Posted on Tuesday, 16th November 2010 by

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For 25 years I have had moderate to severe asthma, often sending me to the emergency room wheezing and hacking.  Four years ago I began using an amazing new drug that controlled my symptoms, allowed me to back off the steroid medications, and kept me from those late night visits to the ER.  However, since I have only had the HMO insurance provider for the past three years, they had no past history of those prior, frequent ER visits, and my Federal Employee Health Benefits (FEHB) insurance provider recently decided there was not adequate justification of my need for the prescription.  The FEHB provider refused to cover this medication – even though it was prescribed by their own HMO doctor — and the insurance company required that I use the same medication I used 15 years ago, which did not adequately control my symptoms. This old drug is significantly cheaper.

Regardless of whether a private sector for profit company or a future government entity such as Medicare controls our health care needs there will be coverage limits and treatment conflicts that will need our personal intervention.

There is really no debate that America has the best health care facilities and the best educated doctors, but do we have the best health care available?  I know my doctor must be frustrated that her professional medical opinion was undermined by an insurance company clerk reading the procedures manual.  This happens across the board today because we have finite resources and Medicare must make these same determinations. We may have to provide proof to whomever must justify needed treatments and medications so it is best to be prepared and know what steps to take in your personal situation

What can you do if you find yourself in a dispute with your FEHB insurance company?

1.      Understand that YOU are the master of your own health.  Research the medications and medical options available and understand what is best for your health and why.  Keep copies of your medical records, recording past treatments and dates.

2.      Call the insurance company’s customer service center to understand the reason for any denied claim.  If possible, try to work through the insurance company’s process, providing them the information they are requiring.

3.      Request reconsideration of a denied claim from OPM by following the directions at: http://www.opm.gov/insure/health/planinfo/consumers/index.asp

4.      Consider selecting a new insurance provider during open season.  This may mean you have to change physicians or hospitals.  Do your research to make sure the new insurance company will cover your needs.  For information about the insurance providers available in your area see: http://www.opm.gov/insure/health/planinfo/index.asp

I resolved my dispute by following the procedures listed above. I wrote a lengthy letter to my doctor about my medical history and called the insurance company for a copy of their denial letter so I could submit it to OPM for reconsideration.  The next time I went to the pharmacy, I found they had approved the Rx.

This is not the first time I encountered this situation.  Not long ago my father went to the doctor because he was having breathing problems and spitting up blood.  Since he was a long-time smoker we all feared the worse.  However, when the x-ray came back negative, the physician began treating the symptoms of a bronchial infection.  As the symptoms continued and worsened, they tried other treatments to address the symptoms.  Eleven months later, the doctor finally had enough justification to order costly CT and MRI exams.  The tests confirmed my father had stage III-B lung cancer.  He only lived another six months after that diagnosis.

After the tumultuous health care debate over the last two years, there are sure to be many changes and much confusion on the part of health care providers, insurance companies, and patients alike. Whatever you think of the changes it is important that you understand your treatment options, advocate for needed treatments and medications, and take the time to understand your insurance benefits. It is also important to carefully review any claims or reimbursements from your health insurance provider.

FEHB Open season this year runs from November 8th through December 15th. If you aren’t receiving the care through your plan that you deserve investigate other options.

Linda Duncan

While the publisher and author have used their best efforts in providing retirement and benefits information, they make no representations or warranties with respect to the accuracy or completeness of the content of this article and they specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. The advice and strategies contained herein may not be suitable for your situation. You should consult with a financial professional where appropriate.

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