About a month ago, I went to the store up the street to pick up a prescription medication for my diabetes. The clerk behind the counter told me I owed close to $50; I was stunned. I told her that my medications are supposed to be free, which they are. She checked on it and again it came up that way. She then picked up the phone and called. When she got off the phone, they told her that the new policy had just kicked in four days earlier. I told her that made no sense, that we hadn’t received anything in the mail, and to hold the prescription because I was going to have my wife check with her employer, since I’m covered under her insurance. It took a week of her employer wrangling with the insurance company, but in the end everything was corrected and I got my medication for free.

Fast forward to earlier today. I had to go pick up more prescriptions and the same thing happened once again, this time for another of my medications, one that cost drastically less than the first. I told the clerk, a different one than the last time but someone I’ve talked to over the years, that the same thing had happened a month earlier. She called the insurance company, got hung up on twice, and then when she finally did get to talk to someone, that person was rude to her on the phone. She was also told that the new policy had just kicked in four days earlier; hey, déjà vu!

I told her to hold the medication and that this time I was going to take care of it myself. After all, I am a health care consultant, right? I came back to the office and called the insurance carrier and asked to speak to a supervisor. I was told the supervisor was at lunch, so I left my information. When I was asked what it was about, I told the representative that I believed I was a victim of insurance fraud by their company, and that I had witnesses and expected a call within the hour. I also told her I was a health care consultant, so that she wouldn’t think I was just another patient calling up with a gripe.

I got my call in 35 minutes and immediately told my story. I told him that in just over a month the store where I’d picked up my prescriptions had been given what amounted to a lie to tell me, the consumer, in order to get me to pay for what should have been totally covered. I said it reminded me of the book The Rainmaker by John Grisham, where the insurance company was told to deny every claim up front, then deal with complaints if they got any later on. The truth is that at least half the people who show up at the store and are told they now have a co-pay are going to pay it without question, even if they are upset, and in essence that’s fraudulent. I told this supervisor that I was a health care consultant who has articles published in two national magazines and that I was inches away from outing his company publicly. I also indicated that the hospital where my wife worked was an almost 600 bed hospital, and that I had a direct quote from someone in human resources that switching over to this insurance at the beginning of the year was turning out to be one of the worst mistakes they’d ever made because they were getting so many complaints from their employees. All of this is true, by the way.

The gentleman apologized profusely, stating that they know the policy for all diabetic medications is that they’re covered in full, and that his company actually contracted with another company to pay the claims, but that they must have their information incorrect. I pressed, saying that wasn’t good enough because many other patients were going to end up paying out of pocket expenses they didn’t owe, especially with that made up excuse of when the new policies kicked in. I know that any time there’s a change in an insurance policy that subscribers are supposed to be given at least a 30-60 day notice, but also that insurance companies that cover major corporations are not allowed to change benefit structures during the benefit period, having to wait until the benefit year is over.

My issue was handled within 5 minutes, as I received a second call saying they had called the store where I get my prescriptions and taken care of me. Still, as satisfied as I am that I shouldn’t have this issue again, I’m still wondering what will happen to the next diabetic patient that walks into that store, or any other, and is told they owe a co-pay amount that they really don’t owe. The main company is a subsidiary of a major pharmaceutical chain that’s known for its customer service, which I found interesting; obviously, they haven’t been able to extend any of their own policies towards their contracted payer.

I write this as a warning to anyone who ever has questions about a changed medical policy that doesn’t make sense. I do know that there are some people in 2008 who suddenly owe major co-pay dollars based on what’s known as Tier 4 pharmaceuticals, high end drugs that, because they’re for special illnesses (as in, there aren’t a lot of people who use them compared to the general populace), including HIV, are much more expensive to produce, but those families were sent the required notifications before the new policies kicked in, and, unfortunately, like many other people, they didn’t read the letter when it came, or didn’t understand it, and therefore were caught off guard. There may not have been anything they could have done about it anyway, but at least they’d have known and possibly could have made some other arrangements. Always question, verify with your employer first, and once you know where you stand you’ll have some idea of how to proceed.

But don’t ever be the victim.