Insurers know it’s profitable to discourage patient claims

As Republicans work to repeal Obamacare, they say they want to safeguard coverage for people with pre-existing conditions. 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 is the obstacle course insurance companies and middlemen create for policyholders trying to get claims approved, often for chronic conditions. Industry bean counters have the power to reject drugs or treatments recommended by doctors.

“It’s a moneymaking tactic,” said Carmen Balber, director of Consumer Watchdog. “The companies know that when they deny claims, most people will just give up.”

Not Bill Waxman.

The 66-year-old has had repeated encounters with Anthem Blue Cross and Navitus Health Solutions, which handles his family’s prescription-drug coverage.

His 24-year-old daughter, Alison, grapples with multiple autoimmune disorders that cause chronic pain, migraines, extreme dizziness and debilitating fatigue.

There’s no cure, so he and his wife are resigned to holding jobs for as long as possible to maintain coverage. Still, Waxman estimates his out-of-pocket medical costs last year ran about $14,000.

A recent run-in involved treatment for his daughter’s postural orthostatic tachycardia syndrome, aka POTS, which keeps blood from 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 been shown to lower the heart rate and help a patient find equilibrium. Waxman said they tried samples of the drug and saw “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 with drugmakers 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.

Waxman arranged for a “peer to peer” 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 — and, lo and behold, Navitus approved a year of Corlanor. A Navitus spokeswoman declined to comment.

Last summer, Waxman said, Anthem approved a monthly IV drip to boost his daughter’s immune system. Then in September it reversed course and declared 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 he again prevailed.

Darrel Ng, an Anthem spokesman, attributed the situation to “miscommunication.” Waxman only knows that he’s had to fight repeatedly for his daughter’s health care.

“I’m not asking for a rhinoplasty for my daughter,” he said. “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.

“You have to do all the investigating yourself. You have to become conversant in medicine. You have to find the right people to contact,” Waxman said.

Balber at Consumer Watchdog said the insuers’roadblocks are intentional. “Their main tactic is to deny everything and hope the consumer won’t put up a fight,” she said.

This is the health care system we’re stuck with. So be like Waxman and stand up for what’s right.

— Los Angeles Times