Dealing with Insurance Issues
While most group health insurance plans cover the diagnoses and treatments relating to migraines, not all insurance is created equal. Also, some insurance plans may not cover preferred doctors or specialists. Research all available options before making an insurance decision.
If you carry your health insurance plan yourself and don't have the support of your company's human resource department to help you determine coverage and fight claim denials, you face additional challenges and obstacles. Become familiar with the health insurance claims and appeals system so you can use the process to your best advantage.
When choosing insurance plans, the first step is to make an accurate estimate of your anticipated medical costs. Look at the Explanation of Benefits from your current policy to see what types of services were covered and at what average costs. Next, obtain your medical records and assign a price to every expenditure; include everything from hospital stays and X-rays to lab tests and prescription medications. Use an average from the past year, or from the past several years if you had unusual medical circumstances arise during one or more years.
The following is a very general guide to costs typically encountered by migraineurs:
Doctor's visit: Co-pay range $10–$30
Prescription medication: Co-pay range $10–$20 (generic), $20–$50 (name brand)
Triptan medications: $20–$70 per dose (out-of-pocket)
Laboratory tests: $80–$100
Brief hospitalization: $100–$200 (co-pay), $5,000 (out-of-pocket)
X-ray or MRI: $300
When considering which insurance plan to choose, there will usually be several options at varying levels of coverage provided by an employer (or more, if insurance is being purchased outside of employment). One of the most important considerations is whether the plans you are considering include the doctors and specialists with whom you want to work. Also, read the general plan description to ensure that all services you anticipate needing are covered.
Always compare apples to apples when looking at different policies. Compare covered medications and co-pays, as well as premiums, deductibles, and lifetime maximums. Based on your anticipated migraine treatment plan, calculate which plan makes the most economic sense.
Does migraine count as a preexisting medical condition? Generally speaking, the answer is probably yes. Migraine disease is a recognized neurological ailment. Once a diagnosis has been made and becomes part of your medical record, insurance companies have access to that information. If you were covered by one insurance company during migraine treatment, there may be a period of time during which time a new insurance plan will not cover some migraine-related treatment or testing as a “preexisting condition.” However, if you have had continuous health insurance coverage for twelve months or more prior to moving to a new insurance plan, the Health Insurance Portability and Accountability Act (HIPAA) may protect you from a lapse in coverage. Find out if a “preexisting” stipulation will impact your migraine care with a new health insurance plan by speaking with the new insurer before you switch plans. Get any promises or assurances about coverage in writing.
Suppose you require a procedure from your doctor and, rather than risk a large bill, you choose to presubmit the claim to your insurance company. When the claim is presented, you receive a “denial of coverage” letter and bill for the full cost. Rather than resorting to panic, form a plan to fight back.
First, never assume that the bill you have received is either correct or final; call the insurance company and ask them to explain the bill. If that proves fruitless, ask to speak to a manager and explain why the procedure should be covered under the existing policy. The rule of thumb is that medically necessary procedures should be covered, so make the best argument you can toward that end. Obtain statements from your doctors indicating that the procedure was, in fact, necessary. Any documentation the doctor's office can provide to the insurance company will further your cause.
Speak to the insurance handler with the doctor's office and ask their advice. They may have suggestions for medical billing codes or other insights into how to have the procedure covered. Prepare yourself with evidence showing how other insurance plans cover the same procedure.
If you feel that the insurance representative you reached just doesn't understand the coverage issue at hand, it may help your case and your sanity to end the call. Cool off and regroup, then phone again later and try your luck with someone else. Insurance companies are typically large organizations with a full staff of customer service representatives on hand, and speaking to someone new gives you the opportunity to explain your case again. Remember that no matter what your level of frustration might be at the time, being courteous will only help your case, as customer service representatives almost always respond better to a polite customer than an irritable one.
Insurance companies have an appeals process for denied claims. If coverage is denied, always inquire about the appeals process and start it immediately. Gather any additional information or data from your doctor that you feel might help your case and check back regularly with your insurance company to ensure that the appeal is being processed in a timely manner.
Always document the full names of insurance representatives that you speak with on the phone, in addition to the time and date of the call and the details of what you spoke about. Ask the representative to send you written confirmation of coverage promises and clarifications she makes over the telephone.
