"Embracing my Inner Masshole*" by Kate Funderburk
Do any of you wish for the good old days?
The days when there was no social media, when banks reliably gave out lollipops, when dollar stores had items that actually cost a dollar, and when insurance would just outright refuse to pay for your life-saving medications and medical equipment?
Oh, wait, not the last part? Just Me?
No, I’m not advocating for insurance companies to reject claims.
What I would like is for them to be honest and upfront.
Let’s take an example.
Not terribly long ago, I hadn’t heard in a while about my recent order for my continuous glucose monitor (CGM) sensors. For me, a CGM is a vital part of my diabetes management. After over 24 years with diabetes (yes, this May will be our 25th anniversary, and yes, I am expecting my diabetes to give me something silver), I can no longer feel low blood sugars, so a CGM alarm tells me when my blood sugar is heading into the danger zone.
So I called the insurance company, which will be hereafter be referred to as Inherently Fair Insurance Bros (which will hereafter be referred to as IFIB), where the following conversation ensued:
Me: Hi there–I ordered my Dexcom sensors several weeks ago and I haven’t heard anything. Do you know what’s causing the delay?
IFIB: Hm…let’s see. Oh, we need a certificate of medical necessity.
Me: Like, lab results? (side note: my insurance company requires regular labs before approving CGM supplies, so that they can be assured I am, in fact, still diabetic, because of course they do.)
IFIB: No, we have that. Your doctor needs to confirm medical necessity.
Me: Like, write a prescription?
IFIB: No, we have that.
Me: Prior authorization? (side note: prior authorizations, as many of you know, are the equivalent of the “are you sure you want to complete this action?” button after a doctor has prescribed something, just more time-intensive and with more paperwork.)
IFIB: No we received that as well. We need a certificate of medical necessity.
(And here, my friends, is where the magic begins. A Masshole is a unique term for someone from Massachusetts who is, well…you get the idea. This phenomenon is so common in my area of the country that we take pride in our Masshole-ishness and do not shun such names. And with my unique powers, this is the moment in which I become…Lady Masshole™.)**
Me: Ok, here’s the deal. You’re going to stay on the line. I’m going to connect us both to my endocrinologist’s office, because they’re telling me they’ve submitted everything and you’re saying they’re not and I guess it’s up to me to figure out where the breakdown in communication is.
IFIB: Ok.
(Call endocrinologist. Get somebody on the line who can look into this.)
Endo: Hi, so we submitted the lab work and prior authorization a week ago.
IFIB: Yes, well we also need a certificate of medical necessity.
Endo: Is that a specific form?
IFIB: Yes.
Endo: Provided by you?
IFIB: Provided by a subcontractor of the local supplier.
Endo: Ok, so that company subcontracts with several different suppliers, depending on the insurance plan. Right now we have the contact information for (insert name of supplier here.)
IFIB: Oh, no we changed it recently to (insert name of other supplier here.) They have a different form we need you to fill out.
Endo: Ok, can you send that form over to me?
IFIB: …I’m not authorized to do that.
Sadly, this kind of situation is not at all unusual for me or for most of us who live in the US***:
Another time, due to virtual visits, I had not had my labs done at the endocrinologist’s clinic but at an outpatient blood lab. The insurance will only accept lab results sent by the clinic, and the clinic said they didn’t have access to the outpatient labs, even though my doctor did. When I asked if they could send over the clinic note in which my doctor noted my results, they said that the insurance would only accept a report from the actual lab.
I once was repeatedly told a generic medication was not covered, only to realize that my insurance ONLY covered the more expensive brand-name medication because of a pre-existing agreement between the insurance and that medication’s manufacturer. Nobody thought to clue me or my pharmacist into this when the system automatically defaulted to the generic medication and the claim kept being denied.
Periodically, I have to just switch insulin or test strip brands because my insurance has set up a new agreement with another manufacturer. This wouldn’t be so bad, as the products are basically identical, but it does require a new prescription from my doctor, and with all the scenarios outlined above, you know how complicated that can get.
And God, oh God, do NOT get me started on copay accumulators/maximizers/adjustors/whatever they want to call themselves. (IYKYK)
Now insurance companies will tell you that they just want to make healthcare cost-efficient, that they want to eliminate waste, that they want patients to be mindful of less costly alternatives to current treatment. But the truth is, as you all know, it’s not like there’s a wide selection out there for most of the treatments we take. And I don’t think there’s really a question of whether or not these treatments are, in fact, medically necessary. If a doctor were to say they were necessary when they weren’t, that’s insurance fraud. That would lead to a doctor losing their license to practice, so the chances of that happening are quite slim.
