Dealing with insurance coverage is of course one of the biggest headaches of living with a chronic illness like diabetes. These days, it's even more nerve-wracking with all the political back-and-forth about healthcare policy, leaving folks with "pre-existing conditions" unsure how our coverage will be affected.
With the nationwide open enrollment period about to begin for many employer-based insurance policies, and the unfortunately shorter 'Obamacare' enrollment period only lasting until Dec. 15, this is a key time for many of us to make insurance decisions. And it's no picnic trying to review options, we know.
To offer some assistance, we compiled the following list of tips on how to get satisfaction from your insurance company -- things they often don't tell you but are important to know when dealing with them. This list was originally published a few years ago following the second annual MasterLab advocacy training event featuring some key D-advocates with insider knowledge of "payers" (a telling name for health insurance companies).
Here's the 2017 update on what may help if you're a PWD navigating coverage issues:
Tips for Swaying Your Health Insurance Company
Search online. Sounds like a no-brainer, but you can often find insurance companies' medical policies online for a specific drug, device, or therapy just by Googling it. Look for language outlining the criteria they use to determine whether or not you’re eligible and covered.
As a non-doctor, of course you won't have access to the “physician’s only” portal on your payer's website, so using Google, just type in your payer's name (Aetna, BCBS Virginia, etc.), the name of the treatment category (subcutaneous insulin infusion, insulin pump, continuous glucose monitor, SGLT-2, etc.) and the words "medical policy." See what pops up. We found that you'll usually hit the specific policy within the first page of results.
Ask Three Times, Demand a Supervisor. When you have an important question, chances are you’ll call the insurance company at least three times and get three different answers – sometimes even from the same person. Often, payers have different levels of records access for various people in their customer service and other departments. So the rep you're talking with may not just be dumb or elusive; he or she might not be able to see all the notes and different screens in your file. Be assertive, and insist on going up the chain of authority to speak with someone who has access to all the relevant info and decision-making power you’re in need of.
Publicize It. Not getting the answers or service you believe you should? Use social media to voice your gripes. Most of the insurers and distributors have Twitter accounts (for example ), so Google their Twitter handle and then post some notes about your experience. You may be surprised how quickly that gets attention, pushing your case through from the payer's customer service department to their marketing and even executive levels sometimes. Don’t be afraid to write directly to the head honchos, including the CMO or CEO. That can also get prompt attention.
Prove It. Know going in that you’ll have to show proof of A, B, and C. If you test 8 times a day and need that many test strips per month, you’d better have BG testing logs or downloaded data showing that. You want a CGM (continuous glucose monitor)? Then be sure you have a history of your highs and lows to demonstrate the need for this expensive device. Make sure you work with your doctor so that all the paperwork is in place in advance of your request. This also helps in an appeal, in case you try to get a decision reversed based on the payer’s own stated criteria.
Track Your Doctor's Notes. It’s important to get access to your doctor's notes as part of your arsenal of proof, as these days, insurers are often asking patients to provide documentation showing that they actually go to their doctor regularly. The mentality is: “Why should we give you an expensive device if you’re not even seeing your physician regularly?” Be sure to have your doctor take copious notes on any low blood sugar episodes you experience, because this can also help show a future need for obtaining or maintaining the D-device you want.
- Yes, you do have diabetes! Believe it or not, you may even have to provide evidence of this basic notion, which you can only do by keeping track of those doctor visits, diabetes data logs, and in the case of type 1, a C-Peptide test showing that you aren’t producing insulin or maintaining “non-diabetes” blood sugar levels.
Find a Health Advocate. Insurance companies often employ their own specialized "health advocates" whose job it is to walk through your file and advocate for you (example: Blue Cross of Michigan). It never hurts to have more people at bat for you, especially someone who works on the inside of the company you're lobbying! So be sure to ask about your payer's Health Advocate services.
