One focus of the planned repeal of Obamacare is maintaining coverage for people with preexisting conditions. Republican lawmakers say the current law's safeguards won't change, but they have yet to explain how they'll accomplish this without also keeping the mandate that everyone buy insurance.
What isn't being discussed — although it should be — is the obstacle course that insurance companies and middlemen often make policyholders navigate just to get claims approved, often for chronic conditions. Drugs that doctors prescribe or treatments they advise may be deemed unwarranted or unproven by industry bean counters.
A 2011 study by the California Nurses Assn. estimated that the state's top insurers rejected about 26% of all claims. A separate study that year by the Government Accountability Office found that denied claims were reversed in about half of all appeals, for those with the stamina to work the system.
"It's a moneymaking tactic," Carmen Balber, executive director of the Santa Monica advocacy group Consumer Watchdog, said of the high frequency of denials.
"The companies know that when they deny claims," she said, "most people will just give up."
Not Bill Waxman.
The 66-year-old Simi Valley resident spoke with me this week about his repeated encounters with Anthem Blue Cross and Navitus Health Solutions, which handles the prescription-drug component of his family's health coverage.
For more than a decade, his 24-year-old daughter, Alison, has grappled with multiple autoimmune disorders that cause chronic pain, migraines, extreme dizziness and debilitating fatigue.
"If she chooses to shower, that may be it for the day," Waxman said. "If she chooses to come downstairs and eat, that may be it for the day."
There's no cure for what ails his daughter, so he and his wife are resigned to holding jobs for as long as possible to maintain family coverage and help deal with the costs. Waxman estimates his out-of-pocket medical costs last year ran about $14,000.
His most recent run-in involved a treatment for his daughter's postural orthostatic tachycardia syndrome, a.k.a. POTS, which prevents sufficient blood getting to the brain when standing. According to WebMD, the dizziness, fainting and fatigue that characterize POTS "may make it hard to keep up with daily living."
A cardiologist prescribed a heart medicine called Corlanor, which is not intended for POTS but has shown promise in treating the disorder by lowering the heart rate and thus helping a patient's body find equilibrium. Waxman said the doctor provided some samples of the drug "and we saw almost immediate improvement."
But when he tried to fill a prescription, the claim was denied by Navitus, which deemed Corlanor medically unwarranted for POTS.
Pharmacy benefit managers such as Navitus negotiate deals with drugmakers and pharmacies for the best prices. If a drug isn't on its preferred formulary, it may not be covered by insurance. Sixty tablets of Corlanor can cost more than $400, according to the website GoodRX.
Waxman arranged for a "peer to peer" phone conversation between his daughter's cardiologist and a Navitus health professional. Again, the claim was denied.
So he appealed directly to the head of Navitus, Terry Seligman. This resulted in his claim being considered at a higher level and, lo and behold, Navitus approved a year of Corlanor coverage.
A Navitus spokeswoman declined to comment.
Last summer, Waxman said, Anthem approved an IV drip his daughter needed monthly to boost her immune system. Then in September it reversed course and denied the claim, arguing that the treatment wasn't medically necessary. A four-month regimen of intravenous gamma globulin can cost as much as $25,000.
Waxman said he spent six weeks challenging the decision. And in that case as well, he prevailed.
Darrel Ng, an Anthem spokesman, attributed the situation to "a miscommunication" with the doctor's office.
Waxman only knows that he's had to fight repeatedly for his daughter's healthcare.
"Look," he said, "I'm not asking for a rhinoplasty for my daughter. I'm asking for things that will improve her quality of life."
His advice to others: Never take no for an answer, especially with the first denial. Make your case, stick to your guns and work your way through the appeal process.
"It's very arduous," Waxman acknowledged. "You have to do all the investigating yourself. You have to become conversant in medicine. You have to find the right people to contact. You have to compose your letters in such a way that they can't be refuted. It takes a lot of time."
Balber at Consumer Watchdog said all these roadblocks are intentional. She noted that Obamacare prevents insurers from denying coverage to people with preexisting conditions — a costly measure that's offset by the requirement that healthy people buy coverage or face penalties.
Insurance is only affordable for everyone when the risk pool is composed of both healthy and sick people. Otherwise, premiums would skyrocket.
"Since insurers can't turn away people with preexisting conditions, they've had to find other ways to not pay expensive claims," Balber said. "Their main tactic is to deny everything and hope the consumer won't put up a fight. They know the consumer usually won't."
This is, of course, a shameless and sad form of profiteering.
But it's the healthcare system we're stuck with. So be like Waxman and stand up for what's right.
On Tuesday, I'll share tips on how to appeal a denied claim.
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