“Why won’t my insurance cover a CT Scan of my heart that the doctor says I need.”
That was the call we received recently from a woman who was confused, upset, and uncertain about getting the care she needed. She’d had questionable results from both her stress test and her cardiologist recommended that she follow up with a CT scan ( to be exact, her doc wanted a CT scan of her coronary arteries, affectionately known as code 0146T).
But her insurance company refused to authorize this critical test.
Why? Was there anything we could do to help?
We went right to work and here’s what we discovered:
- The cardiologist’s office followed protocol by calling the woman’s health plan and submitting the required information. However, what was submitted didn’t meet her insurance guidelines.
- We obtained a copy of the company’s guidelines for radiology, and then compared the information sent by the doctor.
- We then interviewed the woman and discovered she’d neglected to mention certain symptoms to her doctor.
- We discussed those symptoms with the doctor’s office; they updated the information, sent it off for insurance review, and the test was authorized.
- Always ask why. If you need a test/procedure and your health plan won’t authorize it, ask for clarification. You’re entitled to a copy of the guidelines used to make the decision.
- Don’t assume that your doctor’s office will engage with the health plan on your behalf. Stay on top of the situation.
- Review the information and symptoms you’ve shared with your doctor and see if there’s more that might be helpful.
- If you’re having trouble getting answers, enlist help. Don’t just settle for “no.”
- Realize that by enlisting a private advocate, you save time and money and get results.
We were sorry to hear the news about Billy Joel and Christine Brinkley’s daughter, Alexa Ray, who apparently attempted suicide. We’re deeply saddened for her and her family and wish them healing and support.
Among other things, this tragic incident once again calls attention to the disparity between the “haves and have-nots” when it comes to getting good mental health treatment. Depression and other psychiatric problems cross all age and economic boundaries. But access to appropriate care does not.
No offense to Alexa, but we bet she won’t have any problem getting the help she needs. It’s not so easy for the rest of us. Especially those on Medicare.
Private health plans are required to demonstrate credible provider networks across all medical specialties. They also have to show they have contracts in place and that appointments are available.
Medicare (original), on the other hand, is not held to similar standards. In addition, docs are leaving Medicare due to low reimbursement. The result? Inadequate networks of providers across specialties and across the country. If Medicare was a private health plan, this situation would be blatantly unacceptable.
If you’re on Medicare and having trouble finding a qualified mental health professional, here are some tips. And, if you’re uncomfortable advocating for yourself, enlist the help of someone you trust.
Explain you’re paying out-of-pocket to a provider who doesn’t take Medicare; ask for a block of sessions at a discounted price.
- Contact Medicare for a list of participating mental health providers. Call 1-800 Medicare. Verify current participation.
- Use these national resources:
National Institute of Mental Health Information Line:
Provides information and literature on mental illness by disorder for professionals and the general public. Call: 1-800-647-2642
- National Mental Health Association:
Provides information on specific disorders, referral directory to mental health providers, national directory of local mental health associations, and a Stigma Watch. Call: 1-800-969-NMHA (800-969-6642)
- Share your story. Giving voice to the problem is essential for positive change.
Whether you’re trying to get through the health care maze on your own, or need to engage the services of a health advocacy group, such as Health Champion, one thing is certain: you need unbiased, credible, up-to-date information. That’s what you’ll find here.
Through this blog, our goal is to help you become an empowered health-care consumer. And, because we’re a private advocacy company — without ties to government or insurance companies — beholden to no one — you can count on us to be in your corner. We commit ourselves to honesty and integrity. We’ll share what we know, offer our opinions, help you find answers, and give you information you won’t easily find elsewhere.
Over the past few years, there has been a growing need for health advocacy, giving people somewhere to turn . . . someone who will support and promote their rights within the health care system. Health Champion is answering that call.
We’re a young company with passion and experience; all of our established health care professionals are dedicated to helping people navigate today’s complex system, finding the answers they need when they need them. We work with individuals and families on a variety of levels, privately or through their employer.
We’re excited about starting this blog, a natural extension of our commitment and outreach to health care consumers. Look for a new post every Wednesday, where we’ll write about everything from health care reform to making wise medical choices to getting the most from your benefit plan. Be prepared for topics such as Ten Stupid Things in Health Care Today, Shopping for Colonoscopies, and What Reform Will Mean to You.
We welcome your comments and look forward to a lively exchange in the months ahead