How to get past the gate keepers of insurance denials
Alicia: UnLeashed! April 2018 monthly article
How to get insurance denials reversed
How to get past the gate keepers of insurance denials
Lace up your Ruby slippers!
I always had an odd take on the movie The Wizard of Oz. I never understood when Glenda just sat on her pink bubble all day instead of doing something about a very serious wicked witch problem. I never understood why an entire town had a choreographed dance number prepared just in case someone should happen to show up and ask for directions. And I definitely never understood how this “Wizard” who showed up, max 40 years ago, managed to con the populace into installing him in a massive city, cultivate entire grooming rituals around his audience chamber and post the most inept security possible at the gates. The whole thing seemed tedious to me. I guess I’ve always been more of a fight my way in, save the day knights and dragons action movie kind of kid. Which is ironic, because I now find myself in a very real fight for my life in which I feel much more like Dorothy in Oz than any action star.
There are a lot of moments that unite people living with diabetes. But by far one of the most loathsome shared experiences is having an insurance company deny coverage for a medication or service. We have been spun from our normal life with Auntie Em, and dropped into the Technicolor haze of diabetes. We have trod the long path of doctors appointments, researching medications and options along the yellow brick road. Finally we reach the Emerald city of a medication or treatment that can really help us! Only to be stopped at the door and told that it will not be covered, by the most inept and uninformed doorman! It might be a pharmacy tech who does not have the complete information from the insurance company, or the insurance company representative on the phone who knows nothing about your coverage beyond the note on the screen in front of them.
Often like Dorothy at the gates of Oz we get an abrupt “NO” and the door slammed in our face. After all, they did their job, their function is to say no, to save the company money and keep us standing on the door step until we give up and go away. The Wizard will not be disturbed!
But wait, this door man doesn’t know us, or our needs. Dangit! Glenda told me to come here and see the Wizard for the remedy to my problem! She didn’t tell me to talk to the door man! What does the door man know about diabetes? Who is behind this door making these decisions?! Do you really think the door man is going in and consulting the Wizard?! No way! So do you think your insurance company has a diabetes specialist reviewing your needs?! NOPE!
So how does Dorothy get in? She knows the right authority to bring up. The ruby slippers! The gate keeper knows that the ruby slippers are Dorothy’s authority and immediately gives way. So what opens the door when the insurance company says no? Ask to speak with the “HIPAA Compliance Officer” right there you have said something very powerful to the gate keeper. You have told then you are aware of your legal rights to information, and that you know that they are not the actual authority. And just that quick the gates open and you are ushered in.
Now you get into the great hall (Sorry no free makeover and carriage ride here) and it’s time to pull back the curtain and reveal the individuals behind all the projections of authority and flames of intimidation. Tell the Privacy office that you would like a full list with credentials of every person accessing your record to make the denial decision.
9 times out of ten the decision to deny the claim will be reversed before they ever send you this list. That is because there is not a great and powerful “OZ” with an MD and diabetes specialty behind their name. There is typically a computer algorithm that instantly rejected your claim based on established formulary guidelines. Then there is likely an administrative level non medical person who reviewed your prior authorization or appeal for key words. IF there are actual medical personnel involved it is likely an RN with a specialty in case management, not in diabetes. The insurance company would much rather just give you what you are asking for than have to admit to these practices. And in the extremely rare case that there is an MD involved at all, when confronted by your doctor’s specialty and knowledge of your individual case, they (like the Wizard) are more likely to admit their own limited knowledge and acquiesce to your request.
You may have heard in recent news that there are investigations and a lawsuit against Aetna in California related to denials without doctor reviews of cases. So insurers are extra sensitive to this issue right now. It may not be an illegal practice in your state, but it is, at best, sloppy medical mismanagement.
See, like Dorothy getting what we need is not a simple task, it’s a journey and we have to bring the right authority to bear at the right times to get what we need. And we need to continue doing it over and over. I’ve found that I get better at it with practice and after a few times banging on the door, the doorman stops fighting and just ushers me into the great hall to save time and effort.
There are few times when shared social media content is particularly helpful in life, but you may have seen this information presented in the following image on your news feed. It is true! Keep it handy, feel free to share it. It might save someone’s life!
Alicia’s diverse nursing career has given her experience with a broad range of clients and a variety of health conditions in addition to diabetes. One of her passions is advocating for the needs of her patients, whether it be in overcoming insurance restrictions, obtaining community resources, or coordinating with school systems and medical providers.