It is not enough to know that a patient’s medical condition warrants an MRI. For most insurance companies, a diagnostic test of this sort requires what is known as a prior-authorization. But, the doctor saying the patient needs this test often fails. The insurance company has a certain guideline the patient must travel first before they will consider the test.

For example, a patient with back pain and numbness in one leg must first do and x-ray and go through physical therapy before the test will be covered. An x-ray is quite a useless test when you are looking for a herniated disc or spinal cord compression. But, the gods of coverage determination found that it is a cheaper test and you may just give up after that.  And, forcing a patient to endure a course of physical therapy with an undiagnosed condition can be not only ineffective but downright dangerous if there were to be some such condition as spinal cord compression present.

Another example is the “you must try these medications and fail first” before a prescribed medication may be authorized for use. It doesn’t matter if you have been on the same medication and it has worked well for you. Formulary changes don’t care about that. They also don’t consider the fact that forcing an asthmatic to switch inhalers of a diabetic to change medications can have untoward outcomes, even ending up in hospitalizations. What does a failure of a medication mean to the insurance company? You failed the cheaper version and they may now consider the medication you and your doctor think is the best. What does a failed trial of a medication mean to a patient? Weeks of pain and discomfort with possible harmful complications.

Many patients justifiably become upset when this happens to them. We file many appeals but it seems no one is listening. While we may win one victory, we are left with many defeats.

The maze of healthcare starts when one enters the system. there are all kinds of plans out there: HMO, PPO, POS, Medicare, Medicaid, and so on. Even within one specific type of plan, the coverage may vary in terms of deductibles, copays, what is covered, etc. There is no answer guide to explain what any of this means. Sure, the patient may receive a packet of benefits. But, it is still difficult to know what it means. A copay for a primary care is different for a specialist is different for an ER visit is different for a hospital visit is different for an ambulatory surgery center.

How to navigate the complicated healthcare system?

Education. The healthcare system is more complex than it ever has been but the best navigational tool for following the maze is education. Patients are becoming more empowered and this is as it should be. Knowing the treatment options help them make the best choices but they should also know their coverage. The best medication in the world is not going to work if the insurance doesn’t cover it and the patient can’t afford it. Many times I have found an insurance company denying coverage on a service they are contractually obligated to cover. This is why it is imperative for patients to know their plan.

Ask for help. The system is complicated even for healthcare professionals. But, they have been in the game for years and have much more experience. If a medication you need is not covered, there may be some routes to bypass this block in the road. Some pharmaceutical companies offer savings that bring the copay down to the lowest so that the copay is no different from generics. Ask!

Fight back. If a service is needed yet denied, don’t give up. Make phone calls, file appeals, and do whatever possible to try to get what you need. The insurance companies bank on the fact that you will just give up.

Find a patient advocate. Yes,there are people whose life mission it is to advocate for patients. It may not be easy to find them but they can be a great asset in receiving the care that you need. In general, we need to train and employee more. In this complicated system, these people have never been more needed.


In the maze of the healthcare system, it is easy to take a wrong turn and end up in a dead-end. We should ever just give up because this will just allow the system to become more convoluted and enrich those with the least interest invested in the patient. Doctors need to be strong patent advocates. It is not sufficient to just hand over a prescription or an order for a diagnostic test and wish our patients the best. We need to lead the charge for getting the care our patients need. If we give up, then who is left?


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© 2017, Linda Girgis MD. All rights reserved.

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One thought on “Navigating the Complexities of the Healthcare System

  1. I wonder whether, and to what extent, this happens in other countries with different healthcare payment systems. For example, does the NHS restrict selection of medicines? That is to say, do they have specific meds for which they will pay and those which are just not available? I know that the VA (which at least superficially resembles the NHS) either bad or still has a list of meds that they would provide. If your preferred blood pressure med or statin was not on the list, you had to use what they did have. It certainly gave the VA better bargaining power for pharmaceuticals. I suspect it may have kept costs down. Does this impact patient health? That’s all a long way of saying that keeping medications affordable may require certain compromises. I did not like it when the VA told my WWII veteran father that he would have to use their favorite meds instead of those his doctor selected, but when I asked his doc about it, he was basically ok with the substitution. Costs have to be contained one way or another.
    I also wonder whether private insurers which exist in other countries for example Germany are permitted to require their insureds to jump through the same hoops
    That Americans must. Anyone know? It’s an honest question. How about a system like Canada? Are there limitations on what tests can be done or in what order they must be performed? Are there formularies for medications from which Canadian doctors must select? If so how if at all does this impact Canadian healthcare outcomes? Does it keep costs down and therefore lead to more universal coverage?
    I think what bothers many of us about the American healthcare payment system is that we assume that restricting care leads to higher profits for insurers. Does that still happen under the ACA? I recall hearing that a certain percentage of every premium dollar must be spent on patient care. I believe this was meant to limit the role profits play in our private insurance system.
    Any thoughts?

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