What Your Health Insurance Company Won"t Tell You

http://type2diabetestreatment.net/diabetes-mellitus/what-your-health-insurance-company-wont-tell-you/

Dealing with insurance coverage is of course one of the biggest headaches of living with a chronic condition like diabetes.

I"ve been dealing with my own insurance woes lately, since my new health savings account policy kicked in, requiring a high annual deductible that"s very different from what I"ve been used to over my 30+ years of type 1. Let"s just say, I"m paying a lot more these days thanks to not reading all the fine print in my policy up front.

With the nationwide open enrollment period for many employer-based insurance policies about to begin on Nov. 1, this is a key time for many of us to have insurance on our minds. And it"s no picnic trying to review options and decide what"s best for the year ahead.

Fortunately, the second annual MasterLab advocacy training event put on by the Diabetes Hands Foundation in July had a great panel on this topic, featuring DHF leader Melissa Lee, DSMA (Diabetes Social Media Advocacy) founder Cherise Shockley, and Dexcom"s customer operations supervisor Marla Hogle -- all type 1 peeps themselves who deal with insurance both personally and as advocates.

Based on that panel discussion and our own insights, we"ve compiled the following list of tips on how to get satisfaction from your insurance company -- things they often don"t tell you but are important to know when dealing with them. Read on!

Tips for Swaying Your Health Insurance Company

Go online. You can often find their medical policies online for a specific drug, device, or therapy by Googling it. Look for language outlining the criteria they use to determine whether or not you’re eligible and covered.

• But how do you find this elusive medical policy? As a non-doctor, you cannot enter the “physician’s only” portal on your payer"s website that would make it easy to find. Use Google instead. Type in your payer"s name (Aetna, BCBS Virginia, etc.), the name of the treatment category (subcutaneous insulin infusion, insulin pump, continuous glucose monitor, SGLT-2, etc) and the words "medical policy." See what pops up. Usually you"ll find the specific policy in the first page of results.

Ask Three Times, Demand a Supervisor. When you have an important question, chances are you’ll call the insurance company at least three times and get three different answers – sometimes even from the same person. Often, payers have different levels of access for various people in customer service and departments. So the rep you"re talking with may not just be dumb or elusive; they might not be able to see all the notes and different screens in your file. Be assertive, and insist on going up the chain of authority to speak with someone who has access to all the relevant info and decision-making power you’re in need of.

Turn It Into Marketing. Not getting the answers or service you believe you should? Use social media to voice your gripes. Most of the insurers and distributors have Twitter accounts (for example ), so Google their Twitter handle and then post some notes about your experience. You may be surprised how quickly that gets attention, pushing your case through from the payer"s customer service department to their marketing and even executive levels sometimes. Don’t be afraid to write directly to the head honchos, inlcuding the CMO or CEO. That can also get prompt attention.

Prove it. Know going in that you’ll have to show proof of A, B, and C. If you test 8 times a day and need that many test strips per month, you’d better have BG testing logs or downloaded data showing that. You want a CGM (continuous glucose monitor)? Then be sure you have a history of your highs and lows to demonstrate the need for this expensive device. Make sure you work with your doctor so that all the paperwork is in place in advance of your request. This also helps in an appeal, in case you try to get a decision reversed based on the payer’s own stated criteria.

Read Your Doctor"s Notes. It’s important to get access to your doctor"s notes, as these days, insurers are often asking patients to provide documentation showing that they actually go to their doctors regularly, and are following the healthcare provider"s instructions. The mentality is: “Why should we give you an expensive device if you’re not even seeing your doctor regularly?” Make sure to have your doctor take copious notes on any low blood sugar episodes you experience, because this can also help show a future need for obtaining or maintaining the D-device you want.

• Yes, you do have diabetes! As noted above, you may have to prove it. This means keeping track of doctor visits, diabetes data logs, and in the case of type 1, a C-Peptide test showing that you aren’t producing insulin or maintaining “non-diabetes” blood sugar levels.

Find a Health Advocate. Believe it or not, insurance companies often employ their own specialized "health advocates" whose job it is to walk through your file and advocate for you (example: Blue Cross of Michigan). It never hurts to have more people at bat for you, especially someone who works on the inside of the company you"re lobbying!

Appeal. Insurance companies love to dish out claim denials, because they know that"s a huge deterrent. They expect that most folks will simply accept the denial and either skip the treatment or pay out of pocket. But the federal Government Accountability Office (GAO) in 2011 estimated that 39-59% of appeals resulted in the insurer reversing its original coverage denial. Those are pretty good odds! If you decide to appeal, be sure your doctor(s) are engaged in the process with you -- as insurance companies expect to deal mostly with our doctors during an appeal process, rather than patients directly.

• “Peer to peer” review – Within a specific time window during the appeal process, your physician can request a peer review, meaning they can call in and speak to a fellow physician at the insurance company to discuss medical necessity.

• Treatment Exceptions – If the issue you"re facing is that your treatment is no longer on the formulary list for your pharmacy, employer, or insurance plan, you have similar recourse. Your physician can appeal for a "continuity of therapy" exception (this can apply to an out-of-network doctor you want to see as well). If you do try the covered alternative (like a generic drug) and you have a negative reaction, you may have a stronger case for continuity of therapy.

• Tell Your Story – Personal accounts do make a difference, especially if provided by your doctor. Write up a letter explaining why it"s so important for you to test many more times a day than the typical 3 days of strips they want to cover. Or explain, from a quality of life standpoint, why the insurer should be paying for a brand-name drug instead of a generic or different medication, ideally with your doctor"s agreement that the alternative is not “medically equivalent” as the insurance company likes to think.

As Medicare Goes… Yes, federal coverage for seniors and low-income households is more complicated. As government programs, these payers have certain elements of their practices codified into law. It"s critically important that people with chronic health conditions take note of what Medicare and Medicaid (governed by the Centers for Medicare and Medicaid Services -- or CMS) cover. This is key not just because we are living healthily into our golden years and will eventually be in their jurisdiction, but also because CMS sets the benchmark for what private payers will be doing in the future. As Medicare goes, so go the private payers.

So that"s what"s on our list of things to keep in mind when dealing with insurance companies.

OK, D-peeps. Now it"s your turn: What do you think about these tips, and what would you add?

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn"t adhere to Healthline"s editorial guidelines. For more information about Healthline"s partnership with Diabetes Mine, please click here.

Type 2 Diabetes Treatment
Type 2 Diabetes Diet
Diabetes Destroyer Reviews
Original Article
#DiabetesMellitus