The Administration of America’s Healthcare:Eyewitness Account of Insurance Bureaucracy

Insurance companies function as the gate keepers of our healthcare dollars which is a double edged sword. Yes, they should control the overboard spending that occurs when physicians order expensive procedures and tests to insure protection against malpractice litigation. (She screams Tort Reform, but that’s another blog story!) But the hoops that insurance companies insist that their clients (patients) have to jump through is just plain wrong!

Radiofrequency nerve ablation or RA is one of the newer procedures in the arsenal to treat chronic pain. Heat waves are used to destroy nerve fibers that conduct pain pathways, thus reducing the pain felt by the patient. The positive effects can last from 6 months to about a year, depending on the patient, nerve damage, and disease processes. I have had the procedure performed 3 times to date and I can attest that it does work well, although the journey there is tedious, frustrating, and painful.

Insurance companies do not arbitrarily invent rules and regulations for the premium paying masses to conform to. They have a medical director, board of directors, and nurse case managers who make the decisions and then enforce their edicts upon us with a simple statement, “Follow the guidelines, or the claim will not be paid.” And they would have you believe that their creativity for development of these insurance standards has a higher purpose; to insure that our healthcare dollars are spent in the most cost efficient manner while achieving the best medical outcome for the patient.

Really? Not a chance! As any patient can tell you, many of the guidelines make no sense at all. For those of us with chronic pain, radiofrequency ablation (RA) provides some short term relief from the day in and day out constant attack of pain. But to have the procedure, you have to endure facet nerve blocks as a diagnostic test. The test is painful and usually sends the patient to bed for several days. Two weeks later, the RA procedure can be performed and if you require another treatment on the opposite side of the spine or at another level, you must have the diagnostic test again. Get it? Repeat the sequence; more pain, bed, wait 2 weeks, RA treatment.

Then it gets worse. Once the effects of the RA treatment wane, insurance guidelines require a specific period of time before retreatment, regardless of the recommendations of the physician who is treating the patient. So the patient is allowed to regress back into a very painful condition. And once that guideline is achieved, the patient is horrified when they are informed that they must have the facet nerve block diagnostic test again before each treatment. Repeat the sequence; more pain, bed rest, wait 2 weeks, RA treatment. Does this insure that our healthcare dollars are spent in the most cost effective manner? Remind me how the insurance standards are set up to serve as a patient advocacy to achieve the best outcome. Not hardly! Waste of money, time, and more important, the well being of the patient!

As you talk to others who are trying to maneuver the healthcare maze, the stories will astound you. Here are a few examples:

• Pharmacology tiers which determine the medications you must take before receiving the prescribed medication.
• Certain medications are too expensive and are prohibited. (Yes, you can have them, but you pay the premium and you pay for the medication too. This one has happened to some of my friends with MS and cancer.)
• Length of inpatient stays are all determined by insurance guidelines regardless of your physician recommendations or the current condition of the inpatient.
• Patients who receive substandard treatment because their primary provider will not provide a referral to a specialist.
• Patients whose insurance maximum is exceeded due to a catastrophic illness and they are now left virtually uninsured.

You must learn to be your own patient advocate. Read your insurance guidelines. Know what your policy covers and what you are paying for in your premium. Learn to read an EOB, the explanation of benefits that is produced by your insurance company, when each claim is paid or denied. If you don’t understand, contact the human resources department of your employer, but don’t rely on your questions being answered by the HR director of your company. They are not insurance coverage specialists! Ask them to set up a meeting with the representative or agent from the insurance carrier. Many times this person can be your liaison between you and the insurance company and they can get problems resolved quicker than you can on your own. They can assist you in the appeal process and many times they know of a special compensation that can be made on behalf of a patient.

Along with your employer, your physician also has leverage with your insurance carrier to ensure a good outcome for you, the patient. They hire coding and appeal specialists who really do work as your advocate since you are both after the same thing; quality care and treatment for the patient and claim payment.

But even as I write this, healthcare as we now know it is in flux and the transformation of healthcare is leaning towards more regulations, increasing costs, and more demands upon medical staff to care for more patients. So, buyers beware or, in this case, patients beware!