 2000
Editor's note Feb. 28, 2006: Armond is currently a consultant to the board of directors and is the past president and co-founder of PHCentral, Inc.
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