Behind The Scenes In Healthcare: Your Med Is Denied

Health Tips / Behind The Scenes In Healthcare: Your Med Is Denied

Your insurance company sent me a 17-page fax with your name on it. Yes, really, 17 pages, eviscerating my paper tray, guzzling my toner. In its ads, your insurance company cynically crows about its concern for the environment, so I doubt a hard copy will ever arrive in the mail. Your name is on page one of the fax, and below your name: denial of medication.

 Like most primary care doctors, I receive several of these multipage wonders daily. Your insurance company is well aware that after a cursory glance, the vast majority go unread, ending their lives in a recycling bin. If you think your name will never appear on one of these, think again. Since everyone in the US is either taking a prescription drug or will likely take one in the future, at some point it’s a safe bet your time will come.

Nothing personal. It’s the system and here’s why it occurs.

Each of the dozens and dozens of health insurance companies in the US, some of which have the lifespan of a mayfly, create a formulary listing the medications it will cover. Most insurers are perfectly willing to pay for cheap generics. Generics aren’t a bad thing, but they’re not the same as the brand-name version. Generic manufacturers sign a document certifying that their product is the same as the branded drug, but the meds themselves are never clinically tested for effectiveness. (Unfortunately, there’s been a recent spate of hedge fund managers buying up generic manufacturers and jacking the prices a hundred-fold, so that now even some generics are being denied by insurance companies.)

When it comes to covering a branded drug (like the ones you see advertised), your insurer will place the drug in its formulary only after negotiating a price with the manufacturer. Whether or not a drug is covered by your policy depends solely on the success of the deal. To the chagrin of nearly everyone, these deals are endlessly renegotiated. (The phrase “Subject to Change Without Notice” appears throughout your insurance company formulary).

Formularies vary among insurers. In January, for example, Aetna will cover Advair for asthma and Blue Cross will cover Advair’s rival, Symbicort. In six months, for no reason apparent to the patient, they’ll switch. That’s because each cut a better deal. If you have Aetna and you go to pick up your Advair in June, the pharmacist may tell you it’s been denied.

It’s at this point I receive your 17-page fax.

The fax is physician behavior modification therapy

My role is to get you switched to Symbicort quickly so you can keep breathing comfortably. No one expects the fax to actually be read by anyone. It is simply a form of physician behavior modification therapy to train me to remember that if you have say, Blue Cross and asthma, that I’m supposed to prescribe Advair and not Symbicort.

Of course it’s all about money. You aren’t naïve enough to think that anyone in the insurance industry gives a rat’s ass about your health and wellbeing, or what drug might be best for you.

 But what could possibly be in that 17-page fax? Answer: health care lawyers at work. Teams and teams of them. Your daughter a lawyer? She and her team are burning the midnight oil to protect their bosses from a class action lawsuit. Remember when she studied so hard for her LCAT, survived law school, sweated her bar exam? It was all to work on those 17 pages, simultaneously getting your meds denied and rendering you powerless in the process.

Over the past 20 years, health insurance companies have been successfully sued for denying much needed medications. Patients died. Families sued and won. You can watch the great 1997 movie “The Rainmaker,” based on a John Grisham novel, in which a young attorney played by Matt Damon goes for an insurer’s jugular. The film is a perennial favorite among doctors. I’ve probably seen it more often and shed more tears of happiness than you ever did from “It’s a Wonderful Life.”

So before I toss your fax in the recycle bin, let me walk you through it.

Dear Dr. DAVID EDELBERG (the letter begins):
The first line is in Chinese (I swear this is true) with an 800 number.
The second line is in Navajo (I needed an online language identifier to figure this out).
The third is easily recognizable Spanish.
The fourth is Tagalog (back to the language identifier: Philippines).

There are no lines in French, German, Norwegian, or Swedish. These people have decent health care systems.

Now to the meat of the letter. Your drug is denied, I am told, unless I can verify a history of drug failure, allergy, or intolerance to any of the five cheap-o generics listed in the next paragraph, some of which may not be approved for your particular condition. Because I had not provided them with any information about your intolerances (who knew they’d ask?), the drug is denied.

What follows next is an interesting disclaimer. The company responsible for the review and denial of your medication is a separate entity from your insurance company. This deftly hides the fact that the reviewing company is a wholly owned subsidiary of your insurer. The disclaimer also suggests I call another 800 number (different from the Chinese and Navajo numbers listed earlier) to discuss the situation “with a clinician.” The clinician is usually a semi-retired pharmacist who sounds like he’d rather be playing golf than arguing with me. I am also given a rap on the wrist warning me that if you remain on the drug, you’ll be responsible for its full cost.

That was just page one (you might want to quit now)

On page two I am reminded that you are entitled to an appeal process outlined in the 15 pages that follow. Page three is headed “Member Appeal Process in Illinois” and starts with a seven-line preamble about your legal right to appeal. Even though you live in Illinois, all appeal correspondence must be sent to some address in Utah (sure, why not?). My appeal letter must adequately answer five specific questions. I won’t elaborate, but you can guess these are all variations on why we think you’re entitled to the expensive drug that eats into company profits instead of the cheap generic you deserve.

There are two parts to the “Member Appeal” section, one called the “Standard Appeal Process,” which takes no more than 15 days. The other is for “Emergency Appeal.” If I can prove you’ve got one foot in the grave, I can request an expedited appeal. This promises an answer in 24 hours (weekends and holidays excluded). Before I request an expedited appeal, I must talk to someone called a Customer Care Professional at another 800 number to verify it’s a real emergency.

If we cave in, accept their denial, and you’re willing to swallow whatever is allowable in their formulary, we can stop here.

If, on the other hand, we want to keep fighting, pages 4 through 17 walk us through the process by which we can call on our friends in the government to help with the appeal. By law, the denial letter must walk us through the appeal process as required by the Illinois Department of Insurance.

Pages 4 to 14 contain a lot of stuff. It begins with ten paragraphs and 17 bullet points in a print so tiny it challenges my 3.5 diopter Walgreen cheaters. Pages 15 and 16 are blank forms for you to complete, including a section in which you release your medical records to everyone. Lastly, on page 17, there’s an appeal process checklist similar to that used by airport ground crews before a 747 is released to the clouds.

A reminder to you Health Tips readers who are also citizens of Illinois: four Illinois governors have done jail time, the state’s finances are in total chaos, and due to constant squabbling  Illinois legislation has ground to a halt, bills are unpaid, offices are on skeleton staffs, pensions are perilously funded, and no serious budget exists. If the Illinois Department of Insurance still exists, they’re operating by candlelight. Don’t expect much help.

If you’re fortunate enough to live outside Illinois, the final seven pages of this fax list, state by state, the addresses, phone numbers, and websites of all states with “Consumer Assistance Programs under PHS Act Section 2793” (created by the insurance exchanges to “protect” you).

Page 1 of these last seven pages: Alabama through Delaware.
Page 2: District of Columbia through Maine.

I won’t continue, but I’ll bet you didn’t know that there’s no Consumer Assistance Program in either Alaska or American Samoa. Perhaps you didn’t even know there was a place called American Samoa or where it’s located.

In the very last paragraph of the very last page is one final important point your insurance company wants to make. If you’ve gone through the insurance company’s internal appeal process, been denied, and then applied to your state insurance department and been denied, you can finally call Washington, specifically the US Department of Health and Human Services Health Insurance Assistance Team, at 1-888-393-2789.

For best results, speak Navajo.

Be well,
David Edelberg, MD

0 thoughts on “Behind The Scenes In Healthcare: Your Med Is Denied

    Hi Karen
    As we learn more and more about this, it looks like an industry called Pharmacy Benefit Managers are very much involved with these outrageous prices and denial policies.

    Dr E
    Posted January 15, 2018 at 11:09 am

    Sadly, you’ve described the current state of affairs between me, my doctors & insurance companies. In my case, since receiving an expensive medication, Blue Cross & OptumRX insurance company through Denials for amount & type of prescribed medication are, in my opinion, attempting to become the prescribing physician. Letters of denial for medications often have explanations with misinformation; recommendations for different kinds of meds for treatment of said rare disorder; & will not acknowledge ‘off label’ medications used to treat rare disorder. With the pharmacies being held captive by insurance companies price gauging/fixing these denial & attempts to manage our treatment plans causes me to me wonder if the long term plan of pharmaceutical companies is to become the prescribing physician ..thereby cost & kind of medications are ‘managed’ by their doctor’s & pharmacies who are held hostage as well. Question is..How does fight Goliath?

    Posted January 9, 2018 at 6:39 am

    The patient have time to die before they get the medication they need when they have to go through all the process because it take forever before they get a reply. Even making an appeal with Medicare for help take forever because the insurance companies don’t appreciate it when you complain about them to Medicare so they make it harder on you to get your medication. It is about time we get these corrupt insurance companies out of our health care system.

    Posted January 22, 2016 at 11:44 pm

    And then we wonder why doctors get burned out….
    This is what we get when we let insurance companies write our health care laws with nothing in mind but maximizing profits.
    Can we move to Canada now?

    Posted January 19, 2016 at 11:55 am

    The meaning of this article is very true–health care in the United States is really about money. I was on a medication for pain control for several years that worked very well, until the next January 1st came around and it was removed from the list of approved meds. I had already tried most of the alternatives with poor results. My doctor didn’t even offer to submit an appeal on my behalf, though I was aware of this next step. And to seek out another physician who is willing to pursue it is unrealistic–for all are under the same pressure. In reality, my physician is unable to make decisions in my medical care, but must choose among a set of alternatives provided by the bureaucrats at the insurance company, who know nothing of my medical history. My doctor is also required to follow a sequence of medical remedies, which frequently have already been tried and found ineffective, before the insurance company will agree to his recommendation based upon his knowledge and experience. Not to leave me without hope, my insurance company provides an advocate, but her function is nothing more than to clarify communications.

    Robert Miller
    Posted January 19, 2016 at 11:18 am

    The day Blue Cross Blue shield “community health” sent me a letter that they wouldn’t cover my Armour thyroid I got a Good Rx prescription drug card in the mail. It made another med affordable for me before the ACA act. Trying to get a primary Doc though this is like being in the movie Brazil. My Doc friends told me, that there won’t be enough primary care Doctors to see all the the people who get covered…… now I am going through it myself. I STILL pay cash so I can get quality health care and see Dr E. Not that there aren’t good Medicare accepting Doc’s. There are. But the whole system is set up to exhaust you, deny you, and wear you down to not get any services. It isn’t worth my time for an no co pay visit to have some Doctor who will give me maybe 10 minutes try and make me go on synthroid. No thanks.

    Posted January 19, 2016 at 9:59 am

    Bernie Sanders’ comment that a single payer system is unlikely here without campaign finance reform is spot on. Congress,indebted to the insurance and pharmaceutical sectors, won’t move on single payer in our current system. Even if we voted out the current Congress, the problem would remain without eliminating this “legal bribery,” as Tom Friedman called it.

    Posted January 19, 2016 at 8:20 am

    This article is spot-on! Just yesterday, I had a much needed drug denied because there is no generic version available. The chances of my doctor filling out the paperwork needed for medical necessity is slim. She is a GREAT doctor, but is so busy I wouldn’t even expect her to take the time for such nonsense.

    Healthcare in the US is truly in crisis…I have worked in a hospital for almost 20 years. I see it everyday.

    Posted January 19, 2016 at 6:00 am

    Which is why for the sake of these poor Doctors who have to waste their skilled time on this daily, and patients who are sick of trying to justify their needs to some medically ignorant insurance company my opinion….. having lived in the UK for over 30 yrs…….we need a single payer system, and universal health care coverage. Yes we then pay higher taxes, but don’t deductibles and copays go up each year anyway whilst coverage goes down? It’s a basic difference of who we pay the money to -the Ins. co to the Govt. There will be a lot of teething problems, and the UK system isn’t perfect either, but at least when your Dr. prescribes a medication you get it and don’t have to wait to get ‘authorisation'( after your ‘DR’ has just GIVEN the Rx to you!), then maybe ‘appeal’, then ‘be denied’. All the while, whatever the issue , it has gone on for another few weeks with no relief! The US spends so much more per capita/year on health care than any other developed nation, and still even 1 office visit can turn into a major time- consuming hassle for Drs and patients alike:-(.Being chronically sick becomes a full time job in terms of dealing with the ins. companies in every aspect- as if being sick in the first place wasn’t bad enough:-( Dr.E-you are exactly right-healthcare is huge business for lawyers every minute of every single day-whether it’s defective metal hips/mesh implants or generic drugs!!! Sure the law has a place in medicine ,, but not to the extent that it stops Drs doing their jobs and patients getting the treatment they need, when they need it.

    Tina Hepworth
    Posted January 18, 2016 at 10:23 am

    Thank you for sharing this unbelievable story. After watching the Democratic Party debate last night and reading this, I am convinced that Bernie Sanders’ plan to eliminate insurance companies and go to a single payer system is the best way to get the middle man insurance companies out from in between the patient and their doctor. I’m ready for a Canadian or European type of health care. And last night I finally understood how increasing taxes by $49 a month to pay for single payer health care is much cheaper than paying private insurers their many thousands of dollars a year to do what you outlined above. It makes so much sense!

    Posted January 18, 2016 at 8:44 am

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