Lyme disease patients feeling the bite of insurance companies

The number of reported cases of Lyme disease has increased 25-fold since 1982 and there are more than 177,000 people in the United States who have been infected with the disease, according to the Centers for Disease Control and Prevention (CDC).

Left untreated, Lyme disease can cause arthritic complications, chest pain, and severe neurological impairment including paralysis. Not all health insurance companies cover the cost of full treatment for Lyme disease. Do you know what your health insurance policy covers if you contract Lyme disease?

Despite the wide range of tests available to detect Lyme disease, confusion over coverage for the disease often arises because no test is 100 percent reliable. Many doctors still rely on a symptomatic diagnosis, which can be problematic because Lyme disease has many symptoms. Inaccurate tests can result in denial of health insurance coverage if a Lyme test comes back negative — even if your doctor believes you have Lyme disease.

According to Jan Hennings, a spokeswoman for Blue Cross and Blue Shield of Minnesota, the cost for treating Lyme disease depends on:

• The stage of the disease.
• The antibiotic used and the length of therapy.
• Whether the antibiotic is administered intravenously or orally.

Hennings says the cost of Lyme disease drugs can range from 21 cents per day to $10 per day, which does not include the cost of administering or dispensing the drug.

What health insurers cover

If you contract Lyme disease, HMOs are generally willing to cover the standard intravenous antibiotic treatment, which involves administering antibiotics for 30 days.

Many patients and doctors say this treatment alone is insufficient. They believe even after the initial 30-day treatment the disease can go into remission and the symptoms can return later. Patients who still complain of symptoms after the 30-day antibiotic treatment are often left to fight with their HMOs for coverage.

In a Health Committee hearing in the New York State Assembly, Connecticut Attorney General Richard Blumenthal said there were a large number of consumer complaints over alarming insurance industry practices about Lyme disease coverage.

“Most alarming, what we found was a pattern of insurer denials of coverage following the single 30-day course of antibiotic treatment, even in cases where positive blood tests indicated continuing infection,” Blumenthal said. “And I was also alarmed that the testimony made it clear that the insurance companies were consistently overriding the diagnoses and prescriptions of treating physicians, despite the fact that a third-party medical-necessity determination required deference be given to the opinion of the treating physician,” Blumenthal said.

Although health insurance coverage for Lyme disease treatment is available in all states, Minnesota and Connecticut mandate health insurance coverage for Lyme disease. States without the mandates leave Lyme disease coverage up to individual health insurers, which can result in varying degrees of coverage.

Connecticut passed legislation in 1999 that requires that health insurers provide not less than 30 days of intravenous antibiotic treatment, or 60 days of oral antibiotic treatment, or both. Also, insurers are required to provide further treatment if recommended by a certified board of rheumatologists, specialists of infectious disease, or a neurologist. Businesses with group health plans that are self-insured are not mandated to provide this coverage.

Preventing and correcting coverage problems

The best way to prevent health insurance problems over Lyme disease treatment is to know exactly what your health plan covers before you receive treatment. The responsibility of payment falls on you unless your policy states otherwise, so be sure to read your policy carefully. Here are five steps you can take to reduce insurance claim problems:

1. Always double-check whether the benefits, services, or providers you need are covered under your plan before you receive treatment. Do this by calling your plan’s customer-service department. Remember to take notes. Get the representative’s name and write it down, along with the date, time, and key points of your conversation.

If a claim problem arises and you need to file a grievance, these notes will come in handy. Most insurers’ customer-service phone calls are recorded. Having the date and time of your call will make locating your call history with the representative much easier.

2. Should you have a problem with a claim, call the insurer and ask for an explanation. Again, remember to take detailed notes.

3. If your claim denial is not consistent with your understanding of your health benefits and you have a group health plan, call or visit the person in your company responsible for benefits administration. Because of their position, they might be able to quickly resolve your problem.

4. If you have a claim problem that’s unresolved, file a grievance with your health plan. If you get a denial, don’t give up. In many states, if you are still unsatisfied with your denial you can take it to a grievance committee that’s outside the plan.

5. If you discover your network of providers or benefits has changed, and you have not been notified, bring it to the attention of the person in your company responsible for benefits administration. Ask if this situation is covered under the company’s contract with your health plan. If it’s not, ask how a situation like this will be prevented in the future.

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