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So you think you’re covered?

MATTHEW EDLUND M.D.
Contributing Columnist
health@lbknews.com

Over many years the health insurance industry has labored to perfect methods that obstruct sensible use of medical services. As their abilities improve we should expect worsening care, higher prices and a poorly served, frustrated population—including you.

Here is just one very small but instructive example of how insurance obstruction works—through the preauthorization “process.”

My quest was to get a higher dose of a rather cheap generic antidepressant for a woman who had been on the medication for years. Her diagnostic list was long, including sleep apnea, lupus, hypoadrenalism and diabetes. In this case I was trying to persuade representatives from one of the many Blue Cross Blue Shield insurers, though my experiences with other insurers have been similar.

The pharmacy sent me a fax declaring I would need to get preauthorization through the health insurance company. The form included the listings of the patient’s insurance card number and group. Here’s how it went:

I call a 1-888 number. A stalwart voice answers—the number has been changed. I must call a 1-900 number, and I will be charged $1.99 a minute. Is Blue Cross really going to charge me two bucks a minute because I’m trying to get my patient a bit more of a generic drug?

I examine the form again with my office manager. In very small print, there is another number we can call—a 1-800 number.

I call through. This one really does reach Blue Cross Blue Shield. After a wait, I’m switched through to voice mail, which gives me several options for bill paying and checking charges. None of them have the specific option for which I’m calling, so I hit the final option, “other.”

I’m rerouted to the same message. I carefully listen to the options, hoping there is something that will give me a chance to get through to a person. I’m disconnected. (That happens all the time.)

I call again. This time there is another option available for “doctors and doctor representatives.” I pound the proper tones on the phone and get a demand to call another number.

I call this new 1-800 number. This time I’m requested to punch in the “ID” number of the patient without its first letter prefix. I have two insurance identifiers, but the only one with a prefix is for a group. I try it. I wait.

More numbers are requested, including my “NPI” number. I punch those in and… The phone is dialing something else. I listen to ads about the fine medical coverage available plus the option to take “just 30 seconds” to review my call experience when everything is finished.

Then—eureka—a human voice!

“Please tell us the patient’s number, date of birth and identity number.”

I give these but am further requested to give my “provider number,” which is not the same as my NPI number. Fortunately, I can run out of my office again and find my office manager, who knows this other number.

I’m switched to another line. More ads and more opportunities to later discuss my pre-authorization experience with another representative.

The next person I talk to sounds extremely bored and requests the same information again. She wants to know if I am the “doctor’s representative” and my position.

“I am the doctor.”

Long silence.

More numbers are requested, including my Federal Tax ID number; the only number I know they have left out is my Drug Enforcement Administration number—don’t they want that? We are talking about a drug, after all. Again I give the patient’s information.

“Did you already talk to Prime?”

Prime? Huh? “No,” I say.

“You should have talked to them. I’ll give you another number for them.”

“They’re not connected to you?”

“I can connect you.”

I take down the new number anyway. More ads, more opportunities to talk with a representative about my review experience. Yet after a relatively short wait and no further disconnection, I reach Prime!

This “representative” is also surprised that I am the doctor calling for my patient. For the third time I’m asked to give the same patient information; I’ve already given my information four times. Do they need my tax ID that badly?

Finally I receive my reward: “By the end of the day,” I may receive a fax allowing me to explain my “clinical decision.” I’m asked to give my fax and office numbers again.

“Why do you need this information again?”

“In order to make sure the fax goes through we need a backup number. Have you had any problems?”

“Yes. This whole system is a problem.”

I’ve been on the phone 26 minutes. And at the end of the day, I might get a fax! I opt not to discuss my review experience with another representative.

The fax
The fax arrives three hours later. On it is all the same information again, to be filled out longhand, plus a lot more.

I have to give all the patient’s diagnoses; a history; all the reasons for selecting the medication and why alternatives cannot be used; and all the similar drugs she has been on, the dates and doses of when they were tried, why they didn’t work; plus what other medications will be used in combination.

My patient has been on such drugs for decades. I have some of the information in my chart, but by no means all. I will have to call her to get this information.

The con
My experience is a tiny sampling of what millions deal with daily, frequently in life-threatening forms. I know the potential results of even “successful pre-authorizations.” In one case I spent an hour on the phone attempting to get a generic drug approved, finally obtaining agreement from the very concerned-sounding health insurance pharmacist. However, the dose sent to the patient was one-third what we agreed upon, a dose well below therapeutic level.

I understand that health care is complicated and expensive. I am willing to fill out paperwork, explaining what my patients need, and I am willing to talk to a pharmacist or “care manager” about why I am doing what I do.

However, this present system is clearly set up for obstruction aided by behavioral conditioning. In the old days they just sent the fax without making you burn on the phone to get it. Instead, multiple requests for the same information are routine. Multiple phone disconnections are routine. I suspect the constant repetition while you wait for “opportunities” to review your “pre-authorization experience” is just a diabolical way to give the appearance of caring while infuriating people more.

Because the whole point of this process is to make you quit.

My physician friends don’t bother anymore. Their PAs and medical assistants are also fed up.

What about patients who are too sick or too disabled to call and defend themselves? They pay up—or they don’t get the treatment. And the insurance companies? Big savings.

Who pays?
You do, folks. Everyone connected to health care in this country is paying—through the nose and the heart and soul of the society.

You’re paying for the most expensive health care system in the world, where the administrative costs are 30 percent, four to seven times what they are in comparable industrial countries. You’re paying for it in tears and pain when the care you need to survive is refused, or is first authorized and then de-authorized at the last moment.

You’re paying for it in frustration and anger as the health insurance companies keep you on the phone to obtain information they already have. You’re paying for it through a bought Congress that could not pass even a tiny experimental “public option,” because health insurance companies regarded that small comparison choice a potentially mortal blow.

You’re paying for it in suddenly gigantic health care bills for care you were told was pre-authorized, but later told by the insurance companies that they never agreed to pay for it. You’re paying for it with a system where one-sixth of the population has no insurance and one-sixth is on Medicaid.

Most of all, you’re paying for it with health statistics that shine like a beacon across the international stage—the 49th highest life expectancy of any nation—according to our CIA.

That’s right, folks, we are 49th in lifespan, at twice the cost of countries like Britain and France. That huge tax is only increasing and may eventually sink both the U.S. government’s ability to pay and our entire economy.

What matters is health, a system that provides for it at an adequate cost, not a health care insurance industry that provides uncoordinated care and generally disregards the public health, since there’s no profit in that—except for the whole population.

So please think about two things: one, health not health care; and two, recognize that a healthy economy requires a healthy population.

Right now, for many of us the only effective health care will be what we can do to keep ourselves well. Because when we get sick, too many of us won’t have the energy to fight for pre-authorization or authorization.

And the care we thought we paid for won’t be there.

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1 Response for “So you think you’re covered?”

  1. Excellent article. Thank you for highlighting and illustrating just one of the systematic problems of our current health care non-system. There is a lot else that you could have mentioned!

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