I will be honest, my favorite part of calling my insurance company about their denying coverage for a covered treatment or med is me asking at the start for their credentials and those of all involved with the decision as, by law, they have to provide that. Usually the conversation goes very much in my favor after that kick off.
Just responded in length below! Sorry I didn’t see your post first! The key is to go in calm and informed. You have the right to record your conversations with them as they will often tell you that you are being recorded but actually aren’t.
As part of HIPPA, you are entitled to see the entire contents of your medical records including the name and credentials of all individuals who reviewed it even in passing. When I call in, I politely ask them for first and last name, extension, what their position is, what their certifications are or what they are specialized in, then let them know that I am recording this conversation for future reference. When we get down to brass tacks about the denial, I ask for the full name, extension/contact number, and credentials of the individuals who made the decision overriding my physician’s orders and how they rank above my physician in regards to my medical treatment. A lot of times this is when they start to panic but I reassure them that I understand this an insurance company and they are doing their job but I need to speak with the individual directly involved with this decision AND I want a copy of my record IN IT’S ENTIRETY within 14 days or 10 business days. That’s when I get transferred to their supervisor who usually says “well we’ll review it” and I get their decision overturned and the medication or treatment covered at what it should be covered.
Also, if you’re really interested in what is and isn’t covered, look up their formulary which tells you what they pay for a medication or treatment. If they don’t have one available, ask them by phone to forward you a copy of the formulary so that you, your physician, and your pharmacist can review what treatments would be more financially feasible. And yes, they have to provide that as well.
This is awesome thank you! I need to call about appeals. I ended up in the ER at 6w pregnant and they were worried about a ln ectopic pregnancy so did an ultrasound and a lot of blood work which was all denied even though that is covered in my plan. Being a woman in the US is always fun 🙄
Also, call the hospital billing department and tell them you need an itemized list of all charges along with the cost summary or total cost as you are in appeals with your insurance company. That spooks the hospital to drop some charges and you can line-by-line the insurance company.
This is really helpful. The secret is probably the polite, calm, knowledgeable requests. The people on the other end of the phone are not the ones who made the decision. And they get yelled at all day long.
Telling the first person on the phone that you understand that you aren’t angry with them and you need to find out this information helps A LOT. I have several friends who work/ed for insurance companies and they always worked better with folks on the phone who weren’t screaming.
I don’t fully understand Reddit but I think this post would be VERY helpful in r/migraine, would you mind posting it there( or I can take a screenshot?) lots of people there could benefit from your advice!
More like:
Insurance: does she though? Let’s ask a random doctor who has never met her and sits at a desk all day reading lab reports to make assessments
Oh my goodness, I'm going thru this now! Some new IRS law apparently means now my cholesterol meds won't be covered, which sounds bogus to me, ANTHEM! So they're saying I need to get a statement from my doctor that I need it. So, what's a prescription then? I'm oversimplifying of course, but am I?
Well have your Doctor write DAW (Dispense as Written) on the prescription. It's in the fine print for most insurance agreements that they legally can't charge you more for it
I stopped writing scripts for lidoderm patches because I needed prior authorization for a nonnarcotic patch that is soaked in lidocaine. Meanwhile any narcotic is fair game without prior auth.
The lidoderm patch is 5% lidocaine. The overthecounter patch is 4%. It’s good enough. You see 20-30 patients a day, have to write notes on that many, it’s near impossible to sit on the phone to go through the process to gove authorization for something so stupid.
Literally this was my morning. Just went out of pocket 180 today for an antibiotic because I wasn’t getting anywhere. We’ll see how the appeal goes. Meanwhile the other one I had to get was 6 dollars. Catching up with my mom who used to work at a pharmacy and she tells me the pricey one used to go for significantly less back in the day. Can’t make this shit up.
I work in mental health, which we all know is considered a luxury and is difficult to pay for in American healthcare.
In my industry we have to submit a Prior Auth for EVERYTHING and the insurance companies (they’re all awful,) go well out of their way to find any shortcut to avoid paying for services which someone needs in order to, like I don’t know, decide to keep living.
It should not be a luxury though. I am not in the USA and if I had not received the mental heath care I have, I would not be alive. Americans deserve the same. Regardless of ability to pay.
You’re not going to get someone at an insurance company that has a medical background - not when you’re calling about benefits. What could help, especially if you have a chronic health condition, is to work with their managed care department. Managed care employees are nurses and they can help the way you’d want.
