Insurance Lessons Learned

…In the School of Hard Knocks

david vs goliath corpBecause right now I’m doing a lot of insurance related things I thought I’d share some “tips” drawn from my own experiences.

Disclaimer:  EVERYBODY is different. I believe these tips to apply to most people but you need to double check when applying them to your own situation.

None of this stuff is new, there are tons of sites out on the Interwebz that can tell you this stuff…

HOWEVER…  whatcha get here is proof that those “tips” — well these “tips” actually do produce results.  I’ve “been there” and “done that” and have the battle scars to prove it.

So, hopefully my experience can help you minimize the pain of dealing with insurance companies whose primary goal is to make money.

You gotta know the rules

My personal experience has shown me that “Insurance companies are NOT your friends“.  Insurance companies are not there to make you healthy or to get you healthy.

They are there to make money. They are a BUSINESS and the less that you use your insurance, the MORE money they make.

Which seems counter productive from the view point of us folks who NEED the medical services.  The insurance company will say “NO” unless they are required by law or by contract to say “yes”.

Don’t misunderstand me — I am not advocating that you try to stick it to the insurance companies and rack up unneeded medical costs.  That is called “fraud” and will get you in trouble.  But what I am saying is that if you and your doctor think you need it then make the insurance company do EVERYTHING it is obligated to do.

Insurance companies are restricted by laws and by the contract to which you agree when you buy the policy.  But they are counting on your ignorance to not utilize all of your benefits.

And they do NOT make it easy to figure out exactly what you can get.  sigh

To protect yourself, you will need two VERY IMPORTANT DOCUMENTS:

  1. Your Policy Handbook — This is your contract with your insurance company. It has TONS of information about your benefits under the policy and sometimes has forms and/or procedural information.  Often, near the front is a “summary chart” that gives you the basics of your policy including Out of Pocket Maximums, Copay information for doctors and drugs
  2. Your Drug Formulary — This is a list of the drugs which are covered or not covered under your policy and the level at which they are covered.  Prices and coverage vary from plan to plan even within the same company.  (see the above disclaimer)

Often these are available online either as a webpage or as a PDF file.  The Drug Formulary is often available as a searchable interface online.


Save a copy of every email sent and received.  EVERYTHING!!!!


Because if push comes to shove and you have to do some pushing to get the insurance company to do what they are supposed to do, then you need to be able to document what happened and when.

  • Download a copy of the PDF versions of the Drug Formulary and the Policy Handbook and save it to your computer
  • Download and save a copy of every claim paid by your insurance company.
  • GET A PAPER VERSION OF YOUR POLICY HANDBOOK!  Sometimes there is no replacement for paper.
  • Save receipts for all medical expenses, including the Rx information that comes with the drugs when you pick up your prescriptions.

Actually READ your policy handbook…

…and any other information that your insurance sends you.  Yes, I know it isn’t fun, but the point is:


And you need to hold them to it!!!!  This isn’t “scamming” the system.  This is getting what you paid for.  In my case it is getting what I paid for with the assistance of my fellow citizens paid for in the form of subsidies from the US Government thanks to the Patient Protection and Affordable Care Act.

Deductibles, Co-pays, and Out of Pocket Maximum


…are what you pay up front when you get a medical service.  These are usually written on your insurance card.  It helps with real examples so, here are my basic co-pays for my current Insurance Plan: Silver HMO 004 with Blue Cross Blue Shield of Texas

  • Primary Care Physician – $20 per office visit
  • Specialist – $40 per office visit
  • Tier 1 Generic drugs – $0 (free)
  • Tier 2 Generic drugs – $10
  • Tier, 3 & 4 – Preferred & Non-preferred Non-generics (Brand names) – depends on the drug
  • Tier 5 – must have pre-authorization and the amount I pay for the drug depends on the drug

Get the idea?


This is what you have to pay at 100% before the insurance will pay anything.  And the deductible amount is all over the map.  From zero to 5,000 or more.  NOW do you see why knowing this stuff is important?  On this one, my deductible for medical is zero.  Yeppers, you read that right, zero. My dental is $75.

