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Insurance Appeal – Just The Fax

Insurance. Ugh, yes, I said the “I” word. It’s something most of us with chronic illness have extensive experience dealing with, unfortunately. Just saying the word is enough to put us into fight or flight mode, and the anxiety that comes with this nine-letter four-letter-word makes terms like “pre-authorization,” “expedited appeal,” and “out-of-network” take on a sinister quality that induces panic in even the most even-keeled among us. It’s a necessary evil in the purest sense – both necessary and evil in equal parts – and we all have war stories of dealing with these masters of obfuscation. Here is one of mine.

Insurance: the good, the bad

Insurance as a concept isn’t inherently bad. What it does, at its core, is move the money for medical costs to those who need it when they need it. Think about it – those who aren’t ill pay their monthly premiums and help offset the cost of the doctors for those who are sick. Until they get sick themselves, then they are the ones who benefit and someone else healthy picks up the tab. It’s basically medical bill timesharing. It’s not perfect but it’s the system we’ve got and it works pretty well – unless you are chronically ill and then the entire scheme breaks down like a DeLorean without a Flux Capacitor. When you begin to take more than you contribute, it becomes a fight for every inch and if you don’t pay attention before you know it all insurance will be paying for is brown M&M’s and Band-Aids featuring Hello Kitty’s unlicensed knock-off, Corporate Mascot Cat.

Fighting with the insurance company

Changes to my pain medications

My health insurance fights are epic, Lord of the Rings, there-can-be-only-one, Mortal Kombat “Finish Him!” level throwdowns, and the fight for my pain meds was no exception. It started out with a formulary change, two words that cause more anxiety than sharks and public speaking combined. Public speaking with sharks? Yikes. Anyway, I found myself with a letter stating that insurance would no longer be paying for my monthly dose of opioids. “This seems ominous,” I thought, and I prepared a measured response. Calling my carrier calmly and with all my ducks in a row… is what I should have done. Instead, I immediately phoned my doctor and told him to prepare for battle, rally the troops, and make some sandwiches (for while on hold). He took the lead and filed an expedited appeal, which means they have 72 hours to make a determination. Fast forward to the next day and the decision came down – denied again, they were cutting my opioid dose by 3/4 overnight.

The perils of an abrupt change in medication

Now anyone who has any experience with narcotics, has taken any medication at all or is a person who is alive, knows that you can’t cut someone’s addictive opioid medication by 75% overnight. Put aside the fact that it could cause my heart to say “nuh-uh, I’m out,” it’s just not a safe practice by any stretch of the imagination, which makes it all the more hilarious… no, that’s not the right word… ironic… no, idiotic, yes that’s it. It makes it all the more idiotic that the appeal denial was signed off on by a doctor. A doctor who works for the health insurance company. Hmmmmm…  A physician who is paid by a health insurance company to review appeals is just about as impartial as…  umm…  you know what? I can’t even think of one of my classic analogies to illustrate a conflict of interest more clearly than a doctor who’s salary is paid by a company whose job it is to save money on patient care. Of course, they left me no choice but to appeal the appeal, and that’s when I truly began to realize just how far down the rabbit hole things go.

The insurance appeal process

First, there’s the second level appeal. It is, again, administered by the same appeals department of the same medical insurance company with the same doctors that dealt the original denial and then the appeal denial, sooooo… yeah. Let’s just say I wasn’t optimistic about my chances. Guess what? I was wro… right, I was right. Denied again. As if there was ever any question.

Trying to talk to an actual human

By this point, I figured if I could just talk to an actual human being and explain my situation, there was no way they could deny me. So I called up the insurance company and asked to speak with the appeals department. They told me they didn’t have a phone. So I said you mean they don’t have a phone number, right? Cause if they don’t have a phone then how do you talk to them? Do you send messages by carrier pigeon? Smoke signals? Semaphore? (Google it) Sidebar: I also discovered Insurance company customer service reps understand sarcasm just enough to not take kindly to it. They told me I wouldn’t be able to speak to anyone in the appeals department and I realize now that is by design. If they had to deal with pesky things like human kindness and compassion when making appeal decisions, they’d never be able to meet those denial quotas that don’t exist. wink.

