How Not to Have a Panci Attack When Your Insurance Company Denies Your Claim

When I ordered my monthly prescription from my specialty pharmacy, I knew I would have to pay a large amount because it was my first order of the year and I needed to meet my deductible under my prescription drug plan. The sales rep told me the price, which was large, but I knew it would be in that range.

No problem.

When I went online to check the order status, the invoice said my insurance company had not paid its share, and the outstanding amount set my heart racing. It was four times what I had already paid. It was a LOT of money. Cancer-fighting drugs are expensive.

I tried to think logically in this illogical situation.

My heart raced.

My mind spun in 100 directions.

My normal life of stability was upended.

What to do?

1. Take a deep breath. Or several deep breaths. Your heart is dashing, your mind is exploding, and your blood pressure might spike. Breathing helps you get close to your normal range. Close to, because the news’ll still flummox you. Try to stay calm, which is easier said than done.
2. Check your facts. Review your insurance provider’s statement. Is the drug in the formulary? Was the invoice actually paid? In my case, the answers were yes and yes. There should be nothing to worry about.
3. Was there a miscommunication between payers? Or was the communication not updated yet? I’m guessing this happened in my case.

In my case, I think I’m set. But if you see a discrepancy, take these steps.

4. Print out all relevant information, or take screenshots of the invoice, denial letter, and any other relevant paperwork.
5. Call your insurance advocate. You might have an “insurance agent,” but make sure you work with an agent who loves to advocate for you, not just sells insurance. When you enter the medical maze and work with your first insurance person, ask them what their goal is. If they want to sell insurance and never see you again, RUN. If they say they love to beat up on insurance companies, you’ve found your advocate.
6. If you don’t have an advocate, then you must act. Realize that insurance company customer service agents are told to say “no” to any claim, even legitimate claims. They hope you will give up. But don’t give up. Call. Call. Call. Pester. Pester. Pester. In many cases, they will do what they should have done in the first place: the right thing. Google this and you’ll find many articles that prove this point.

Here’s an article that offers more information.

Good luck!