Out of Pocket Maximum

This is the MOST that you’ll ever have to pay for the entire calendar year.  Mine is $500.  I just passed my max Out of Pocket so…


So, whatever the negotiated price for a procedure, office visit, prescription etc that exists between the insurance company and the service provider, well the insurance company now pays the full amount.  No more co-pays for the rest of the year!!!!!!!

Yay!  See? Get it?

EVERYTHING is negotiable

You can haggle with your doctor.

You can haggle with the lab.

You can haggle with the dentist.

You can haggle with the specialist doctor.

You SHOULD haggle with them.

You’d be surprised how many times you can negotiate the price and how many times they say ‘YES’.

It makes a lot of sense when you stop and think about it.  Either they negotiate and get a lower amount from you AND the amount the insurance will pay.  Or you decide you can’t afford it and they get nothing.

Do a Google Search for “negotiate doctor hospital medical” — there are TONS of articles, but here’s a really good one from WebMD:

How to Negotiate Your Medical Bill

There is often a cheaper option

This applies to drugs more than anything else but it also applies to procedures and labwork.

For drugs, use generics wherever possible.  Tell your doctor that you want the “generic OK” box checked on the prescriptions.  If your doctor checks the “fill as written” box then the drug store can not use anything but the brand name they write on the prescription, even if a cheaper generic version is available.

Ask your doctor if there is a less expensive test or procedure to get the same results.

Ask your doctor to schedule expensive procedures and/or referrals to specialists (if medically possible) for AFTER you’ve met your out of pocket maximum for the year.

Check to see if an “Over the Counter” drug is still available as a prescription

This is where having that formulary comes in handy. When your doctor mentions that an “over the counter” medication will do the trick, Zyrtec for example, ask your doctor for the “chemical” name of the drug or do a Google search on the Internet.

Then once you have the chemical name of the drug, to to your Drug Formulary and do a search for it.  TahDAH!  If it is in the formulary you can then ask your doctor to write a prescription for the drug even though it is available off the shelf or “over the counter.”

Sometimes the Rx is higher cost than the over counter, but SOMETIMES, it is cheaper.

My doctor has prescribed me one drug and one vitamin supplement, both of which are currently available both as “over the counter” or as a prescription.  In both cases the PRESCRIPTION is cheaper than the bottle that you would grab off the shelf out in the aisles of the store.

In my case, normally, through most of the year, each of these drugs have a small copay/negotiated price of under $10.

However since right now I have met my Out of Pocket Maximum, my copay is ZERO.

Don’t be afraid to file a complaint with your state’s Board of Insurance

I have.  And it worked.

I was amazed at how quickly the insurance company moved after I uttered the words “I have filed a formal complaint with the Texas Department of Insurance”

What did I want?  — I wanted a paper copy of my policy handbook.  That is a pretty basic kind of request and the insurance company will try to steer you to their website or email you a PDF copy.  But I needed a PAPER copy so I could take it into the doctor’s office with me and my doctor and I could both look at the same thing, at the same time, in PAPER!

And if you ask this is something the insurance company is REQUIRED BY LAW to send you.

After repeated requests and 3 months had gone by and I still had not gotten my paper copy, I pulled out the “nuclear option” and filed the formal complaint.

I had the paper copy a week later.

And I’m about to do it again.

I have pimples.  There.  I said it.  For whatever reason, I am over 50 and I still get bumps.  Quite frequently.  Mostly now on my arms, shoulders and torso, where I have lots of hair.  Yeppers, that’s an image that will be stuck in your head for a while.

Sometimes they pop up on my face, on my nose or ears, usually under my beard; not as often as on my shoulders and back, but enough so that I want a cream on hand to handle it when it occurs.

Anyway, for years, since 2001, my doctor has been prescribing me the generic version of Retin-A which is called Tretinoin.

And it works awesomely.

Then I lost my job and my insurance in 2012 during the “great recession” and that cream went away because I could not afford the $270 retail price for the friggin’ generic!  Yes!  The generic price is $270!!!!!  Sheesh!

Why? well because after folks got rid of their pimples, they noticed something really cool.  They didn’t have as many wrinkles.  Yeppers, Retin-A aka “Tretinoin” can be used for cosmetic purposes by folks with no pimples, on their wrinkles.

