Medical Insurance - How to Deal with and Stick It Out

Insurance. It’s a necessary evil when living with rheumatoid arthritis and chronic illness and many of us spend an inordinate amount of time doing so.

Prior approvals, EOBs, authorizations, co-pays - the list goes on and on and the terminology is more confusing than the manual for that really good digital camera you got because you were going to "take pictures" but ended up using your phone because it’s just so much easier.

Insurance use with chronic conditions

I have Medicare, but whatever insurance you have, I’m sure you know that dealing with the system can be a nightmare. I really believe that insurance was designed for those who have short-term, acute issues and when chronic illnesses like RA came along, they literally broke the system.

Long-term diseases throw a wrench into the works of medical insurance because they require so much care and treatment that the insurance companies have to fight you on everything. God forbid you spend too much money and become a "non-profitable patient."

Unfortunately, I don’t know one person who has an autoimmune disease like RA who isn’t considered a non-profitable patient. In fact, I’m going to make t-shirts that say "proud non-profitable" patient and sell them.

Insurance issues that I've experienced

Dealing with insurance can be stressful, which leads to anxiety, which leads to a flare, which leads to the need for more medical care, which leads to more insurance usage, and then the circle repeats.

It’s a vicious cycle, and it’s hard to break once it gets started. So, I’m going to give you some tips I’ve learned over the years to help deal with the quagmire that is insurance.

Prior authorizations

One of the things you’ll definitely need to deal with is prior authorizations. It’s a funny name because, as I found out the hard way, prior authorizations don’t give you guaranteed authorization and it doesn’t happen prior to the procedure.

As I have been told, quote, "it only lets the insurance company know you are getting a procedure." In other words, they can deny the claim if you don’t get one, but if you do get one...they can still deny the claim for other reasons. Has your brain exploded yet? Well, buckle up.

Paperwork that impacts treatment or medications

In addition, most insurance companies will only go by whatever the latest paperwork is that they have on you. One time my rheumatologist’s office screwed up and sent an authorization request for a "new" medicine that I had actually been on for years.

Unfortunately, since the insurance company thought it was new, I needed more paperwork. I called them to tell them I had been on it for more than 10 years, and to check their history. I was told, "We can’t go by the previous paperwork, only the most recent one."

I said that it’s paperwork, not a flux capacitor; it doesn’t change history simply because it’s written. It’s not a magic notebook. Unfortunately, none of those arguments swayed them and I had to go without for days while it was settled.

Helpful tips

This is life with insurance, and it’s just a taste of the things you’ll have to deal with on a regular basis. Now we get to the good part – what can you do to help mitigate this quicksand of paperwork so you can reduce it from a Grand Canyon-sized issue to a bunny-hill-sized issue?

Get permission for everything

Well, the first thing I recommend is that you always get permission from your insurance company for everything, even if you don’t need it. I know it sounds silly, but unless you are 150 percent sure that you don’t need to get insurance approval for a medicine or procedure, it’s a good bet to give them a call and see.

Yes, it may take several centuries to talk to an actual human being, and you’ll have to listen to that mind-numbing smooth jazz or classical hold music until you want to beat a conductor to death with a trumpet, but stick it out.

Awareness of the policies like the "fail first"

The next thing is to be aware of the policies that most insurance companies use. One of those is called the "fail first" policy. What that means is before an insurance company will pay for and approve a costly, lesser-used medicine, they will require you to try and fail on more-readily available (read: less expensive) medicines.

In other words, if your doctor says you need to start taking MedicineX, but it’s a new drug and it’s expensive, the insurance company will deny payment because you haven’t tried MedicineA and MedicineB first. Even if your doctor says that those medicines would be worse for you, they can still deny it.

In that case, you can file an appeal and have your doctor write a strongly worded letter, backed up by your clinical history. It should say that you need MedicineX and hopefully, the insurance will approve it. But in some cases, you will simply have to suck it up and fail on A and B first.

Use the appeal processes available to you

Finally, you have to remember that insurance companies are always going to try to save as much money as possible and they put obstacles in your way in order to weed out the people who aren’t 100 percent determined to get what they need. It works, too! Many people simply give up.

So my advice is: don’t! Use the appeals process that every company has, and in the case of Medicare, you can even go before a judge (as I did once). It may take a while but many times you will win because of the sheer fact that they are only trying to dissuade those who aren’t willing to put in the work, which, I guess, is insurance in a nutshell. Now, if you’ll excuse me, I have a digital camera manual to read. Talk soon.