Anyone living with type 1 diabetes knows firsthand what a nightmare calling your insurance provider can be; repeating yourself constantly, defending your right to have the services and the medications that you need in order to live and function like a normal person. This is rarely anyone's idea of how to spend an afternoon. We get it. With the help and expert guidance of Dr. Ann E. Goebel-Fabbri, We Are Diabetes has developed a helpful "How-to" of tips and important things to keep in mind during your next phone date with your insurance company. We hope this information helps you avoid future headaches and overall frustration!

-- The Phone Call
-- Helpful Hints to Avoid Future Headaches
-- Preventing Denials and Appeals
-- Important Links


The Phone Call

Before you call:
  • Have your insurance card and any other information you might need right in front of you. Most insurers have different phone numbers for medical coverage and mental health coverage. Make sure to call the correct number for mental health, it is typically on the back of the card. Most mental health coverage does not require referrals from primary care doctors. Instead, insurers require something called "authorization," which you get when you call the mental health number directly. Make sure you also have any other important paperwork at arm's length that you think you may be addressing during your call.

  • Make sure you know exactly what you're going to ask. If you have a question that you can't fully articulate, don't call until you know exactly what you're going to say. If you have more than one question or it's a complicated situation (we type 1's have a lot of those, don't we?) write down what you need to address as well as the questions you want to ask before you pick up the phone.

  • Make sure you've gone to the bathroom, get yourself a drink (maybe a snack, too) and have a good book or other things to do close by. Seriously. This process can take a while.

  • Make sure you have allotted a good chunk of TIME. The phone call could be easy; you could get all your questions answered and your issues resolved in less than five minutes. Or you could be on the phone for the next two hours. Get comfortable either way.

  • Make sure your blood sugars are stable. You want to be in the best possible frame of mind when you repeat yourself over and over again.

  • Grab a writing utensil and some paper. Take a nice deep breath.


During your call:
  • Remember: Insurance companies are a business. They make money when they get to ration out what services they will cover. They must in some way count on most people taking no for an answer without pushing back and advocating for themselves. When you have a chronic disease like type 1 diabetes, you owe it to yourself to make sure you get the care you know you need.

  • Speak as clearly and calmly as you can. Try to remember that the person on the other end of the call is just doing their job; they have a family and bills to pay, too (and they probably wish they could help you a lot more than they are "allowed" to help). It's easy to feel angry and upset about having to fight for your right to equal care when you're living with a chronic illness, but try to remember the saying, "You can catch more flies with honey than with vinegar."

  • Write down the name(s) of the people you speak with and the date and time of the call(s). You can even make notes about who said what in case you need to clarify these conversations later when fighting a denied claim.

  • Remember to be assertive and DON'T GIVE UP! Self-advocacy means speaking and acting for yourself. It means deciding what is best for you and taking charge of getting it. It means standing up for your right to the health care you need. You will be more likely to get what you want/need if you are assertive. Being assertive means that you talk respectfully and professionally to others and communicate effectively. Don't be someone who chooses to fight or argue instead of talking calmly about the problem. Arguing will get you nowhere.

  • Speak with the right person. Be willing to get bounced around from one extension to another; one phone number to another. One example of being assertive is to ask to speak with a supervisor (sometimes called a Clinical Reviewer or a Case Manager) if you are not getting what you need from the health plan representative.

  • Your health is important and you deserve to be healthy. If you are denied, file an appeal. Just by filing an appeal (referenced here and there), you greatly increase the chances of your health plan saying yes to the service(s) you want/need as it will force them to take another look at your claim. Ask for help from family members, friends or other advocates (like us) whenever you need it! Sometimes just taking a friend or family member to an important appointment or meeting will make every bit of difference.

Helpful Hints to Avoid Future Headaches

  • GET ORGANIZED. This is the most important thing to do! If you cannot find important documents, or if you don't remember whom you've spoken with, you will lose out. Period.

  • START A FILE. Keep all of your paperwork together in a binder or drawer so you always know where to find them. Put all papers about a specific service in its own folder.

  • KEEP A COPY OF EVERYTHING. Keep copies of all of the letters you receive from your health plan. Also, keep copies of all of the letters and other records that you send to your health plan, especially letters written by your doctor or health care provider. Health plans are big companies and it is easy for your paperwork to get lost.

  • KEEP A RECORD OF PHONE CALLS. You will talk to many, many health care providers and health plan staff. When you call about your health care, have your insurance card nearby with your member and/or group number at the ready. Write down the date, name of whom you spoke with, their title and what was discussed. You'll thank yourself for this one someday.

  • MAKE A LIST OF YOUR PROVIDERS. Keep an updated list of the names, addresses and telephone numbers of your health care providers. This will make your life a lot easier.

  • KNOWLEDGE IS POWER: KNOW YOUR POLICY. To be a good consumer you must know about the products you buy. Know what services your health plan is required to provide. You should always know the following basic information about your health insurance plan:

    • What services are covered?
    • Which doctors or providers am I allowed to visit?
    • When do I need a referral?
    • When do I need a prior authorization?
    • How much do I have to pay out of pocket?

Preventing Denials and Appeals

The best defense is a good offense. You can prevent a denial and the headache of an appeal if you get your doctor involved early in the process. Your doctor and other health care providers are key to helping you get the health care you need. They are busy individuals so you must be forthcoming and ask for the help you need.

  • Letters of Medical Necessity
    The most common reason a health plan will deny a service is that they do not have enough information about you and the service you need. To avoid this problem, ask your doctor or health care provider to write a letter of medical necessity and send it with the request for service. The letter should have the following:

    • Your medical condition with exact diagnosis.
    • How long your condition will last.
    • Why you need the service and a description of the service.
    • What health problems will occur if you don't get the service.
    • What other treatment or services were tried, if any, and why they did not work.

    The doctor can ask the health plan to call him or her with any questions about the letter. You can also get letters from any health provider or other professional who knows about your condition and why you need the service.


  • Medical Records
    Your medical records can help prove to your health plan why you need the service. Ask for copies of your medical records. Ask your doctor to send in copies of medical records that support their letter of medical necessity.

    Decisions on whether a service is medically necessary are usually made by a doctor who works for your insurance provider under the health plan you are covered by. If your service is denied, call your insurance provider and find out what doctor or professional made the decision to deny your service. Ask your doctor to call the health plan directly to discuss your condition and the service you need. Sometimes the health plan will change its mind after discussing your situation with your doctor. Getting your health care provider involved early on will avoid denials and appeals and get you the services you need faster.

Are you ready to fight a denied claim? Read these articles first for some great tips!
The Mental Health Parity and Addiction Equity (MHPAEA) FAQ - Know Your Rights!
(Please note: This resource is very long but VERY useful!)
Here is a very helpful article from NEDA and Eating Disorders Coalition regarding how to fight insurance issues (another long but good one).


 


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The Eating Disorders Information Gateway is a resource offered by the Eating Recovery Center Foundation that provides a single portal through which the eating disorders community can access a variety of materials to advance public understanding of eating disorders.
 

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