We are seeing more and more issues with insurance in the past 6 months and I wanted to pass this information on to you so you know that this is happening.
First we need to understand that insurance is not what we think it is. If you have home insurance it is only to cover catastrophic damages to things like your roof from a storm (and it might not cover all of it depending on your policy). They day to day fixing the toilet, making sure the furnace runs is your responsibility. Your car insurance may cover a part of your fender bender but doesn’t cover your gas, your routine oil changes or any other maintenance your car might require. This items are your responsibility. When Obamacare came on the scene deductibles shot up, what was covered dropped and more limitations on drug choices have occurred. Medicare is predicted to be bankrupt by 2026 if things continue as it is. No wonder they are making major changes to the system.
READ ON to learn about what type of tests your insurance is not covering, the changes occurring with coverage for medication and how to navigate these changes….
Medicare refuses to pay for certain screening tests (and have refused for a long time). Examples like a hemoglobin A1C which looks at a 3 month average of your blood sugar and can be an important tool in finding pre-diabetes can’t be ordered unless it is known you are already are having a sugar issue (diabetes). High sensitivity C Reactive Protein is an inflammatory marker than can help predict who is at high risk of cardiovascular complications and this can’t be ordered unless you have already had a heart attack. Now they have gone even further…
Medicare has always discouraged using “panels” of labs unless medically necessary. A typical panel would be a cmp (comprehensive metabolic panel) which includes labs screening for glucose level, electrolytes, kidney and liver function or a lipid panel which looks at cholesterol, LDL, HDL and triglycerides. I consider these test panels very basic. With recent shifts in Medicare/Medicaid the United States Department of Health, Office of Inspector General is taking the position that if a physician orders a medically unnecessary test they may be subject to civil penalties. This means without knowing you have kidney issues I am not supposed to do a test that checks on your kidneys. Symptoms of kidney failure don’t really occur until they are very impaired! I can’t screen for a blood sugar problem until you have diabetes which will be only diagnosed after significant issues have occurred because high blood sugars are often silent for years before causing symptoms. Get the picture?
Let’s talk medications. Oh boy. This has blown up our fax machine this year. We are seeing people who have been on the same medication for YEARS suddenly have that Rx denied. It doesn’t matter what we write to them they just aren’t going to pay for it. We have had times when we can show a person has had a reaction to the medicine they are proposing and they still won’t pay for it. Recently, Humana is refusing to pay for Armour. Doesn’t matter why you are on Armour – they won’t pay for it. Period. Trying to use other medications that are considered the drug of choice have proven extraordinarily difficult with consistent denials even with prior drug failure of their recommended choice. We are perplexed. The bottom line is if you need to stay on that drug or need a different drug they aren’t paying for then you have to pay cash for it. More and more people are having to do that. The amount of time it is taking my staff to submit all the documentation for these prior authorizations only to have them continually denied is wearing us out!!
How about physician appointments. It is so frustrating to be fully established with a physician and then suddenly they don’t take your insurance anymore or you switch networks and they aren’t part of that network. This happened to me several years ago and I chose to stay with my physician and pay the out-of-network price rather than start all over. It is your choice!!
The bottom line is…. We cannot rely on our insurance to cover all medical expenses and more often than not you are going to be faced with the situation of paying cash for something or changing to whatever they are dictating you change to.
Just because your insurance won’t pay for a test you don’t have to skimp on what is done. First know what your insurance will and will not cover and what deductible you might have. Second, if labs aren’t covered then consider a cash pay arrangement for the best price. Third, if they won’t cover your medications reach out to the manufacturer for discounts and coupons. Often they will have a specific pharmacy they have contracted a better cash price to help their consumers. GoodRx often has good coupons and discounts so check them out.
To help you have optimal health, we are offering cash pay labs when needed so we can get the screening tests that are appropriate making sure you are going down the right path.
To your health,