How hard are you willing to fight to bring about change? If a new medical treatment is denied by your health insurance carrier, are you more likely to go back to the old way, or to try and try again to get your health insurance company to reconsider? Kerri Marrone Sparling, a Type 1 diabetic, is trying to get her health insurance carrier to cover a continuous blood glucose monitor. Disclaimer: I’m not a doctor. I don’t have diabetes. My authority on this subject is basically nil. And my knowledge about CGM for people with diabetes is what I’ve read today on Kerri’s website. But I can see the logic in continuous glucose monitoring. And I’m impressed with her tenacity in the face of repeated denials from her health insurance carrier. The letters she has written to her insurer are clear, concise, and include detailed price comparisons of CGM versus conventional testing (turns out the health insurance company would actually save money if she were to switch to CGM, but that little nugget of knowledge hasn’t done the trick yet) I found it especially interesting to note that in Kerri’s letter after the second denial, she explicitly tells her health insurance company that she’s considering pregnancy in the relatively near future. Health insurance companies are required to cover complications of pregnancy just like any other illness. So when an insured with diabetes gives her health insurance carrier a heads up that she’s planning a pregnancy and would like to wear a continuous glucose monitor in order to ward off wild swings in blood sugar, it seems to me that it would be prudent for the insurance company to do whatever they can to assist her in managing her diabetes as closely as possible. But that information hasn’t done the trick yet either.
I wish Kerri the best of luck with her endeavors. Appealing a claim or pre-authorization denial from a health insurance carrier isn’t easy. Health insurance companies want to make money, while the insureds want to save money and stay healthy at the same time. Sometimes it can seem like the two agendas are at odds with each other. But it’s important to remember that the people in the underwriting and claims departments at your health insurance company are just that: people. They are in the unenviable position of having to make decisions that please a lot of different interests at the same time (insureds, share-holders, state insurance commissioners, and their own bosses). But don’t be afraid to try to convince them to see things your way. Show them logic. Show them details. Show them science. Show them respect (Kerri’s letters are a perfect example of all of these things). If you don’t get a receptive audience the first time you call your insurer, try again. Get names, write letters, thank people who help you.
We work with all of the major health insurance carriers in Colorado, and I talk with people from most of those companies on a daily basis. And almost all of them go out of their way to be helpful. The appeals process can be long and painful, but if you think you’ve got a good case, don’t give up.
A big thank you to Theresa Chan from Rural Doctoring, who hosted Grand Rounds this week, where I found Kerri’s article.
