Tuesday, July 16, 2013


As so many of us know, we are often being faced with the difficult decision about whether or not we can actually afford to pay for a treatment that might help us with our IC because our insurance company doesn't want to cover said treatment, deems it too "experimental" or just classifies it at a top tier treatment with the most expensive co-pay or even worse, doesn't cover it at all!

Well, you don't have to just take this sitting down. First, there are ways to appeal these decisions through the insurance companies, having your doctor write a letter of "medical necessity". If that doesn't work, then you can turn to your state for help.

Did you know that many states offer assistance in dealing with insurance companies in appealing these types of issues? They do. So if you've been denied coverage for something, go to this website and contact the agency in your state and get help to see if you can win your appeal for coverage.

You can also contact your Congressional Representative by calling their local office (not DC) and ask to speak with someone in Constituent Services. Explain what the situation is and ask if they can help you or what services might be available for you.

It gets frustrating dealing with insurance companies; I know I just about lost my mind in 2011 fighting with my insurance company to pay for my surgery. I WON, I believe in large part, because I never gave up calling them, documenting everything and in general, making a pain of myself until they paid up! Often insurance companies have an "unwritten" policy to simply deny claims because so many people don't know enough to fight that denial because they don't understand their own insurance coverage and what is and isn't covered. KNOW YOUR COVERAGE! Learn to be your own advocate. Never give up fighting. There are changes every year to your coverage; don't assume what was covered last year is covered this year. Make sure you understand your Drug Formulary; read it. The Drug Formulary is one of the places insurance companies like to make changes to every single year. When I get mine at the start of the new year, I go through it with a fine tooth comb to see if what I am taking is still covered or if they changed the coverage or tier it's in. When my doctor(s) prescribe medications, I never just get them filled before I check to see what my coverage on that drug is. Recently, my doctor prescribed a medication for me and when I got home I called my pharmacy and found out the medication was way more expensive than I could afford. So I stepped in, asked the pharmacy to help me figure out what, if any, was a less expensive alternative. There was and I called my doctor's office and we switched the prescription.

We need to take total control of our health care. Understanding your health insurance is a huge part of this. So many patients don't understand what is covered and this is key to managing your own care.

So, take some time, read your insurance policy; I've read mine and I refer back to it often to make sure I understand something when I have a question.

Use the resource above from your state if you need to fight a decision about denying coverage for a treatment/medication. 

Taking control, knowing what your benefits are, can help us all receive better outcomes and save us lots of frustration. Don't just take no for answer; you can sometimes beat them if you just try. Most people just give up out of lack of understanding and frustration; the insurance companies count on this. Don't give in; keep fighting! It's worth the effort!

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