Appeal! Insurance companies love to dish out claim denials, because they know that's a huge deterrent. They expect that most folks will simply accept the denial and either skip the treatment or pay out-of-pocket. But the federal Government Accountability Office (GAO) in 2011 estimated that 39-59% of appeals resulted in the insurer reversing its original coverage denial. Those are pretty good odds! If you decide to appeal, be sure your doctor(s) are engaged in the process with you -- as insurance companies expect to deal mostly with our doctors during an appeal process, rather than patients directly.
- “Peer to Peer” Review – Within a specific time window during the appeal process, your physician can request a peer review, meaning they can call in and speak to a fellow physician at the insurance company to discuss medical necessity.
- Treatment Exceptions – If the issue you're facing is that your treatment is no longer on the formulary list for your pharmacy, employer, or insurance plan, you have similar recourse. Your physician can appeal for a "continuity of therapy" exception, which can apply to an out-of-network doctor you want to see as well. If you do try the covered alternative (like a generic drug) and you have a negative reaction, you may have a stronger case for continuity of therapy.
- Tell Your Story – Personal accounts do make a difference, especially if provided by your doctor. Write up a letter explaining why it's so important for you to test many more times a day than the typical 3 strips per day they want to cover. Or explain, from a quality of life standpoint, why the insurer should be paying for a brand-name drug instead of a generic or different medication, ideally with your doctor's agreement that the alternative is not “medically equivalent” as the insurance company likes to think. If the issue is a CGM, describe how glucose lows and/or hypoglycemia unawareness affect your health and well-being.
We found this great "health insurance hack" graphic posted on Facebook by a registered nurse. While some of it may not be 100% accurate point-by-point, it does show some general excellent tips in navigating the insurance appeals process, so definitely make sure to make a mental note of these too!
As Medicare Goes… Yes, federal coverage for seniors and low-income households is more complicated. As government programs, these payers have certain elements of their practices codified into law. It's critically important that people with chronic health conditions take note of what Medicare and Medicaid (governed by the Centers for Medicare and Medicaid Services -- or CMS) cover. This is key not just because we are living healthfully into our golden years and will eventually be in their jurisdiction, but also because CMS sets the benchmark for what private payers will be doing in the future. As Medicare goes, so go the private payers.
Step-By-Step Guidance: We are thrilled to see others in the Diabetes Online Community focusing on these systematic issues, particularly our friends at the diaTribe Foundation who recently published a Step-by-Step guide for comparing health insurance plans, and for those Making the Switch to Medicare. Be sure to check them out!
Non-Medical Switching: More attention is going toward the huge issue of soc-called "Non-Medical Switching," i.e. when an insurance company switches the covered brand of medication or treatment without consent from you or your doctor because they prefer a different company's product (for financial reasons). This may mean you have to pay a higher co-pay amount or even the full cost out-of-pocket for the now "non-preferred" brand. This is happening more often on the diabetes medication and D-device front, something many of us have endured through the years with test strip coverage.
Thankfully there are growing resources out there to help those in the D-Community push for a "Prescriber Prevails" focus so that this decision-making remains between physicians and patients, and not insurers or cost-focused third parties. A new initiative spearheaded by the non-profit, industry-sponsored Diabetes Policy Collaborative made up of many D-orgs and industry folk (the 'Mine included) is working to address this issue at both the state and national levels -- see this online video and resource just recently launched in October 2017.
No Insurance? Clearly, everything above is aimed at those with insurance coverage. But we can't forget about all those living without insurance. That's as many as 3% of PWDs using insulin and a whopping 7% of the American population, and it's likely going to increase as we see more healthcare policy changes nationwide. Resources must be shared and these stories must be told more broadly, to help those facing this no insurance reality. See this great personal testimonial with links to sources for specific supplies, and this JDRF Financial Assistance flyer for starters.
So that's what's on our list of things to keep in mind when dealing with insurance companies.
OK, D-Peeps: What do you think of these tips, and what mght you add?