Health Insurance Merry-Go-Round

I am ridiculously healthy, which I attribute to both good luck and determined effort. But I am one of the 10-13% of the American population who gets migraines. Given that proportion, if you don’t have them yourself, most likely you know someone who does.

There really is no such thing as a “mild” migraine, though they do range in intensity to extreme. They are disruptive by their nature. A few years ago, by luck, I was prescribed a medicine that takes the pain away. (I say “luck” because not everyone finds a solution that works for them.) I want to be clear, it doesn’t take the migraine away. But it makes the headache very tolerable for me. That prescription made my work life possible, as really no one gets 40-60 paid sick days a year, every year, for years on end.

Due to multiple circumstances, I hadn’t purchased that prescription using my current insurance. This spring was the first time, with this insurer, that I tried to. My prescription was denied. They would not cover it.

Instead my doctor and I each received notification that the insurer has a list of four approved migraine medicines in the same class. In order to consider an appeal to cover the one we know works, I would need to FAIL with at least three of the four approved ones. While this notice was frustrating, I’m game. If I can buy something that works as well and is cheaper for me and cheaper for the insurer, I’m all for that.

In fact, one of those four was the first thing prescribed for me years ago. It did not work. Strike one. So I only needed to fail at two more, or better yet, have one of them work, to stop the process. I thought…

In the following months my doc prescribed two others on the list. Neither works. Let me repeat: NEITHER WORKS. In fact, two of the worst headaches I’ve had in recent years were when trying them. Strikes two and three.

The doctor again prescribed the one we know works. The prescription was denied. Before the insurer will pay, they first need to consider the merits of my need. In other words, I need to file an appeal. Yes, that’s right. Covering the good one is not automatic. I need to appeal.

The doctor submitted an appeal, based on the criteria the insurer set out, that I needed to fail on at least three of four approved meds. It was denied. No reason given. Just denied.

The doctor submitted a request for review, and she requested the review be expedited. An “expedited” review can take 30 days. That request was faxed to the insurer last week.

This morning I received a phone call from the doc’s office. In order for the insurer to consider the appeal, I needed to go in and sign a release form authorizing disclosure of my protected health information. (I expect this restarts my 30-day expedited review period.) Here’s what it says, in part:

I understand that if the person or entity that receives the information requested is not covered by federal or state privacy laws, the information described above may be redisclosed and will no longer be protected by law.

In other words, there is NO PROTECTION, because if they don’t take care of my information, anyone could get it. Then they absolve themselves. Too bad for me.

Another interesting item was that requests for review must be received within 180 days of notification of their “adverse decision.” Which one? The initial one when I tried to fill the script in the first place?? If so, you could (in theory) easily go 180 days just playing their try-and-fail game. And if that last attempt is more than 180 days out, you’re screwed.

While we wait for a decision, my doctor wrote a prescription for codeine, which the insurance covers. Because it’s much better and safer cheaper to take a narcotic for pain than something that’s non-addictive.

Am I frustrated? You bet. And part of my frustration is not for me, but for people who are fighting their insurance companies every day for coverage of necessary health care. We have a close relative whose treatment is not covered at all, but is paid out-of-pocket.

There are solutions to this merry-go-round, but they will require broad agreement and not a piecemeal approach. Unfortunately our current government is a failure and can’t agree on the most fundamental things, much less complex problems like paying for health care.

[Note, please don’t tell me about your migraine solutions and how if I just do things differently, I’ll get relief. I’m sure you mean well, but I’m not looking for that kind of help.]







14 thoughts on “Health Insurance Merry-Go-Round

  1. Anarette

    It is strange how insurance companies work. Try getting coverage for Lyme Disease treatment. They rather pay for the treatment of symptoms instead of treating the cause of LD directly and more effectively. And what really bothers me is that this practice means that people without proper medical education (those who work for the insurance company) determine a patient’s treatment instead of an MD.

    1. Melanie McNeil Post author

      Yes, exactly. Lyme is a prime example of poor coverage, and it’s made worse by the difficulty getting a good diagnosis in a timely way. But as you say, we all depend on that person at the insurance company being in a good mood or having a sibling with the problem or otherwise being sympathetic. Thanks very much for your comments.

  2. jimfetig

    You do realize that you’ve tossed a match into gasoline… It’s hard to get more emotional or personal than when dealing with the capriciousness of the health insurance industry. I often wonder if they calculate the paperwork costs of the 10-denial-before-final-approval cycle. It’s like a software do loop.

    1. Melanie McNeil Post author

      Maybe it’s time to burn it down. The way we do things now is about the least efficient possible way. HOURS have been spent by me, my doctor and her staff, the pharmacy, and the insurance company, just on this one small issue for me. It’s like when I worked at the bank and my computer was slowly dying. How many hours did I (paid well) and various techs (paid probably not quite as well,) spend on the phone? How many new computers could we have bought with same resources? What a waste.

  3. JoAnn

    Seems like you have the option of paying the full price of the medications that you want. What is covered by insurance is not set by someone’s sibling on a whim, any more than are bank interest rates or rates of return. The costs and benefits for health insurance are determined by actuarial projections. As 0bama would say, “…if you like your migraine drugs, you can keep your migraine drugs…” with 0bamacare.

    1. Melanie McNeil Post author

      I’m not talking about Obamacare. I’m talking about health insurance. And yes, I understand about cost-benefit analysis as I spent many years in investment management. Yes, I can pay full retail price for my migraine meds. Yes, I’ve already paid many thousands of dollars for my health insurance. They should cover what my doctor prescribes, assuming it is FDA approved for the purpose and assuming there is not another appropriate alternative. There is not. If there were, I would take it, as I said in the post.

  4. Debra

    I am so sorry to hear this. I do know someone who gets migranes and while I can’t fully appreciate what that must be like I have seen the suffering for myself. This whole system of health care fills me with such anger. You know I am from Canada. Universal health care is one of the things I am most proud of. In fact, my son’s great grandpa was one of the people who worked terribly hard to make a single payer system happen. It wasn’t easy and he and his fellows were labeled reds. You said, “Our current government is a failure and can’t agree on the most fundamental things.” Oh, but they do agree on some fundamentals. Both parties agree very strongly that big pharma, big ag, big banks, the fossil fuel industry etc etc all need endless amounts of protection. Ordinary people are just there to be exploited. Who knows best what a patient needs? Her personal doctor who cares about her well being or some person working in an insurance office who cares about the botom line?

      1. Debra

        That political/economic situation won’t last forever because it can’t. It is unsustainable. Meanwhile I sure hope you can get some relief. Can you go on a trip to Mexico? I knew a group of teachers that did that once a year in order to stock up ….

        1. Melanie McNeil Post author

          I have some options. One thing I can do even they continue to say “no” is file a complaint with my state insurance commission. If an insurance company can just deny paying for anything they don’t want to pay for, all the other “protections” are meaningless. Thanks.

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