No, there’s a bigger thing going on here. Instead of being straightforward and denying claims, and then being clear about the opportunities available to appeal those decisions, insurance policies keep adding more and more and more requirements and forms and complicated structures to their plans. Over the past five years or so, the frequency with which extra requirements have been put in place has reached a fever pitch.
What’s the result? Well, for someone like me, it’s just a lot of extra wasted time and frustration. But let’s say you were intimidated by all this language or unfamiliar with the workings of our healthcare system. Let’s say you were elderly and lacked the technology skills to look up the information you needed, or perhaps didn’t feel comfortable enough with English to navigate the jargon (or more likely, only speak English and still can’t navigate the jargon), or worked fifty hours a week so you didn’t have the time to harass these people like yours truly does on a regular basis. Perhaps you take care of children or elderly parents or have to spend time, you know, taking care of the illness that has left you with all of these prescriptions in the first place. Perhaps you don’t actually read white papers on this topic as a leisure activity. Perhaps you aren’t used to tapping into your inner masshole/self-righteous white lady/school librarian/insert any expletive you want and you actually wanted to be…pleasant?
Well, in any of these cases, you may very well give up. You’d run out of time, or patience, or just get tangled in webs of everyone trying to toss you back and forth between different entities. And, in the end, you wouldn’t end up getting that life-saving treatment.
And that’s how your insurance wins. Because every time you do not get your treatments, that is another penny they save.
This is not about eliminating waste. This is not about efficiency or health care reform. This is about making it as difficult as possible for patients, particularly the most vulnerable patients, to get treatment. These systems are not complex by nature; they are complex by design. And good luck if you’re trying to make a short phone call to ask a clarifying question, especially if it’s outside typical working hours.
So what can we do?
Sadly, not much.
But there is one thing we absolutely can do.
I am hereby calling on you, yes, you, to tap into your inner Masshole.
“But I’m not from Massachusetts!” “But I’m a nice person!” “But I would never be a school librarian because those ladies are SO mean!”
But nothing.
No, we should not have to fight these battles–especially not when our very survival is a constant struggle. But fight we must.
There are a few encouraging signs. The insurance industry’s unethical business practices and lack of medical price transparency are getting some much needed attention from entities like the Kaiser Family Foundation, the Pioneer Institute, many state legislatures and disease advocacy groups, and prominent figures like Mark Cuban and rapper Fat Joe.
And the one thing that encourages me the most is that we have each other.
Here’s how much masshole-ishness I’ve put into this. I’ve been in contact with the Massachusetts Attorney General’s office, the Massachusetts Division of Insurance, my legislators, the Boston Globe Spotlight investigative journalism team, and been tweeting at a few different podcasts and TV shows to do some reporting on this.
Has any of this gotten through? No. Absolutely not. I’ve been hitting lots of dead-ends. But here’s my promise to you: I’ll keep masshole-ing. I’ll poke more (mass)holes into this problem than a freakin’ woodpecker. I’ll keep poking (mass)hole upon (mass)hole until there are enough (mass)holes that something will have to break through and someone will have to listen and maybe, just maybe, the whole wall of insurance obfuscation will come tumbling down.
And I encourage you, my CF community, to join me, if you haven’t already. In a time when our country is so divided over so much, people generally agree that insurance companies should not be such dishonest brokers.
Massholes, assemble.
*Here’s how obnoxious people in Massachusetts really are. Lots of people can say that they’ve been on the receiving end of the finger while in traffic. But how many of you can say the person giving the finger was actually riding a bicycle? Not a motorbike–a real, honest-to-god two-wheeler. Like, with a basket and a little bell. That has in fact happened to me. Like, more than once.
**Lady Masshole is a term I have not actually trademarked, and if you use it without my expressed written authorization, you will suffer zero legal consequences…or any kind of consequence. But it looks cool if I say I did. And I am nothing if not freakin’ awesome.
***A note for all readers who reside outside of the United States: I apologize for this myopic post which has a decidedly U.S. worldview. I am completely and utterly guilty of this charge, as I assume that Canada and all European countries are magical places where everyone gets all the free healthcare they want, along with personal unicorn rides to every medical appointment. These beacons of paradise are full of sunshine that won’t give you cancer and chocolate that won’t raise blood sugar and babies that sleep through the night, and are overrun by fauns who vomit out magical elixirs that heal all ills, which, incidentally, are also freely available to all. Please do not use the comments section to crush my dreams.