Prescription Roadblock
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I just spent an hour and a half on the phone with a commercial insurance company that was requiring repeat authorization on a medication that I have been taking for over 2 years. I was due to pick up the medication last week. When I called to see if it was ready, my pharmacy told me that the insurance company was requiring pre-authorization, which they had requested the day I called in the refill request. Mysteriously, the insurance company says they have “no record” of the pharmacy’s pre-auth request, nor a record of their own 2023 approval, a copy of which I have in my hands. When presented with this evidence, they said, “oh, that was only good for a year, we change what meds need pre-authorization from year to year.” It is unclear why I didn’t have trouble obtaining my meds in 2024. Same insurance company for the entire time period.
I am unable to reach anyone in the pre-authorization department of my physician’s office. They have not returned my calls. I’m sure they’re overwhelmed with these silly rules which not only impact hundreds, if not thousands, of their patients, but create busywork for providers and staff.
When I asked the 4th person at the insurance company (2 regular reps, 2 supervisors, of which 2 were offshore) why they were delaying my care, they said “we need to verify your medical records and that you still need the medication.” Well, if I didn’t need it, why would my doctor have prescribed it and why would I be paying the out-of-pocket costs associated with receiving it?
The US doesn’t have “the best” health care system in the world, it has one of the worst. And I still don’t have my meds.
Fighting My Insurance Company from My Wheelchair: An Unnecessary, Mismatched Battle
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In 2022, I suffered a traumatic spinal cord injury. Rendered a tetraplegic (paralyzed from the chest down), I was in rehab for months after spending three weeks in the ICU. The administration on many occasions dumped their responsibilities on me, forcing me to figure out everything from insurance coverage, to primary care, home care, outpatient therapy and the numerous specialists I would need for the foreseeable future. They promised to assist with applications for grants to secure necessary durable medical equipment, but actively dodged and deflected my attempts to push the paperwork through. Consequently, instead of focusing entirely on my health and recovery, I was placed in a position of having to deal with additional, yet avoidable stress.
Despite an incredible amount of assistance from family, it still took months of working as my own care manager and trying to navigate the intricacies of our healthcare system before making any progress with insurance, doctors and other care. It was devastating when I found out I couldn’t start outpatient therapy for five weeks following my discharge from inpatient because they had not given me the correct type of referral. In that time, I saw much of the physical progress for which I had worked so hard, actually regress, taking away what little independence I had gained.
In the times when I called my insurance company, with questions concerning coverage, the representatives couldn’t give me a clear answer of whether or not I was covered, nor guidance on how to acquire that information. Once accepted by the doctors I needed, appointments were scarce to say the least. For months, insurance assigned me to primary care providers who weren’t taking new patients. During that time, I was forced to ration my medications as it was difficult to get them refilled; this was very stressful and probably quite dangerous. At the start of the new year, one of the specialty medications I needed cost me $3,600 out of pocket before insurance would cover any cost. Insurance also neglected to cover necessary at-home nursing, and at $70/hr I’m struggling to afford the care I need while my family and friends work. Furthermore, I was told I would need a neurologist, physiatrist, cardiologist, hematologist and urologist. To this day, I only have appointments scheduled with three of the five necessary physicians. Of those three appointments, two of them are still months away, placing my health in a tenuous position.
Would someone please explain to me how it is that in the United States, considered to be one of the strongest and most affluent nations in the world, we cannot seem to get our own health care system functioning in a way that is truly helpful, free from unnecessary entanglements and puts patients’ needs first? My injury has turned my life, and the lives of those around me, upside down and my experience with our health care “providers” has only added to the stress and adversity I have to deal with. The country would be better off with universal healthcare.
Insurance Obstacles and the Surgery that Almost Didn’t Happen
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Being diagnosed with breast cancer is devastating enough, but going through treatment while simultaneously navigating insurance coverage can be overwhelming. After enduring a double mastectomy surgery, expanders, and reconstruction, I sought a second opinion from a local plastic surgeon.
Most local plastic surgeons do not accept insurance or perform reconstruction surgery on breast cancer patients. I contacted my insurance company for a list of approved plastic surgeons and proceeded to call their offices. The nine names on the list actually consisted of only three group practices that participated in my plan. I had already seen a doctor in one of the practices, so I called the second practice. I was told that they did not accept my insurance plan. There were four names on the list from the insurance company in this practice. That left only one other practice, with four plastic surgeons. When I called for an appointment, I was told only one plastic surgeon would be available and accepting new patients. He was new to the practice and not yet board certified.
I contacted my insurance company and told them of my dilemma that several names on their list, including one my general surgeon had referred me to, did not participate with my insurance plan. She was not able to address my concerns, nor did she bother to forward this discovery to anyone who could update this list.
I did schedule another surgery before the end of the year yet struggled to get prior approval from the insurance company. When the office did not have approval two days before surgery, I contacted the insurance company directly and was told it was in the stack to be reviewed. I wasn’t willing to risk covering the cost of the surgery out-of-pocket and was stressed about whether the surgery would be postponed or actually take place as scheduled in two days.
The office called me the day prior to surgery to say they finally received approval from the insurance company. I received a letter in the mail approving the surgery three weeks after I had the procedure. Needless to say, the stress of dealing with breast cancer was compounded by the hurdles imposed by my insurance company.