Oh, How I Hate Insurance Games

I’ve just received an EOB from my insurance company and a corresponding bill from my doctor’s office, and would like to scream.

  • Even though my auto insurer said they’d pay for all the claims for treatment related to our auto accident for up to three years, they’re refusing to pay two of them.  My doctor’s office then billed my health insurance.
  • My health insurer says that these are for an MVA injury and they won’t pay.

The EOB actually says that the doctor’s office has to just eat the charges.  That’s so wrong.  I know that I could appeal, argue my case, and get this covered but it just isn’t worth it anymore.  Between this and the other medical bills sitting in a stack on my desk, I’ve spent three hours on the phone trying to straighten out what should be simple, routine payments.

My time has value, too.  I would rather just pay my doctor than keep fighting with the insurance companies over this.

Prior Authorization for Meds

Insurance companies – those paying out money – understandably want patients to use the least expensive treatment possible.  If the money was coming out of my own pocket, I’d definitely want to try a $20 treatment before shelling out $100 (or the $80 drug instead of the $2,500 drug).

When a rheumatologist writes a prescription for a biologic medication, it’s expected that the insurance company won’t authorize the pharmacy to fill the script without first making sure that less expensive treatments have proven ineffective.  When I was first prescribed Enbrel, that prior-auth worried me.  I’d heard from others about insurance companies dragging their feet and taking an excessively long time while patients sat and watched their fingers and toes become permanently misshapen.  That worry was needless because everything went quite smoothly – it took two days.

Since then, I’ve changed pharmacies, insurers, and biologics, and discovered that things don’t always go that well.  It would be nice if step one was for the doctor’s office to fax a form to get the process started with the insurer.  Unfortunately, different insurers have different paperwork requirements, and it’s not realistic for a doctor to have on-hand the forms required by every insurer.  It would also be nice if insurers – once they received information - dealt with the information promptly, but that doesn’t always happen, either.

I’ve learned so much about the way the procedure works – or doesn’t.

The first step is to make sure that the doctor is looking at an accurate record of past treatments.  If you’ve ever changed doctors, there’s no guarantee (even if you provided all the information) that the information made it into your chart in the right format/location for your doctor to find that info when completing paperwork for the insurer.  My rheumatologist looks at her prescribing history to determine how long patients have been taking a specific drug, so she hadn’t taken into consideration the year+ that I’d taken meds prescribed by someone else.  It’s was a simple matter to add that information to the drug list so that it’s easily visible, but we had to first recognize it’s an issue.

The second step is to not dawdle in taking the script to a pharmacy.  The sooner your pharmacy gets the third-party reject, the sooner things get moving.  You can wait to contact the drug company for activation of a patient-assistance card until after leaving the prescription at the pharmacy.

Third, patients need to know how their insurer handles PA’s.  This, I’ve discovered, is key.  Some insurers want the pharmacy to contact the doctor, and some insurers want to do it themselves.  Find out who sends that the fax your doctor, and see if there’s anything you can do to hurry the process along.

One Friday I went straight from my doctor’s office to the pharmacy with my new prescription.  Ten days later I still hadn’t heard anything, so I phoned the insurance company to find out if there’s any way to speed the process up.  When the doctor prescribes a med to be taken every two weeks and provides a sample for the first dose, it’s ridiculous for the insurer to wait more than three weeks to process the paperwork to get the patient those subsequent doses.  That’s how long it took last time, and I was determined that this time would be different.

One would think that when the insurer tells the pharmacy that a PA is needed, the insurer would start working on it right away.  Not so.  My insurer could have – and should have – contacted my doctor promptly on Friday.  It would be incredibly easy to program the computer so that a pharmacy reject would trip a flag; the computer would then automatically (immediately) fax a form to the doctor’s office to begin the paperwork process for approval.  Instead, it’s a cumbersome process handled by snails, and my insurer didn’t even contact the doctor’s office until the following Wednesday.

The staff at my doctor’s office was expecting the insurance forms and returned them promptly; insurance logged receipt on Thursday – then did nothing.  When I phoned (four days later), they couldn’t even find the forms.  At least my call alerted someone to be looking, so this time it only took 17 days to get my approval.

I’m so glad I phoned, because I learned that patients can help the process along.  I now have the direct phone number of one of the people who handles PAs for my insurance.  I hope to not need another med change, but if I do, I can call him directly to expedite matters.

And if I ever get rid of this cold, I can take that second dose.


When more than one doctor can be seen for a problem, deciding which one to call can be tricky.  What matters most?  Skill?  Bedside manner?  Convenience?  Cost?

It probably depends on the situation.  In this case, I need a cortisone injection.  Okay, I’m not a doctor.  Maybe I’m not qualified to make such a decision.  In the past, though, when my shoulder has felt like this, I’ve gotten a steroid shot, and it’s helped.  Whom should I call?  Rheumatologist, orthopedist, or family physician.

My rheumatologist might be able to do it at my next appointment.  That would be simplest.  No extra appointments, no extra time required.

Another option is to see the orthopedist.  Last summer he said that he suspects I’ll need surgery on the shoulder within a year.  I’d like to prove him wrong.  If he’d said he could fix my shoulder, I might be interested, but that’s not what he said.  There’s only a 50/50 chance of surgery helping, and those odds aren’t nearly good enough.  A better plan is to resume the exercises that have helped in the past (and not stop once my shoulder is better).  Steroids would make the PT exercises a lot more doable.

I’d rather have my family physician do the injection.  His cortisone shots seem to work better and hurt less than steroid injections I’ve gotten elsewhere.  I don’t know if it’s individual skill, or if it’s the fact that he uses kenalog and everyone else has used depo-medrol on me.  It doesn’t matter.  That’s where I’d prefer to go.  The drawback is that if I go see him about my shoulder, he might tell me to go back to the orthopedist.

That’s my choices of whom to see.  Then there’s the financial aspect.

My old insurance policy covered injections at 100%, so cost wasn’t really a factor.  New insurance only covers 80% so expense is now a consideration.  Add in the fact that under this will be entirely out-of-pocket since I haven’t yet met my annual deductible.

Steroid injections vary widely in price.  Looking back through my old EOB’s, I found:

  • My rheumatologist charged $172 when I got a depo-medrol injection from her.  Insurance allowed $128.51.
  • My orthopedist charged $269 for the exact same thing.  Insurance allowed $168.33.
  • My family physician has charged $134 for the kenalog injections (plural) that he’s given.  Insurance allowed $41.18.

That means I can pay $128.51 for the convenience of getting a cortisone injection at my next rheumy appointment, or I can pay $41 plus a $30 co-pay and get the shot from my PCP.  Although this reduces my costs, my insurance company will be out an extra $70 since they’ll be stuck with the tab for an extra office visit.  For a savings of $57, it’s worth making an extra appointment to have my PCP be the doctor jabbing a needle into my shoulder.

When you have a choice, how do you choose?