So, insurance companies put a “age restriction” — if you are over a certain age, the drug is not covered automatically.  You have to get a “pre-authorization” to get it covered as medically necessary.

Basically what happens is that you have your doctor fill out a form.  The doctor says “This dude has pimples and needs the cream”  and up til now that’s been that.  EVERY OTHER INSURANCE COMPANY I’VE HAD SINCE 2001 has approved the drug.  And my copay has been zero – $15 depending on the insurance company.

[dramatic drum roll please]

Blue Cross Blue Shield of Texas is saying “no” — they in their infinate wisdom have overrulled my doctor(s) and said “nope” you just have to live with the pimples or pay $270 to get the tube of cream.

And it isn’t like I smear the stuff all over me every single day.  I use it when a bump pops up.  Right now I have a lot of them, but normally we’re talking 2, maybe three tubes a year.

Let’s review:

  • My PCP (primary care physician) last year determined that “yes” I have acne and I need this drug
  • My PCP this year determined that “yes” I have acne and need this drug
  • I can show you photos of my bums if ya really wanna.  Ewwwwww!  Ick!  Although I’m told that the “zit popping” videos on YouTube get amazing numbers of hits… Hmmm….  (moving on…)
  • EVERY other insurance company that I’ve had since 2001 has approved the “pre-authorization” request
  • But BCBS says “no”

And I can prove EVERYTHING I’m saying because (see above tip) I have the documents.

Well, yesterday, I’d had enough.

After trying two years running with two doctors and after calling the customer 800 number, I sent them an email through the customer portal.  If they continue to deny coverage of this drug as a generic, then I am going to file a formal complaint with the Texas Department of Insurance in Austin.

Hopefully they’ll realize that they don’t have grounds to deny the drug and that it will be easier and cheaper for them to just pay for the medicine instead of spending the time, effort, and money to defend themselves against a formal complaint investigation from the state board of insurance.

Don’t know how it will turn out but we’ll see.  Their ass is probably well covered by some teeny tiny clause in the several hundred pages of paper…. Grrrrrrrrrr   Gotta stop.  My blood pressure is going up.

Wish me success.  There’s no battles like the David / Goliath battles.

Summing up…

You’re paying for a service.  But the insurance company will do only what it is required by law and by your contract to do.  Nothing more.  But if you don’t know that they are required to do something, then you may be missing out on benefits that you are not “entitled to” but which you are paying cold hard cash to get.

Do your homework.  Document everything.  Don’t let them get away with anything.

I’m exhausted.  Dealing with the insurance company should NOT BE THIS FRIGGIN’ HARD!

And I despair that it will get better.  Don’t get me wrong,  I am very grateful to have insurance at all.  If not for the ACA, I’d be on my way to a cozy spot six feet under.

But wouldn’t it be nice if instead of “doing battle” with the insurance company, you just got what you needed, no fuss, no bother.  There is something fundamentally wrong with a model that sets up an adversarial relationship between the customer and the business providing the service.  Where it is in the business’s best interest to say “no” and where the customer who is PAYING for the service must dig through pages and pages of complicated legalese in order to determine IF something is covered and at what level then dig through tons of OTHER pages to determine the procedure to get the benefit.

Something has got to change.  We can do better than this.  So…  [heads up–I’m about to talk politics for about 60 seconds]

… if you are as pissed off as I am about how our medical system works, and you think it could be better, SHOULD be better…

then I invite you to listen to what Bernie Sanders has to say on the subject.  I’m voting for him.  At least do some research on him and his policy positions.  You may be surprised by how many of them with which you agree.

See ya on the dance floor!


About TxCowboyDancer

Professional Dance Instructor teaching Country, Ballroom, Swing, Latin and Line Dance. Eleven time Country Dance World Champion.

Posted on Fri, Oct 9, 2015, in Tony's Tips and tagged , , , , , , , , , . Bookmark the permalink. 1 Comment.

  1. Very informative, Tony. Thanks! ~Charlie


Join the discussion or just say "Howdy"

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: