Expanding Health Equity through Health Care and Payer Navigation Literacy

Introduction

Navigating healthcare decisions is difficult, especially in the United States where the healthcare landscape differs so widely from state to state, and even county to county. These decisions are made even harder when payers—any person, organization, or entity that pays for care services—often serve as an additional hurdle to accessing the healthcare services you need. Think about anytime you’ve interacted with your health insurance carrier. That’s a payer; really often two payers (one for your medical coverage and the other for your medication coverage).

This patient resource is designed to explain in the easiest terms the types of tricks that insurance companies and other payers use to make accessing healthcare services harder, how to navigate the challenging healthcare landscape, and what resources exist to help you when you need assistance.

In the United States, there are two types of payers: Commercial/Private and Government/Public

·      Commercial/Private

Commercial or Private payers include publicly traded and private insurance companies, such as:

• UnitedHealth

• Aetna

• Humana

• Blue Cross Blue Shield

  • Government/Public

Government or Public payers include federally- or state-funded healthcare programs, such as:

• Medicaid

• Children’s Health Insurance Program (CHIP)

• Medicare

• Veterans Administration

Each of these payers has a variety of policies and procedures in place to manage the amount of money spent on your healthcare needs. Examples of such measures include:

·      Narrow provider networks (if your healthcare provider, clinic, or hospital is “in-network” or “out-of-network”)

·      Limited medication formularies (where the payer doesn’t include particular medications or prefers generics over what your healthcare provider might prescribe or not including medications for specific medical conditions)

·      Hard to meet prior authorization requirements for treatments or medications

·      Refusing to count drug company co-pay assistance coupons toward your deductibles and out-of-pocket maximums (in this case, while you might not end up paying a co-pay, the payers is collecting the whole value of your assistance just because they can – or the payer is double-dipping at your expense)

·      Refusing to cover a medication your healthcare provider has said you need until you try and “fail” another medication – where you don’t get better or get sicker on the payer’s covered medication first (this is known as “step-therapy”)

·      Denying services that are explicitly covered in your insurance contract in the hopes that neither you nor your doctor will appeal and force them to cover the services (this is similar to the worst practices of automobile or home insurance coverage)

The purpose of this patient resource is to expand health equity through healthcare and payer navigation literacy in Merced and Stanislaus Counties.

Practical Steps for Patients

- Selecting a plan (for privately insured patients):

Health insurance that’s “good for you” is more than monthly payments and deductibles, it needs to cover your medications and the doctors you want to see. The federal “Marketplace” (Healthcare.gov) is working to better provide transparency tools, including estimated total annual cost of care, so patients can better navigate selecting their insurance. There are some helpers if this feels just a bit overwhelming to you. HealthSherpa is an unbiased group to help you figure out what plan works best for you. They won’t make any recommendations, but they will help make sure you can make an informed choice.

-  Understanding what your plan covers:

Patient Advocate Foundation may be able to help you to better understand what your plan is supposed to cover when your payer has told you, “no”. PAF also offers a tool for finding “co-pay” assistance for certain conditions and other financial assistance for qualified patients.

- Resources for if you don’t have insurance:

Federally Qualified Health Centers are not “free clinics” but they are required by the federal government to offer healthcare “regardless of [patient] ability to pay”, including uninsured and uninsured people and non-citizens. These clinics often offer sliding fee scale, post-visit billing, insurance and assistance navigation, and other resources for clients who may struggle with affording their healthcare. FQHCs also often have networks with specialty healthcare providers and may be able to help you or your family.

- Preparing for a provider visit:

If you are visiting a new doctor for the first time or the doctor you have seen for a long time about a new issue, be prepared to ask your healthcare provider to “advocate” for you with your payer and to educate you about your care. Bring a list of your current medications, including over-the-counter medications, and be honest about any alcohol or drug use – your information is protected by patient privacy laws and your doctor needs to know in order to make sure they don’t accidentally prescribe your something that could cause additional health concerns. When being told your doctor would like you to start a new medication, ask about medication interactions and if there’s a difference between the brand name medication and generic medication. You may even wish to bring your payer’s covered medication list (known as a formulary) and see if the medication your provider is suggesting is covered. If it’s not, ask about how prepared the doctor’s office is to handle “prior authorizations” or coverage appeals (the next steps after a payer has refused to cover your care or medication). If you’re concerned about being able to afford your medication, ask your provider if they’re aware of any “patient assistance programs” for that medication.

- Preparing to pick up your medications:

Before your trip to the pharmacy, we recommend calling ahead to ask any or all of the following questions:

·      What will my copays be?

·      Are the options for copay assistance that may lower what I pay?

·      Have any of my prescribed medications been switched, either by the pharmacy or my insurance company?

o   If so, what are the differences between the medications prescribed and any substitutions?

·      Did any of my medications require prior authorization?

o   If so, were those completed and approved?

Asking these questions ahead of your visit can save you time at the counter and avoid confusion when you arrive to pick up your prescriptions.

- Appeals:

When your payer has told you they will not cover a procedure, screening (i.e., labs or images), or a medication, your first step is to appeal the decision. Your payer is required to provide you documentation, often as a letter, as to why they denied your claim. KEEP THESE DOCUMENTS. It is important to review these documents carefully, and if possible, with your doctor’s staff, to understand the process of appealing this decision. Appeals should be handled by your doctor in order to ensure the right documentation is given to your payer about why you need what your doctor has recommended – this is often called “medical necessity” and is particular to your health needs. You may need to follow up with your doctor, your pharmacist, and/or your payer in order to make sure they are not allowing your appeal to sit on a desk.

Most appeals are answered quickly but can take up to 60 days to get an answer, in most situations.

Having your payer policy available may help your doctor in writing an appeal letter that addresses the definition of “medical necessity” as your payer defines it.

- Complaints

If your insurance company denies coverage for a service, test, or medication, you have the right to appeal those decisions. This process can be timely and can also be confusing. Your healthcare provider will play an important role in this appeals process, and you should always request their assistance if it is needed. If you find yourself in need of additional assistance, you may also reach out to the Patient Advocate Foundation for additional assistance.

Healthcare.gov has put together a guide that lays out what you can expect when you file either an internal or external appeal:

https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

When filing an appeal, you will need to ensure that you collect and prepare each of the following types of documentation:

• The Explanation of Benefits forms or letters showing what payment or services were denied

• A copy of the request for an internal appeal that you sent to your insurance company

• Any documents with additional information you sent to the insurance company (like a letter or other information from your doctor)

• A copy of any letter or form you’re required to sign, if you choose to have your doctor or anyone else file an appeal for you.

• Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.

• Keep your original documents and submit copies to your insurance company. You’ll need to send your insurance company the original request for an internal appeal and your request to have a third party (like your doctor) file your internal appeal for you. Make sure to you keep your own copies of these documents.

California’s Insurance Commissioner is the state agency responsible for making sure patients get their fair share from their payers. If you don’t think your healthcare insurance is treating you fairly, you or your doctor can file a complaint and ask for an independent medical review. You or your doctor can file a complaint here.

Conclusion:

The healthcare landscape in the United States is incredibly complex and every patient will inevitably find themselves in need of assistance at some point. We believe that every person living in the United States should be entitled to quality health care services and coverage, regardless of their ability to pay. Ensuring that everyone receives the services to which they are entitled does, however, require patients to advocate on their own behalf and their providers to be well-equipped to advocate for them. We aim to make this process easier by providing patients with the tools they need to do just that.

Always remember that health insurance companies are in the business of making money and they often do so by denying coverage for services, procedures, and medications that they have already promised to cover. We encourage patients to work with their providers when their payer tells them “no” in order to get to the “yes” patients deserve.

Payers are notorious for finding new and creative ways to deny covering patients’ care. Patients and providers will need to stay aware of the broad barriers payers are willing to institute as well as the specific details of their own plans.