Wednesday, August 11, 2010

Fighting For Our Health

I came home from work on Tuesday to a letter from my current insurer, United Healthcare.

Suzi had the day off work, and had alerted me to the letter after finding it in the mailbox that afternoon. She'd phoned to tell me earlier what the letter basically said, but I was curious to read it for myself.

The letter involved my coverage for One Touch Ultra Blood Test Strips, which I'd learned upon my new insurance beginning in June were "limited" according to the terms of my policy. I wrote about this back in June. Basically, my insurance policy allows for 102 test strips a month of this particular "preferred" brand. Math dictates that's 3.4 tests a day, significantly less  than the 8-10 tests a day that my Endo agrees is the amount needed to best manage my diabetes. 

Back in mid-June, a kind representative explained that it was possible for this larger amount to be obtained, and that my Endo would need to contact UHC and specifically request an "exemption" for this additional amount. Of course, UHC still retained the authority to say NO. At the time, I still had enough previously-stocked strips to last a few months, so I wasn't in danger of running out. A phone call to my Endo's office in early July led to them contacting both the insurance company and Medco mail-order pharmacy for this larger BG strip amount.

This form letter was the answer to that request.

At the top of the tri-folded letter, I saw the words: Coverage Approval.

I smiled, feeling all good about the approval and patting myself on the back for achieving this triumph in the name of my health. Then, I read the 1st paragraph...

"We are pleased to inform you that the additional supply of One Touch Ultra Test S Strip requested by your physician has been approved up to the plan's supply limit for this medication. You will be responsible for paying your co-payment and any additional amount, as required by the provisions of your pharmacy benefit." (emphasis added, to illustrate my areas of concern)

What The Fructose does THAT mean????? This sounds like they're telling me exactly what I'd already been told about "supply limits" that had sparked this whole request in the first place. Hmmm. And what, they're going to try to jack up my cost because of some vague, lawyer-written provision buried in the footnotes of my encyclopedia-length benefit booklet??? Double Hmm.
 
Is this really a win??

Stewing over this while prepping for an awesome dinner made by my awesome wife, I decided to call the insurance company just as I was drawing up my dinner-time meal bolus for a 92 blood test. The first representative was nice, but despite taking three minutes to confirm my identity and getting a rundown of my situation, she informed me that she didn't have access to my full claim status. That meant talking to someone else, who also had to confirm my ID and then needed another explanation for why we were on the phone.

Me: "I just want to confirm the amount of test strips that I'll be receiving."

Mr. Rep: "It's what your doctor ordered."

My eyes rolled, shoulders slumped. Same old game, I thought.

Me: "I know what my doctor ordered. However, I want to make sure you do. And that what you're sending me is the correct amount."

Mr. Rep spent 34 seconds typing into his keyboard, and found the answer: "9 boxes for 90 days, which would be three boxes of 100 strips per month."

A smile came across my face. I had won, after all. Outstanding.

Reflecting on this later with Suzi, I quipped that it was funny to me how this all played out. I took on the voice of the insurance company, in narrating the life of my claim for test strips:
  1. Insurer tells you that your test strips are "Tier 1" and that's great because they are one of the insurance company's preferred brands. That's good for you, the patient, of course.
  2. But you can only have a certain amount, regardless of what your doctor prescribes and what you've been traditionally using to best manage your Type 1 diabetes. When explaining the need for more, they assume you're simply mistaken about the number and wonder why anyone would want to test that much. As if we have a choice to stab our fingers this much, and we choose the highest number simply because it costs our insurance companies more money (you know, the rationale they use in denying claims).
  3. After being reminded that your Endo is prescribing this as a medical professional, insurance company basically says: "Nah, we don't really care what your doctor says. They're welcome to ask us to approve more, but there's no guarantee."
  4. Doctor asks again, echoing what he or she had originally prescribed. A month passes before the insurance company says, "OK. Guess you mean it. That's fine."
  5. Oh, and by the way, do you know about our Health Screenings and Prevention Programs available for diabetics? We'd be happy to send you (more) information on that to help you with your diabetes!"

Yes, I won this time. Typically, I do win. But I don't think I should have had to fight this battle in the first place. Not when my medical professional prescribed something, and despite that the non-medical professionals decide to make decisions about my health based on what it will cost them in the short-term and mean for their stock-holders.

You see this all the time. Take my friend and fellow advocate Kelly over at diabetesaliciousness, who is battling Sticker Shock and unfortunately finding her health decisions in jeopardy because some company decided to jack up a medication's cost for profit's sake. It's just not right. And it's maddening. A direct result is that diabetes has forced us to always be in Fighter Mode, as Kelly puts it.

She's right. We shouldn't have to fight so hard for our health, battling those who purport to be all about our health. But we do. Everything must be in writing. Names. Dates. Times. Faxes. Proof. Never-ending time out of your workdays and evenings to explain, re-explain, and bounce between multiple customer service reps and supervisors to get basic information We understand that protocols are in place for a reason, and that you are in business to make money. But there's a point of reasonableness, a standard, a moral obligation to put people's health - what you market yourself to insure - above the loopholes and shadiness.

Kelly's warning is echoed here: "Insurance Company Practicioners of Bull Sh*t, consider yourself warned - I'll continue to bitch. But more importantly - I'll continue to fight you in order to stay healthy."

Sometimes, we'll win and sometimes we'll lose. Either way, we'll blog about it. We'll advocate and spread the word to others about the ways you operate. The Good, Bad, and Ugly. So that they, too, will be aware of what's necessary to win these fights whenever possible.

10 comments:

AngMy said...

This is one of those blog posts I hate to see because I hate that anyone else has to experience it, but I am also glad to see... for a couple of reasons. First off because you won this round! And secondly, because it's nice to know that I am not the only one who has problems with things like this.
It infuriates me to no end when they question what a doctor prescribes... as if they know better! I've been on the receiving end of that far too many times and am glad you won this round! :)

Sherry said...

Great post and I’m so so glad you won this battle. It’s unbelievable that people have to fight so damn hard to maintain the best health they can in the face of chronic disease. Unbelievable, sad and criminal.

Penny said...

Bravo on the win!
Insurance companies, they stink.

Bernard Farrell said...

Michael, I'm glad you persevered. What a pain, thanks for blogging about it. I'll do the same on my next battle with an insurer..it's not a question of if, just when!

aaps said...

Insurance Companies will always be looking for a reason to avoid the claims we make,What you did is correct, Have to fight for our rights with insurance Companies.

k2 said...

Mike-
I'm glad so glad you won, thanks for the shoutout! Staying healthy is a never a never ending battle in our lives. We are the clients of our insurance companies, you'd think they'd want to make us happy - or at least keep us healthy so that they don't have to shell out BIG BUCKS down the line.
They really don't care about us- which is why we have keep in fighter mode!

Jacquie said...

I'm glad you won! I have UHC, too, and I get so sick of doing all the dances they require.

Katie said...

Mmmm hmmm! I remember when I was younger my parents saying, "wait until you are doing this all on your own. It's SO much fun." (Sarcastically of course!) And how I wish they weren't so right. But glad it worked for you this time! :)

bradleyandme said...

I had a similar problem. Blue Shield said 300 test strips per month max. I had just been placed with Bradley and was checking up to 20ish times per day. My endocrinologist wrote the script per my request and Raley's Pharmacy somehow worked some magic so that I get 200 strips every 10 days...

There always seem to be a lot of hoops to jump through.

ABPS said...

Lots of people have similar experience with the insurance companies, they will promise some thing while issuing policy & will hide lot of things, at the end of the day the policy holder is the one who is at the receiving end.