Do you have any advice about dealing with insurance?
Health care costs can be very high for some patients and families and can add up over time. Some patients qualify for Medicaid based on family income. Most states also have a way to access Medicaid as a secondary insurance due to medical needs of the patient; in Massachusetts it’s called Common Health. If patients have medical needs that require significant medical attention yet the family income is too high to qualify for Medicaid, the patient might still qualify for Medicaid based on medical needs. The way the states run their Medicaid is different, so I encourage families to either go online or go to the Medicaid office and ask to speak to somebody and ask what Medicaid programs are available for children with medical needs. Ideally, someone can help match them up through it, whether they ask to buy into Medicaid or whether there’s a version or a level of Medicaid for kids who have medical needs. It’s not quite the same for adults.
The point of having a secondary insurance is that all the costs that are not covered by the primary insurance should be covered by the secondary insurance. For example, things such as copays, deductibles, and copays for prescriptions are usually covered by the secondary insurance. Therefore the out of pocket expenses for a family are the private insurance premiums and the deductibles.
Brooke Corder, MSW, LCSW
Do you ever have any contact with insurance companies?
MBS: Sometimes we do, if they need a provider to speak to a physician at the insurance company about what we ordered and why. We often have to explain the imaging studies we are requesting and explain to them why the study has to be done in a certain way.
ES: For out of state patients, we often are involved with insurance clearance for procedures. We are asked to provide information on the diagnosis, treatment recommendations and why the patient cannot be treated in their home states or by local physicians. Sometimes procedures (for example sclerotherapy or laser treatments) are thought to be more cosmetic instead of for pain relief or functional improvement due to lack of understanding about the diagnoses.
MBS: My impression, too, is that some insurance companies think that these are cosmetic issues. For example, they equate a young child with venous malformation with older adults with varicose veins. We have to discuss symptoms such as pain and swelling and increased clotting risks that can differentiate these conditions. It’s not cosmetic at all and we call or write letters explaining the need for medically necessary care and treatment..
ES: Another example of speaking with insurance companies is clearance for compression stockings for patients that have lymphedema or Klippel-Trenaunay. Educating the insurance company team on prevention is helpful. For example, down the road compression garments could prevent swelling from getting worse, maintain skin integrity and decrease risks of infections thus preventing the need for possible hospitalizations or treatments.
Erin Spera, MS, CPNP and Mary Beth Sylvia, MS, FNP-BC