Getting Around Insurance Coverage Roadblocks

It’s complicated and it can be frustrating. Fortunately, as these examples and suggestions illustrate, there are many things you can do to gain control and reduce worry. Consider these three recent client examples…

#1. Mr. Smith

He has significant, chronic medical conditions that require care from a primary care physician and several specialists, one of whom is in a different state than where he lives. He has experienced numerous hospitalizations as a result of his conditions and has a favorite specialized unit in a specific hospital that is very familiar with his case.

In choosing an insurance product, his priority was to have coverage for all these physicians and facilities.

Mr. Smith was considering a Medicare Advantage Plan that was a Health Maintenance Organization (HMO) insurance product. I advised against this. To have coverage under this type of plan, he would be required to stay within a network of physicians and hospitals. Further, he would have to designate a specific primary care physician and obtain referrals to physicians and facilities within the network for specialist care.

Given his care priorities, enrolling in traditional Medicare Parts A and B, and supplementing his coverage with a Medicare Medigap/Supplement Plan along with a separate Medicare Part D Prescription Drug plan, was a much better option, one that would give him more choice and less worry about the future.

#2. Ms. Jones

She was told that her insurance would not cover an MRI recommended by her physician for an acute back injury. She was in such pain that she decided to pay the $800 out-of-pocket cost for the procedure and appeal the insurer’s decision later. That’s when she contacted us.

Her insurance product denied payment because of the specific clinical criteria they follow to approve such diagnostic testing. The denial stated:

The test should be used when the pain has not improved after six weeks of treatment by your doctor and that treatment should include medications and other forms of therapy such as home exercises and physical therapy. The test was to be used only if it was likely to result in a specific change in treatment and that the change might be related to the need for surgery or a procedure.

As part of the appeal, we asked her physician to write a letter to substantiate his clinical recommendation for an MRI before more conservative treatment was employed.

An alternative for Ms. Jones would have been to wait for the MRI to be approved, following her physician providing up-front, additional clinical documentation to substantiate his recommendation. Such prior approvals are often successful but delays in care result.

#3. Mr. Johnson

We helped Mr. Johnson overcome numerous delays on the way to being diagnosed with severe sleep apnea. His physicians were optimistic about the good clinical outcomes he might experience from consistent utilization of continuous positive airway pressure therapy (CPAP) to help him breathe more easily when he sleeps.

Unfortunately, his Medicare Advantage Plan only covered a small list of approved medical equipment providers. Of these, the only local one required much additional documentation and was booking appointments 4-6 weeks out. In the end, it took us an additional four months(!) to work through the administrative issues we encountered.

These are just three examples of the kind we experience every day on behalf of our clients. As you can see, the type of plan one chooses plays an important role in determining coverage. Medicare Advantage Plans often appear to be less expensive up front, but the limiting of choice, administrative barriers to accessing care, and out-of-pocket costs as you access that care can be problematic.

Some Practical Suggestions:

As much as I wish our healthcare system were easy to manage, it is complicated and something we must learn to live within. With that in mind, here are some ways you can be proactive, taking control where you can and reducing worry.

Anticipate. Every insurance product has administrative barriers. Expect that yours does too.

Learn. Read about your coverage. Call your insurance company before you access care — to verify that providers are in-network, to ensure coverage levels are what they seem, and to fully understand which diagnostic tests and procedures require prior authorization.

Document. Bring necessary documentation with you to your physician practice. Share what you know regarding steps your physician must initiate to assist with authorization for care. During encounters with your physician’s office and insurer, document the date, time, who you spoke with and what they said (this can be very helpful if you experience delays and/or receive inconsistent information and must escalate a concern to a manager).

Identify. In many healthcare practices, there are designated team members who assist with administrative issues and prior authorizations. Identify these people and develop a relationship so that you can follow-up often and directly.

Ask. When buying an insurance product, call the sales department before you purchase. Ask specific questions regarding scenarios you might encounter. For example…

Regarding networks… “I prefer to receive my care from University of MA Medical Center in Worcester MA. If I access care there, will I have coverage? Will that coverage be considered in-network?”

Regarding prior authorization… “I have a condition that might require an orthopedic out-patient surgical procedure in the next year. How will my benefits work?”

Regarding vendors… “I have Type I diabetes and use an insulin pump. What will I need to do to access my supplies and replacement pumps in the future on this plan? Under what benefit will my supplies be paid and how much of the cost will be covered? Are there specific vendors I must use?”

Whew! I know, it’s complicated and it can be frustrating. Fortunately, as the examples and suggestions above illustrate, there are many things you can do to gain control and reduce worry — not to mention time spent and cost!