How many times have you seen a prescription drug advertisement on TV or read one in the newspaper or magazine. These ads are filled with disclaimers and warnings about possible side effects. After reading such an ad, one might start to wonder why the drug is on the market in the first place. It is on the market because the benefits outweigh the risks when the drug is properly prescribed (or because a drug company influenced the FDA, but that’s a discussion for another day.)

Yet some people stigmatize medical marijuana while being comfortable with morphine, oxycontin, alcohol, tobacco, and over-the-counter cold medications that can make you unfit to drive a motor vehicle. What causes more damage to individuals and society – cigarettes and alcohol that are addictive, proven killers, and can be bought without a prescription or tightly controlled medical marijuana?

The FDA, a “wholly owned subsidiary” of the pharmaceutical industry, and some politicians would have us believe that it would be dangerous to allow us to purchase prescription drugs from Canada. As if the FDA had a good track record of keeping dangerous drugs off the market.

When my health “insurance” carrier removed a prescription drug from its formulary, I had to buy it out-of-pocket for $400/month. I looked online and found the same brand-name drug for sale in Canada for $120! But according to US law, I am not allowed to purchase it from Canada.

Clearly that law is protecting the pharmaceutical industry far more than it is protecting me. If we as a country could cut our prescription drug costs by 50% or more, think about how much we would save in overall health care costs. And it would be so simple to do compared to the complex health care plans that Congress has been debating on and off for the past decades with no results.

And the reality is that, if the law were to change, the prices would become more balanced. If we were able to purchase the drugs from Canada for half the price, Drug companies would lower the prices in the US while raising them elsewhere in order to maintain the same revenue. In the end, we could go back to purchasing our drugs right here in the US under the “careful” scrutiny of the FDA.

If Congress doesn’t pass this legislation, it is nothing less than disgraceful.

In the US, we have an economy that has tanked, soaring unemployment, a huge trade deficit (unless you place exported dollars and jobs in the “out column”), prisons that are overflowing, health care that is crippling us financially, and we’re fighting an imbalanced war. I’m referring to a trade war. Yes, I will tie all this together.

All the headlines are about the imbalanced war that we are fighting against terrorists. They fight dirty and we fight clean. How can we expect to win?

Nobody is talking about the trade war? How can keep industries and jobs from moving overseas when skilled workers overseas work for far less than our minimum wage, receive no health benefits, and are virtual slaves? How can we sell our goods in China when they Chinese government artificially holds the currency exchange rate in their favor? We can’t even compete with the Chinese here in the US market? We lost this war before long before it was in vogue to declare non-military wars such as the war on drugs. Manufacturing is all but gone in the US as are the manufacturing jobs that we once had.

President Obama is touring Asia. When he hints at the unfairness of the way the Chinese tightly control the exchange rate between the dollar and the Yuan, they cry protectionism. But if their Yuan policy isn’t protectionism, I don’t know what is.

We need to level the playing field, and if you think my proposal is protectionism, my response is: so what? Why do we have to label things as always being good or always being bad? If we need to be protectionist to the same extent as the other side in a trade war in order to level the playing field, why is that a bad thing? Clearly it would be better if they would level the playing the field, but history has shown us that they are unwilling to do so because they care about their economy, not ours. Shouldn’t we care more about our economy than we do theirs?

We should place tariffs on imports from countries that don’t play fair. You may argue that doing so will increase the price we pay for these goods. And you’re right. But in the long run, we need to make it financially attractive to bring manufacturing back to the US. Since our labor is more expensive both in terms of salary and health benefits, the cost to manufacture here is going to be higher. Keep in mind that the other option to level the playing field is to lower US wages and get rid of employer sponsored health benefits.

What do we do with the tariff dollars? We fund universal health care in whatever form it eventually takes. That step closes the loop on the fairness and the level playing field. We keep our health care. We regain our manufacturing. And as a by-product, we increase our tax revenue without raising taxes. At the same time, we provide incentive for those countries that don’t play fair to start playing fair with the exchange rate and to find ways to increase the standard of living of their own people. If they start playing fair, we’ll start talking about reducing tariffs.

But let’s get back to the jobs and slave labor. We have millions of people in prison in this country. Not only aren’t they gainfully employed and paying taxes, they are getting free housing, free food, and free health care. One could argue that they live easier lives than the overseas slaves who work in the factories that make our electronic gadgets and lead-coated toys.

Why should prisoners get a free ride? Let’s train them and put them to work in factories that manufacture the things that we currently buy from overseas? Let’s provide incentives to US companies who open factories by giving them free prisoner labor so we can make electronic gadgets and lead-free toys that can compete at the cash register with the overseas crap that we buy today.

Why should we speak to somebody in India when we call for customer service? Why can’t we speak to a US prisoner who works as a customer service agent instead?

You may say that we are taking away US jobs by undercutting the minimum wage with free labor. But the jobs I want to fill are jobs that no longer exist in the US because they have been shipped overseas.

