Tag Archives: insurance

Dealing with insurance is not fun, especially when you’re in pain, and don’t know what the future holds.

My experience has shown, that the first place to start when you have a problem is with your insurance company’s customer service. What I have found, is that when I call customer service, I can get very different answers for the same question depending on who I talk to. So depending on the complexity of your issue, I would encourage you to make more than one call to see if you do get a consensus. We hope that we will, but if information wasn’t understood, or given incorrectly, you are on your own to straighten it out.

When I had my Rituximab treatment, what I actually got from my insurance was  in writing before the treatment. Customer service sent me a document that indicates what charges I could expect.

Labs are another thing to keep an eye on. When seeing several doctors, many of them want their own labs. It’s very easy to get duplicate lab work. Make sure to check your lab records, and what labs your doctor is ordering. For example one complete blood count (CBC) will do. In many cases your doctor will accommodate not duplicating labs, but it is up to you to let them know if you’ve already had recent lab work by another doctor.

Generally it’s pretty easy to get that lab work to the other doctor. I actually had a doctor who  ordered a CBC when I had just had one recently from another doctor in the same clinic. When I brought it to her attention shortly thereafter, she was very accommodating letting billing know so I wouldn’t get charged. She wouldn’t have done this if I hadn’t brought it to her attention.

There are many other areas where being alert and not afraid to ask questions can pay off.

Remember, when you need us we are in your corner!

After months of uncertainty waiting for a diagnosis and finally finding a physician who can treat your rare skin disease, you return from the mailbox with a denial letter from your insurance company. After the shock and frustration has subsided you are now faced with the decision of whether it is worth appealing this insurance determination or should you start back at “square one”.

Chances are that the insurance company is counting on you not appealing but according to the U.S. Government Accountability Office, one report revealed that in the four states that tracked such data, 39 to 59 percent of private health insurance appeals resulted in reversal. Those are pretty good odds!

Here are some tips on how to appeal:

1.      Read the denial letter carefully. Make sure that you learn about your insurer’s appeals process. In the coverage documents and summary of benefits, insurance companies are required to give all the tools needed to properly make an appeal. There are often deadlines to meet, so act quickly and send it to them as soon as possible.

2.      Ask for help from your doctor. Check the medical policy and ask your doctor to review it to prepare something called a letter of medical necessity to support your case. If your doctor is not able to help, be prepared to handle it yourself. You are your best advocate!

3.      Contact the IPPF. The foundation can help provide you with resources about the disease and publications citing the use of treatments used for your condition. These documents can help support your case to the insurance company.

4.      Write a testimonial letter. You have a rare disease and it is likely that the person making the decision knows nothing about your disease. A letter with pictures detailing your story and exactly what happened will make it personal. Tell them that you are seeking approval for treatment, note any supporting science, clinical evidence, expected benefits, etc. Be clear, firm and concise. Make it clear that you plan to pursue the appeal until it is resolved and is approved.

5.      Follow up. Many appeals take weeks, even months, so call often to check the status and take notes of each call. When you speak to the insurance company, write down the time and date, length of the call, the name and title of the person you speak with and all the details of the conversation. Make note of any follow-up activities and next steps to be taken.

Remember, many insurance companies have a tiered appeals process. The first level is processed by the company’s appeals staff or medical director responsible for the denial. Second-level appeals are reviewed by a medical director not involved in the original claim. The third level involves an independent, third-party reviewer. If your insurance company continues to deny the claim; you can then take the appeal to your state’s insurance department, state insurance commissioner or even your local legislators who have staff to assist you.

This process may seem overwhelming but it is worth it. Your health and the health of other pemphigus and pemphigoid patients may be impacted by the awareness you create with the insurance claim.

If you need assistance, just “Ask a Coach!” Remember, when you need us, we are in your corner!

This article is meant for those of you who have recently or about to move to a new area. After living in the greater Seattle area for 58 years, I moved to the San Francisco Bay area in August ‘14.

I encountered more challenges that I had expected. I had to find new medical insurance, since the company that I was with in WA isn’t licensed to cover in California. I also had to find a new dermatologist and general practitioner.
First, I had to decide on what kind of insurance to get. In WA I was with a company for around four years. They were much like Kaiser in the west. You can only go to Kaiser providers, labs and prescription services. I was used to this system, however it felt restrictive. The other option was to pick an insurance company that was a PPO.

Finding a GP was probably the hardest, in the sense that I felt a bit like I was shooting in the dark. My insurance agent unofficially suggested I look for a doctor within the John Muir system. They are close, and generally good. It was much easier to find a dermatologist, because I already knew who I wanted. When moving though you should always contact the IPPF and have them re-send you the physician’s referral list. This way you can see the doctors in your new area.

I was familiar with Dr. Peter Marinkovich at Stanford Medical Center. He is on the medical advisory with the IPPF and I have heard him speak before. I felt great about working with him, and his staff. It’s over an hour drive away from me, but worth it.
I have a few suggestions to keep in mind. If you are moving due to a job change, or your spouse’s, then I believe you are more restricted if you don’t want to self-pay. Read up on what kind of choices you have for a dermatologist in your area. Talk to your insurance company’s customer service if you have any questions regarding coverages. Find out how much experience the dermatologist has treating pemphigus/pemphigoid. In addition to that, it’s important to be able to feel connected, and your doctor understands you.
If you need help finding a dermatologist, feel free to contact Noelle Madsen at the IPPF office. She can make some recommendations, as well as send you a list we have. She can be reached by phone at 916-922-1288 x105 or by email at noelle@pemphigus.org.
Remember, when you need us we are in your corner!