Making my case in front of a judge

Now, it was on to an “external” appeal, which is handled by a separate entity…   kinda. The agency that handles the review is still under the general purview of Medicare, which is who ultimately saves money if I get denied so, yeah, that. I made my third appeal, and in a shocking not twist of events, the denial was rubber-stamped by the external appeal agency. That meant I had only one road still open to me – to go before an administrative law judge and plead my case, which I did, and guess what? I came out victorious. The judge even thanked me for making such a cogent argument. The funny part is that the judge was the first actual human being I had talked to since I got the original appeal denial. Funny, that.

Appeals are all still conducted by fax and mail, and this particular one took almost an entire year. This wasn’t 1985 either, it was well into the age of the Internet, 2010. The entire system is designed to discourage people from following through with their appeals, thus saving the company money. Health insurance serves a needed purpose, I can’t argue that, and you’ll be very happy with their service – as long as you don’t get too sick for too long. Then you better find a fax machine. Talk soon.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

  • mseelhoff
    3 months ago

    Wow, your lucky to have any opioids. Basically, they are illegal in Texas now. As to the lady who wanted Xeljanz. Stay as far as way as you can! The stuff almost killed me! I can’t argue with my current insurance, I just now everything has to be prior authorized, and in network or its as if I have no insurance! It is useless to fight, have your doctor send a documentation letter and if they still disagree look for something else drug wise or just pay for it. Yep that is reality! It’s just not worth the stress!

  • Daniel Malito moderator author
    3 months ago

    @mseelhoff I had no idea that Texas was like that, it sounds awful. It took me over a year to fight for mine, and although it seems stressful and almost not worth it, you only have to do it once. Once I had that court document they never denied me again, and all I ever say if they do is “I have a court order, sorry.” It’s awful the state of pain meds in this country and how innocent people like us are having to bear the burden of public pressure and misunderstanding of the issue. Just know you’re never alone, though, we are here for whatever we can do. Thanks for reading, keep on keepin’ on, DPM

  • 2mra
    3 months ago

    Congrats to you Daniel!! Like R.D. isn’t hellish enough
    without insurance causing more pain and disappointment. It looks like some judges(humans) are compassionate. I hope that you sent him flowers or something. LOL! Good job!!

  • Daniel Malito moderator author
    3 months ago

    @hwb0w4 I wish! I tried to send him a thank you but apparently thats “unprofessional.” LOL. I feel like it was more because I actually made sense and insurance… doesn’t! Thanks for reading, keep on keepin’ on, DPM

  • LifenowwithRD
    3 months ago

    Wow does this hit home for me. I’ve faught for coverage several times for my biologic and lost. Every. Single. Time. When Enbrel quit working a year ago, my insurance would not consider paying for the xelganz my rheumatologist wanted me on, but for some very odd reason I still can’t understand, were ok with Remicade infusions. Say what?? Infusions cost 2 1/2 times MORE than the pills would have cost! Oh, but this was reviewed by one of “their doctors” who I later found out is NOT a rheumatologist, just some internal medicine Dr who thinks he knows it all I guess. I mean could this system be any more messed up? Why do we even see a specialist if what they want to prescribe will never be approved? I could rant on and on about this, but no good can come from that for me. I just wanted to say how i totally share your pain on this topic…frustrating as it Is!

  • Daniel Malito moderator author
    3 months ago

    @lifenowwithrd It is frustrating for sure! It’s never a rheumatologist that reviews us, is it? That should be a prerequisite. It’s never a reason that ever makes sense, is it? Thanks for reading, keep on keepin’ on, DPM

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