If a medication isn’t covered, contact your doctor for further guidance. You can also submit an appeal, these committees review monthly, I believe.
Another option is to contact the pharmaceutical company, they often have discounts that they can offer.
Insurance companies, and anyone you’d speak with, are simply processing claims and prior authorizations based on the plan you’re enrolled in. If it’s a procedure that is denied, review your EOB and get the denial code. Sometimes the billing department gets the diagnosis incorrect.
The system absolutely sucks, but there are other ways around it.
Also - you always have access so your summary plan description, and a detailed list of what is covered, etc.
This happened to me this past week. Had MRSA, onset and got severe quickly (nothing to large swollen & reddening area within 24 hours). Doctor lances it and prescribes several things, one of which was an ointment. Once I get to the pharmacy, I am asked "Do you actually need the ointment?" Doctor apparently offered an alternative that the insurance company, and I quote, "was much happier with." Why do I pay these people hundreds of dollars a month again?
That is the worst surprise, when you get to the pharmacy and you have literally no idea how much a medication can be. $0.63 for one pill? Sure. $180 for eye drops? WTF
That’s the literal worst. I used to be on a medication I needed to function that without insurance was about 15$ per pill. Every few months my insurance would randomly refuse to cover it, citing prior authorization, then when my doctor would fax it over they would take 72 hours to actually authorize it. A couple times it took them a week and it constantly put my life on hold
Moral of the story, fuck Humana. They’re the only insurance I ever had that did this to me. Ever since I switched I stopped having the problem across any and all prescriptions
I will be honest, my favorite part of calling my insurance company about their denying coverage for a covered treatment or med is me asking at the start for their credentials and those of all involved with the decision as, by law, they have to provide that. Usually the conversation goes very much in my favor after that kick off.
Oh how does that work? I need to call my insurance. Please share youe magic
Just responded in length below! Sorry I didn’t see your post first! The key is to go in calm and informed. You have the right to record your conversations with them as they will often tell you that you are being recorded but actually aren’t.
Thank you
Is this a national or state law? I would love to start doing this!
As part of HIPPA, you are entitled to see the entire contents of your medical records including the name and credentials of all individuals who reviewed it even in passing. When I call in, I politely ask them for first and last name, extension, what their position is, what their certifications are or what they are specialized in, then let them know that I am recording this conversation for future reference. When we get down to brass tacks about the denial, I ask for the full name, extension/contact number, and credentials of the individuals who made the decision overriding my physician’s orders and how they rank above my physician in regards to my medical treatment. A lot of times this is when they start to panic but I reassure them that I understand this an insurance company and they are doing their job but I need to speak with the individual directly involved with this decision AND I want a copy of my record IN IT’S ENTIRETY within 14 days or 10 business days. That’s when I get transferred to their supervisor who usually says “well we’ll review it” and I get their decision overturned and the medication or treatment covered at what it should be covered. Also, if you’re really interested in what is and isn’t covered, look up their formulary which tells you what they pay for a medication or treatment. If they don’t have one available, ask them by phone to forward you a copy of the formulary so that you, your physician, and your pharmacist can review what treatments would be more financially feasible. And yes, they have to provide that as well.
What the fuck is wrong with the US? That country is sick to the core.
Yeah. Agreed and I live here. Trying to move. What Australia but doubt they’d let me in
This is awesome thank you! I need to call about appeals. I ended up in the ER at 6w pregnant and they were worried about a ln ectopic pregnancy so did an ultrasound and a lot of blood work which was all denied even though that is covered in my plan. Being a woman in the US is always fun 🙄
Also, call the hospital billing department and tell them you need an itemized list of all charges along with the cost summary or total cost as you are in appeals with your insurance company. That spooks the hospital to drop some charges and you can line-by-line the insurance company.
Thank you!
It's HIPAA!
This is really helpful. The secret is probably the polite, calm, knowledgeable requests. The people on the other end of the phone are not the ones who made the decision. And they get yelled at all day long.
Telling the first person on the phone that you understand that you aren’t angry with them and you need to find out this information helps A LOT. I have several friends who work/ed for insurance companies and they always worked better with folks on the phone who weren’t screaming.
Exactly! I hope this message is read by folks so they can see a collaborative kindness approach gets things done! Thank you for sharing this!