And you might accuse me of going down a slippery slope. If we start with prisoners, the next step will be to get some people to work for their welfare checks if they are in a position to do so. So, what’s your point?

The prior authorization is a cost saving tactic used by the insurance companies to deny coverage for the more expensive treatments. In spite of what they may say, it is far more about maximizing the insurance company’s profits and far less about your health care. I don’t think that comes as much of a surprise to anybody.

Once the insurance company denies a prior authorization, you are left with the decision to start the appeal process. The appeal process is designed to put more hurdles in front of you with the insurance company hoping that most people will give up rather than try to jump over the hurdles. And again, when a subscriber gives up, the insurance company has avoided paying one more claim, which leads to more profit for the insurance company at the expense of your health care.

The best thing to do is to nip the whole thing in the bud. When your insurance company requests a prior authorization, you and your doctor need to figure out under what conditions the insurance company will pay for the treatment. If your diagnosis is not 100% certain, the doctor may have the leeway to choose an “approved diagnosis” – one for which the insurance company will cover the prescribed treatment.

It is possible that your doctor wants to try a treatment and use the results of the treatment in order to make a more accurate diagnosis. Take the example where your doctor prescribes a prescription medication. If the medication works, the doctor infers that you have the condition that the drug is proven to treat. This technique is safer and less expensive than exploratory surgery. But to get the drug covered, the doctor may need indicate in the prior authorization that he or she has made the diagnosis that the drug was designed to treat even though he or she is not yet 100% sure.

Arming yourself with the list of “approved diagnoses” is the trick. The first place to look is your insurance plan’s coverage documents. But that may not include all the details that you need. You can also check the Internet. It is surprisingly easy to find information about prescription drugs and the conditions for which they are approved by the FDA. Your doctor can also check the Physicians Desk Reference. Keep in mind that a diagnosis by itself may not be sufficient. Treatment may further be restricted by a combination of diagnosis, age, and gender of the patient.

If the prior authorization is denied and you find yourself deciding whether or not to appeal, make sure you understand exactly why the insurance company denied coverage. In your appeal letter or phone call, ask the direct question – “Under what circumstances would this treatment be covered?” If you and your doctor can argue that you meet those circumstances, you should say exactly that in your next appeal letter and your doctor should write a note to the insurance company saying the same thing. Be sure to keep your records. Once you have a record showing that your situation matches their coverage conditions, the insurance company will be hard pressed to deny your claim any longer.

 Pam called the pediatrician, who instructed her to take Ben to the emergency room at Virtua hospital in Voorhees, NJ. I left work to meet them at the hospital. Ben was triaged, and we waited the obligatory two hours before seeing the emergency room doctor.

 The doctor listened to our story for a minute or so, performed a lightning speed examination, and gave us her opinion. She said that she did not know why our pediatrician sent us in the first place. She explained that an x-ray would be useless because plastic does not appear on x-rays. She said that if Ben was not exhibiting unusual behavior – this would pass, pun intended.

 Just as the doctor was finishing up her explanation, a clerk entered the examination room to hand us a bill for our $100 insurance co-payment. The timing could not have been more painfully ironic. I don’t regret going to the emergency room, and I fully expected to pay the $100 co-pay for the visit. As they say, it is better to be safe than sorry. Nevertheless, the timing of the clerk’s bad news was a zinger.

 A few weeks later, I received a bill from Virtua. Virtua’s rate for the visit was $872, but being under contract, United Health Care (UHC), our medical insurance company, had a pre-negotiated rate of $642. UHC therefore paid the hospital $542, with my co-payment of $100 making up the difference.

 I have no love for insurance companies, especially health insurance companies. But my dislike for unfairness exceeds my dislike for insurance companies so I had to complain. A charge of $872 for a two-minute doctor’s visit didn’t pass the smell test, especially in light of the outcome of the visit.

 I phoned Virtua’s patient relations department and told them the story. Having dealt with customer service departments a few too many times, I had low expectations. I had no specific goal in mind, but my best-case scenario was that they would refund a portion of the bill, even if the refund would be made to the insurance company. After all, if the charge had been as little as $101, I would have been responsible for the first $100.

 The customer service agent listened to my story. He truly listened! He promised to investigate further and get back to me. Although it took half a dozen phone calls over the next few months, the hospital credited our account. That was far more than I expected. They did not credit UHC’s payment. They explained that UHC reviews each claim and by paying the claim, UHC had come to the conclusion that the charges were justified.

 A month later when it was time to renew our insurance plan, UHC raised our premium by 22%. There went the $100 credit from Virtua. But, as I have learned, many things are negotiable, including insurance premiums. Our insurance broker negotiated with UHC and won us a lower insurance premium – a mere 19% increase compared to a 22% increase. We take what we can get.

 When asked how often a credit is allowed, Virtua indicated that it is a rare occurrence, and it is done on a case-by-case basis. If you have a question about a bill from Virtua Hospital, you can contact them at (800) 418-5685.

 If you need an insurance broker who knows the ins and outs of insurance and who will level the playing field between you and the insurance company, contact Stan Belikoff at 267-975-6512.