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How can patients navigate our complicated health care system?

It is not enough to know that a patient’s medical condition warrants an MRI. For most insurance companies, a diagnostic test of this sort requires what is known as a prior-authorization. But, the doctor saying the patient needs this test often fails. The insurance company has a certain guideline the patient must travel first before they will consider the test.

For example, a patient with back pain and numbness in one leg must first do and X-ray and go through physical therapy before the test will be covered. An X-ray is quite a useless test when you are looking for a herniated disc or spinal cord compression. But, the gods of coverage determination found that it is a cheaper test, and you may just give up after that.  And, forcing a patient to endure a course of physical therapy with an undiagnosed condition can be not only ineffective but downright dangerous if there were to be some such condition as spinal cord compression present.

Another example is the “you must try these medications and fail first” before a prescribed medication may be authorized for use. It doesn’t matter if you have been on the same medication and it has worked well for you. Formulary changes don’t care about that. They also don’t consider the fact that forcing an asthmatic to switch inhalers of a diabetic to change medications can have untoward outcomes, even ending up in hospitalizations. What does a failure of a medication mean to the insurance company? You failed the cheaper version, and they may now consider the medication you and your doctor think is the best. What does a failed trial of a medication mean to a patient? Weeks of pain and discomfort with possible harmful complications.

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