I would like to share my recent journey through the healthcare system for the sole purpose of showing that the same issues came up for me as they do for you. The difference is I was able to anticipate, plan, and avoid any consequences. I hope you can learn from this, I sure did! It made me even more dedicated to doing the work I do because it is a scary and complex system out there!
As a result of a major and complicated surgery I had eleven years ago, I needed a procedure to correct a side effect from this surgery. This procedure was to be a closed endoscopic procedure but yet was still complicated. There are not many people with my issue and therefore there are not many gastroenterologists with this experience.
I needed to get some diagnostic tests . My first experience is what many people experience. My CT scan was denied by my insurance company in the late afternoon of the day before the test! Infuriating! A lot was riding on getting that test that day. I called my local specialist and requested he hop on a call to do a peer to peer review with the insurance company physician. It was approved within five minutes but only after much time spent with the call answering representative and much aggravation by my specialist, who has to go through this administrative pain regularly. The insurance physician had made incorrect assumptions on past testing and therefore denied coverage of the test. Are these the best physicians to be making those decisions? I think not!
Next stop was an intensive search, by me, of the peer to peer journals and clinical data on this issue and procedure. I gained in-depth knowledge on “everything” possible and developed a list of the few experienced gastroenterologists in the area. Next, I interviewed the top two gastroenterologists in the area and took careful notes. I liaised with my local physician to discuss the details and the decisions to be made. The next step was determining who and what was covered by my insurance company. I also obtained a third opinion out of state at a big center of excellence to gather more data. After all of this, I reviewed all of the information and made a decision mostly based on expertise but partially based on my insurance coverage.
I was reminded of the importance of the following steps as you journey through the healthcare system.
Make sure your diagnostic tests are approved ahead of time. Call the provider to make sure that the authorization process has been started on their side.
Verify that the test is authorized directly from your insurance company.
Do your research.
Review the experts in the field and obtain second opinions with them. Get the number of procedures and surgeries they perform in a year and compare to others.
Know what your insurance will cover and especially in the event of a complication or emergency.
The list can be much longer depending on the circumstances. I want to report that all went well with the procedure, despite the “glitches” to overcome. I was grateful to be surrounded by advocate colleagues who are very smart and assisted me every step of the way. I am also fortunate that I am closely connected to man physicians that are willing to collaborate with me. It takes a village to safely get in and out of the healthcare system! Don’t go it alone....
Just know that a private patient advocate is one of the best guides you can have by your side when you are challenged with a health issue.