Why Is My Insurance Company Deciding On My Treatment Plan?

By Lois Caniglia

Last year under a well-known commercial insurance company, decided that my pMD would not take part among their network list. Explanation: “you have enough psychiatrists in your area, we don’t need to add another”. What? How dare they decide to break up my continuity of psych care? Especially when it comes to my bipolar treatment. I would not tolerate handling a switch after a two-year compliance under my candy man’s care. In fact, like a diabetic, we are still adjusting or changing medications where needed.

Despite the phone calls, personally made by my pMD, to my provider’s customer service department always ended with a denial. So, I took matters into my own hands and called the company myself. It took hours and days in dispute that the company had no right to change my behavioral health care plan. This literally took several eight to ten hour days of none stop calls being disconnected, not speaking to the same service representative, and supervisors who lack the critical thinking skills like a broken record stating a policy is a policy nonsense.

So, I demanded an accelerated grievance process and called the main corporate office in Louisville, Ky. I finally got some reasonable results and was granted that my doctor will remain in my network. Unfortunately, the company still refused to allow other card members to continue their care with my psychiatrist. If this scenario or something similar has every happened to you with your insurance co, don’t stop fighting. We have the right to be accountable to our patient care. It is tedious work with extended hours on the phone but worth the fight to keep my quality of care maintained.

This year with another Medicare advantages plan; I have to fight again to maintain my continuity of patient care. Only this time it is to retain my therapist. The company has regulated that they will only pay 20 sessions/year. Any additional sessions will have to come out of pocket. I can’t tell you how many times with other professional providers I had to reestablish to accommodate that complied to my insured network. Feel free to yell out “you betcha”, if you have been here and done that. I have yet, to fight this issue but I am certain I will get frustrated enough to do so at some point this year.

These issues are nothing new to me as there has been a historical change from quality patient care to the stronghold policies by healthcare insurances. These strategic/bottom line/business tactics has been creeping its ugliness for several decades. In my nursing career, I have seen the passive aggressive change by insurances in the early 90’s making itself more evident by the year 2000. Throughout the millennium, there has been a blatant affliction that is destroying continuity and quality of care. Surely, somewhere in the foreseeable future will this be the cause for the mortality of certain policy restrictions.

Utilization nursing was a fairly easy job description that required a simple chart review for cost effectiveness. Today, it has become a ridiculous skill of juggling all insurance regulations and their laws. And that is only one small aspect of the job in hospital utilization. Moving on towards the case management role within a commercial company, where I spent several years before throwing in the white towel of my career, was an eyeopener to how powerful healthcare insurance has over the treatment plan for their customers.

Of course, this is just my own expert observation to the effects caused by insurance companies. I can’t poke the blame on the affordable care act, as this legislation was only a dream and not fruition as federal law. From my own resume with insurance providers I have witnessed the rapidly increasing premiums changed with more stringent restrictions identified with a “high risk” title. Numerous disease processes labeled from diabetes to orthopedic surgical procedures gave allowance for denials.

By the time, I reached 50 I was profiled as, in the words of my insurance representative, a “high risk customer” which meant that my premiums will be charged well over $1000/mo and my access to proper care was being restricted that I will have to pay out of pocket. Over the past fifteen years, I have had to change, at the very least biyearly, primary care doctors. Medical records, lab work, radiology studies were displaced or completely ignored whereby, I would have to start over and my assessment was completely amiss that my diabetes wasn’t treated for several years upon onset. How dare a patient/a lowly RN request for an A1C. A blood sugar below 200 is “fine”. This was all going on under a PPO or EPO plan. Go figure. As you can see from my timeline, the affordable care act has nothing to do with the compromise to quality patient care.

This is my own opinion based on work experiences in utilization review and insurance case management. Having obtained a bachelor in science in business and dealing with my own healthcare insurance due to illness. These credentials by no means make me an expert in the business realm of health insurance and hospital accounting but, I felt if necessary to point out that I am not entirely ignorant to this either.

My point leading up to this is keep accountable to your own self-care when maintaining your treatment plan. If you feel your wellness is being “pushed”, push back. I can’t tell you the peace of mind I have knowing that I am able to continue with my psych care as directed. It has been my recent experience of agreeing to change primary care physicians with every change in insurance policies due to increase costs. I admit it can be a full-time job advocating for your own wellness. It can even become exhausting. A change can come but only if we fight for it, kindly demand it, and stay on top of it.

If you don’t have the medical knowledge but feel you are being mistreated, ask. Always ask the why’s, how’s, and what’s. We are more precious than our car engines; let’s maintain our own bodies that way.

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