Saturday, May 29, 2010

Health Insurance protecting bottom line rather than my health

I genuinely wish I could state that I believed my health insurance was acting in my best interests to protect my health. Unfortunately, my health insurance company seems only interested in protecting the bottom line and doing only what is inside their contract. For people with ENS, this means a challenge to get the treatment we need. It is likely Blue Cross (and many other insurance companies) get paid more to deny surgeries than to approve them.

In desiring a lateral wall implant, a very reasonable (if not among the only) option for someone with empty nose syndrome, I have had to battle my insurance company - and, perhaps thanks in part to my persistence, I won. I have been approved for the lateral wall implant , but this was a 5-month battle, beginning in Mid-January. At first my insurance company, BlueCross, was not even going to grant me a prospective review, because I have an indemnity policy and Blue Cross stated experimental surgeries can only be granted retrospective reviews. In other words, they wanted me to go through with the surgery and stick me with the bill. I filed a complaint with the state department of insurance and, as a result, BlueCross granted me a prospective review and quickly denied the surgery on the basis of its contract which does not indicate use of alloderm in the nose; it was just a quick, knee-jerk denial, from my perspective. So I filed an appeal requesting my case be reviewed and that the doctor speak with Dr. Houser and review the literature on implants for ENS, but the doctor did neither. And denied me the surgery again.

Consequently, I filed another complaint with the state department of insurance on the basis of the doctor not granting me a fair review and I also filed an external appeal to be completed by an independent medical review board. Three doctors reviewed the case, all were ENTs and appeared to have strong credentials, and they all unanimously agreed to "overturn" Blue Cross' decision on the basis of ENS being an extraordinarily difficult condition to treat, Dr. Houser being the one doctor with experience in this area, and the implants being an effective if only treatment, although the research study is Level 4 (not a controlled, double blind study because that would be a difficult feat for any doctor to do given the uniqueness of our health condition). So BlueCross is now forced to grant me a pre-authorization on the procedure. Because ENS is so specialized and doctors have so little understanding on it, our battle to get a lateral wall implant approved is truly an uphill one. Which is a shame, as we ENS sufferers are already so limited in our treatment options.

But the point is, we can get this procedure approved if we persist in fighting for it.


Tony said...

When you are looking for health insurance or a private medical insurance plan, to ensure you get the best possible cover for all the major medical conditions and cancer it is important to consult with a specialist health insurance intermediary.

Chris said...

Thanks for the recommendation. That's good advice. My health insurance is through my employer, which is a public school district, so it is the only option I have. It actually offers fairly good coverage, but I think health insurance companies in general are only interested in protecting their bottom lines.