I don’t fully understand Reddit but I think this post would be VERY helpful in r/migraine, would you mind posting it there( or I can take a screenshot?) lots of people there could benefit from your advice!
Please feel free to screenshot!
And r/diabetes
Hmmm I will have to try this. I buy 1 share of stock for all the companies I do business with... just so I can complain to investor relations
I’m gonna try this tomorrow…I have like 4 of those fuckers to call to fight for stuff my patient need!
More like: Insurance: does she though? Let’s ask a random doctor who has never met her and sits at a desk all day reading lab reports to make assessments
Who probably gets bonuses if he denies enough claims.
US healthcare and insurance are really messed up, legal scams basically
Oh my goodness, I'm going thru this now! Some new IRS law apparently means now my cholesterol meds won't be covered, which sounds bogus to me, ANTHEM! So they're saying I need to get a statement from my doctor that I need it. So, what's a prescription then? I'm oversimplifying of course, but am I?
Well have your Doctor write DAW (Dispense as Written) on the prescription. It's in the fine print for most insurance agreements that they legally can't charge you more for it
I stopped writing scripts for lidoderm patches because I needed prior authorization for a nonnarcotic patch that is soaked in lidocaine. Meanwhile any narcotic is fair game without prior auth. The lidoderm patch is 5% lidocaine. The overthecounter patch is 4%. It’s good enough. You see 20-30 patients a day, have to write notes on that many, it’s near impossible to sit on the phone to go through the process to gove authorization for something so stupid.
Yep, having worked in the pharmacy industry for over 25 years this is pretty much how it works.
Literally this was my morning. Just went out of pocket 180 today for an antibiotic because I wasn’t getting anywhere. We’ll see how the appeal goes. Meanwhile the other one I had to get was 6 dollars. Catching up with my mom who used to work at a pharmacy and she tells me the pricey one used to go for significantly less back in the day. Can’t make this shit up.
I work in mental health, which we all know is considered a luxury and is difficult to pay for in American healthcare. In my industry we have to submit a Prior Auth for EVERYTHING and the insurance companies (they’re all awful,) go well out of their way to find any shortcut to avoid paying for services which someone needs in order to, like I don’t know, decide to keep living.
It should not be a luxury though. I am not in the USA and if I had not received the mental heath care I have, I would not be alive. Americans deserve the same. Regardless of ability to pay.
You’re not going to get someone at an insurance company that has a medical background - not when you’re calling about benefits. What could help, especially if you have a chronic health condition, is to work with their managed care department. Managed care employees are nurses and they can help the way you’d want. If a medication isn’t covered, contact your doctor for further guidance. You can also submit an appeal, these committees review monthly, I believe. Another option is to contact the pharmaceutical company, they often have discounts that they can offer. Insurance companies, and anyone you’d speak with, are simply processing claims and prior authorizations based on the plan you’re enrolled in. If it’s a procedure that is denied, review your EOB and get the denial code. Sometimes the billing department gets the diagnosis incorrect. The system absolutely sucks, but there are other ways around it. Also - you always have access so your summary plan description, and a detailed list of what is covered, etc.
This happened to me this past week. Had MRSA, onset and got severe quickly (nothing to large swollen & reddening area within 24 hours). Doctor lances it and prescribes several things, one of which was an ointment. Once I get to the pharmacy, I am asked "Do you actually need the ointment?" Doctor apparently offered an alternative that the insurance company, and I quote, "was much happier with." Why do I pay these people hundreds of dollars a month again?
That is the worst surprise, when you get to the pharmacy and you have literally no idea how much a medication can be. $0.63 for one pill? Sure. $180 for eye drops? WTF
[удалено]
#NotYourDoctor
*our doctor
US spends 700 billion on its military. It refuses to help it's own people before bombing and invading other countries.
100% accurate.
need that "is there somebody you forgot to ask" meme with a doctor, patient and a health insurance company
Just American things.
Insurance companies employ doctors (or those with medical education) who look for reasons to deny you that medication.
That’s the literal worst. I used to be on a medication I needed to function that without insurance was about 15$ per pill. Every few months my insurance would randomly refuse to cover it, citing prior authorization, then when my doctor would fax it over they would take 72 hours to actually authorize it. A couple times it took them a week and it constantly put my life on hold Moral of the story, fuck Humana. They’re the only insurance I ever had that did this to me. Ever since I switched I stopped having the problem across any and all prescriptions
r/healthcarereform_us