What many Americans don’t know is that even if you can afford insurance, your access to quality care can be restricted by insurance company tactics that limit coverage for certain prescriptions and procedures. These practices are increasingly causing problems for patients, as reflected in another recent poll where 77 percent of all respondents reported “difficulty using their insurance” or knew someone who had difficulty.
As insurers seek to cut costs (which, in turn, increase their profitability) by limiting coverage for certain treatments and passing expenses on to customers, here are some common tactics your health insurance provider may use to avoid paying for quality health care.
1. Questioning Your Doctor’s Orders
Insurance companies often use a practice called “prior authorization” to avoid paying for a specific treatment or medication. This process requires your doctor to request approval from your insurance company before prescribing a specific medication or treatment. The treatment your doctor prescribed will only be covered if the insurance company approves it, based on their own policies and often without considering your clinical history. While insurers argue that prior authorization helps weed out medical errors and limits over-prescription, studies show it can lead to slower and less effective treatment and an increased cost burden on physicians.
Knowing ahead of time that your doctor (or nurse or doctor’s office manager) will need to fill out a prior authorization form for your insurer to cover your prescribed medicine or diagnostic test will help with expectations. It’s almost always because of burdensome paperwork that your prescription has not yet been filled, and not because your doctor’s office dropped the ball. Have some sympathy for the people who are on your team.
2. Delaying Effective Treatments
To cut costs, insurers often use “step therapy” or “fail first” policies, which require patients to try a cheaper drug before the insurance company agrees to cover a more complex or expensive alternative. The insurer will only cover the medication prescribed by your doctor after the first drug fails to improve your condition. This means insurance companies can force patients to take ineffective medications for months before agreeing to cover the treatment the doctor initially prescribed – putting patient health at risk.
The extreme of this is if a patient has already failed first on therapies, but then due to a change in employers or health insurers, has to go back to the beginning of the process – again – even though the required fail first medicines may have been ineffective, or worse, caused a side effect or problem. There is a robust advocacy resource available to people to get involved within their own state, providing helpful tips to navigate this tricky process.
3. Excluding Medications
Insurance companies are increasingly refusing to cover certain medications that they deem too pricey or unnecessary, placing these medications on “formulary exclusion lists” generally administered by pharmacy benefit managers like CVS and Express Scripts. Between 2014 and 2017, CVS’s formulary exclusion list more than doubled, while Express Scripts’ grew 77 percent. Patients have been denied treatments for serious illnesses including diabetes and cancer. Ultimately, a profit-seeking motive is behind these formulary restrictions, because there are rebates from the pharmaceutical manufacturers, which are cloaked in secrecy and go directly toward the insurers or pharmacy benefit managers’ bottom line. So, if a manufacturer doesn’t offer a big enough rebate (or incentive) to the pharmacy benefit manager, then that drug will almost certainly not be available – there isn’t a financial incentive for the insurer. Follow this group for more information about pharmacy benefit manager transparency.
4. Messing With Success
Despite being prescribed the medication by your doctor, insurers can also force you to switch to a similar medication for a non-medical reason. They might do this by eliminating coverage for the original medication outright, by eliminating co-pay coupons or by forcing you to share a greater portion of the drug’s cost. A 2016 survey found more than two-thirds of patients in Tennessee with chronic disease had been forced by their insurer to switch medications; 95 percent said the switch caused their symptoms to worsen, and 68 percent said they had to try multiple new medications before finding one that worked.
5. Leaving Mental Health Behind
Insurance companies across the country offer low reimbursement rates for psychologists and psychiatrists, leading growing numbers of therapists to refuse to take insurance because payers “don’t provide a living wage.” In some cases, insurance companies have outright refused to accept therapists into their coverage plans. According to a 2014 study, nearly half of psychiatrists in the United States (45 percent) did not accept any form of private insurance, a 17 percent decline from 2005 to 2006.
At this point, you may be wondering, “now what?” Knowing about the methods that insurance companies use to save themselves money (often at the peril of the patient) is not enough to get them to reform their ways. Thanks to coalitions of dedicated patient and provider organizations, 15 states have already passed legislation regulating (read: supervising) prior authorization and step therapy practices, making it easier for patients to access the drugs they need when they need them. These states are proving that these types of cost-control regulations are possible and the next step is to reach out to legislators and show them why they are necessary. Getting involved in the advocacy process is a productive and rewarding way to fight back. You need not be a policy or civics expert, just someone who cares passionately about getting access to care that your doctor prescribes.