It is not enough to know that a patient’s medical condition warrants an MRI. For most insurance companies, a diagnostic test of this sort requires what is known as a prior-authorization. But, the doctor saying the patient needs this test often fails. The insurance company has a certain guideline the patient must travel first before they will consider the test.

For example, a patient with back pain and numbness in one leg must first do and X-ray and go through physical therapy before the test will be covered. An X-ray is quite a useless test when you are looking for a herniated disc or spinal cord compression. But, the gods of coverage determination found that it is a cheaper test, and you may just give up after that.  And, forcing a patient to endure a course of physical therapy with an undiagnosed condition can be not only ineffective but downright dangerous if there were to be some such condition as spinal cord compression present.

Another example is the “you must try these medications and fail first” before a prescribed medication may be authorized for use. It doesn’t matter if you have been on the same medication and it has worked well for you. Formulary changes don’t care about that. They also don’t consider the fact that forcing an asthmatic to switch inhalers of a diabetic to change medications can have untoward outcomes, even ending up in hospitalizations. What does a failure of a medication mean to the insurance company? You failed the cheaper version, and they may now consider the medication you and your doctor think is the best. What does a failed trial of a medication mean to a patient? Weeks of pain and discomfort with possible harmful complications.

Many patients justifiably become upset when this happens to them. We file many appeals, but it seems no one is listening. While we may win one victory, we are left with many defeats.

The maze of health care starts when one enters the system. there are all kinds of plans out there: HMO, PPO, POS, Medicare, Medicaid, and so on. Even within one specific type of plan, the coverage may vary in terms of deductibles, copays, what is covered, etc. There is no answer guide to explain what any of this means. Sure, the patient may receive a packet of benefits. But, it is still difficult to know what it means. A copay for a primary care is different for a specialist is different for an ER visit is different for a hospital visit is different for an ambulatory surgery center.

How to navigate the complicated health care system?

Education. The health care system is more complex than it ever has been, but the best navigational tool for following the maze is education. Patients are becoming more empowered, and this is as it should be. Knowing the treatment options help them make the best choices but they should also know their coverage. The best medication in the world is not going to work if the insurance doesn’t cover it and the patient can’t afford it. Many times I have found an insurance company denying coverage for a service they are contractually obligated to cover. This is why it is imperative for patients to know their plan.

Ask for help. The system is complicated even for health care professionals. But, they have been in the game for years and have much more experience. If a medication you need is not covered, there may be some routes to bypass this block in the road. Some pharmaceutical companies offer savings that bring the copay down to the lowest so that the copay is no different from generics. Ask!

Fight back. If a service is needed yet denied, don’t give up. Make phone calls, file appeals, and do whatever possible to try to get what you need. The insurance companies bank on the fact that you will just give up.

Find a patient advocate. Yes, there are people whose life mission it is to advocate for patients. It may not be easy to find them, but they can be a great asset in receiving the care that you need. In general, we need to train and employee more. In this complicated system, these people have never been more needed.

In the maze of the health care system, it is easy to take a wrong turn and end up in a dead-end. We should ever just give up because this will just allow the system to become more convoluted and enrich those with the least interest invested in the patient. Doctors need to be strong patient advocates. It is not sufficient to just hand over a prescription or an order for a diagnostic test and wish our patients the best. We need to lead the charge for getting the care our patients need. If we give up, then who is left?

Linda Girgis is a family physician who blogs at Dr. Linda.

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