Insurance has become a VERY widely discussed topic over the last few weeks. And in most cases those conversations are not good conversations. It seems in the last several years insurance companies have really grown and have total control over a patients treatment! They have the ability to deny procedures that the patients physician deemed necessary. They also have the power to say that patients can’t use certain medications. Whether that’s by actually refusing to pay for them, requiring the patient to try several other medications first or making their “coverage” of the medicine so poor that no one can afford to take it. Some will argue that this has been happening since the Affordable Care Act was instituted, and that may be true. But my purpose today is not to talk about or fight the political side of things. My point is to share the struggles that many Americans, especially the chronically ill are forced to face head on due to their insurance on a daily basis. As well as giving a few pointers on dealing with issues with your current & potentially future insurance carrier.

It’s no secret that medicine as a whole has drastically changed over the last few years. And definitely not for the best in most cases. The costs for medical care has skyrocketed and a big part of that is the insurance companies, who seem to be paying less, charging us more and dictating what procedures, treatments and medications we can or cannot have. I know that I am NOT the only one who is unhappy with the state of our current medical system. Or with the fact that the insurance companies have been allowed to dictate most care.

Many that I have spoken to in the chronic health community about this topic conveyed their frustration to me. Most felt frustration due to what seems to have become the norm. The issue I am speaking of is the “HURRY UP AND WAIT” mindset that has now become modern medicine. Nothing is more frustrating than being told that you could potentially have x, y or even z, only to then be told then that a pre-authorization will be required for the test or procedure needed to diagnose the problem. Getting approval from any insurance company could potentially take weeks. That is IF you are lucky enough to be approved the first time for said test or procedure. Many will be denied once, twice or more by the insurance company requiring anything from very specific documentation, to trying other treatment options. Sadly, even if you do what they ask you may still be denied. If you are approved the tests may be booked for three weeks out. So you could potentially be looking at months before any possible diagnosis could be given. I have discusses this topic with many chronically ill and they feel the same way. The fact that insurance is now controlling medicine(both actual medications and also other treatment options) is not  okay. And the fact that they are also requiring outrageous co-pays and premiums is totally unacceptable! And makes carrying insurance for many just plain impossible.

I did a little research and found that depending on your location monthly health insurance premiums vary greatly. The premium costs for a healthy 21yo range depending on location from $180 monthly to over $400 monthly. That’s not great but when you add age and any health issues the statistics show a dramatic difference in the monthly premium costs.ValuePenguin, shows how the monthly cost will increase with age. A 30yo will pay 1.135 times more, a 40yo 1.3 times more, a 50 yo 1.786 times more and a 64 yo will pay 3 times the cost of the 21 yo’s premium.  And these  rates are just a simple policy. There will be an added cost for mental health coverage as well as if you are sick and will require more care.  These number just absolutely blow my mind.

I know what you may be thinking, “Amber, you are a nurse and have worked in medicine for most of your adult life, you know how this process works.”  Yes, that is true I do know. Well, I knew how the process worked prior to the Affordable Care Act was put into place. But that has changed dramatically. The fact that insurance companies now have more control than our actual doctor in regards to what medication we can have, or what procedure will be approved totally blows my mind and makes me so angry. What ever happened to the day when you and your doctor have the final say. Or the time when a doctor could order a test and it could be done in a day or two with no fight from the insurance company. I do understand that in the long run the insurance companies “GOAL” is to reduce the number of unnecessary tests that are being done that could potentially harm the patients. And they are trying to prevent medical errors bred by disjointed or fragmented care! Some say that the insurance companies are trying to keep a look out for the patients. While that may be true the way they are going about it makes it hard for most people to understand that.

After speaking with several fellow spoonies about what they feel are the biggest struggles when it comes to insurance. The top three that were brought up were as follows:

For me the biggest issues has been having their “doctors” override the recommendations of my own dr and not approving the treatment plan that my doctor feels is in my best interest. – Jane

The insurance company won’t pay for meds that the dr prescribes unless your try X number of medications first. They should pay for all medication. -Mindy

COST!!! Private insurance is more than a house payment for some. I am a couple of years away from not being able to afford it anymore. If you don’t pay high premiums you pay high out of pocket costs. – Valerie

After speaking to many from the chronically ill community the above topics were three that came up again and again. Leading me to believe that those truly are the biggest issues. What kind of government & companies think that it is okay to charge people premiums that cost more than a house. Simple, because they know they will pay it because their health conditions require some kind of medical insurance. The sad part is that many people have no idea how insurance companies work or how they can work along side their insurance in some situations to move along the process of getting tests or procedures approved.

I would like to give you FOUR TIPS for dealing with your insurance provider.

1. If you feel like the prior authorization, whether it be for medication or a procedure, go ahead and make a call yourself to the insurance company. They should be able to tell you what the hold up is. And if they require more documentation from your provider always ask what exactly they need so you can give that I formation to your provider.

2. Please know that if you are talking to your insurance company about it’s benefits regarding a procedure, test or medication you need and you don’t feel like it is going as well as you would like. You have the right as the patient to ask the insurance company to make a conference style call to your physician.

3. This may sound cliche but finding a doctor who is on the same page as you and will stand up for your patients rights is ESSENTIAL in the insurance fight. If you have a dr that you feel wouldn’t do those things for you it is totally 100% for you to start looking for a provider who will stand up for you and your rights.

4.  As far as the costs of premiums & co-pays go I would HIGHLY suggest that you start looking into options for the following year way in advance of the last day. This will give you plenty of time to really look into each plan, what the costs are and what is covered. I would also suggest talking to others with similar conditions and see what plans they have. By doing this you are becoming an educated shopper which gives you the information you need to pick the best options for you.

Sadly, it doesn’t look like the cost of the insurance is going to be changing anytime soon. So we as the chronically ill need to find a way to deal with the problems at hand. In the insurance game we have to be strong and not be afraid to stand up for our rights when it comes to speaking with insurance providers. We also NEED a physician on our side that will not be afraid to do the same. We also need to educate ourselves as I mentioned before. We need to make sure that we know everything we can about the options of plans we have.  By doing this you will be able to make the decision that suits you and your family best.  Chronic illness is a battle no matter how you look at it. But when you throw the insurance bone into the mix it creates many unnecessary problems. So in closing, you should always take your time choosing physicians and your insurance plan. If you and the physician aren’t on the same page then there is no way you can ever become a united front to face the insurance company.  So ALWAYS make sure you have a good physician in your corner.

I hope some of you will find this useful!

With Love,

Amber