ONE of my patients recently had her request for a relatively common medication for attention-deficit hyperactivity disorder, Vyvanse, denied by her insurance provider. I tried to appeal the decision, but her father — the chief executive of a health care company who purchased insurance for hundreds of employees — had better luck. He called up the head of the insurance company and got the drug approved.
Last year, my 5-year-old fractured her ankle. The bill for the 12-minute orthopedist's appointment was $1,125, and about half of it was covered by insurance. I wrote the doctor a letter — please revise this bill, as it is clearly erroneous — and included my "M.D." Instead, the doctor left me a message saying he was waiving the bill entirely as a professional courtesy.
Stories like these reveal an uncomfortable truth. Our health insurancesystem is so broken that pulling strings — or rank — is sometimes the only way to get the coverage you think you've paid for.
Since 2010, when the Affordable Care Act was passed, the major insurance companies have seen their stock prices soar. Though the act expanded coverage to millions, a report last year by the Robert Wood Johnson Foundation revealed that 41 percent of health plans sold on the government exchanges had physician networks described as "small" or "extra-small," covering less than 25 percent and 10 percent of local doctors, respectively. Individuals may have to change doctors or choose out-of-network services, incurring extra costs.
Wendell Potter, a former Cigna executive turned whistle-blower and a co-author of the recent book "Nation on the Take," says that "insurance companies profit by introducing hurdles in the coverage and claims process." These hurdles lead some patients to simply give up and pay or forego treatment altogether. He calls this the companies' business model.
This strategy has given rise to a new business. After his son was born with cerebral palsy, Scott Leshin, then an associate at Goldman Sachs, made it his business to read the fine print of his health insurance policy so that he could fight for the services his son needed.
His son started walking only this year, at age 10. And yet, "I still have to prove to UnitedHealthcare that he has C.P. every six months," Mr. Leshin told me. His success in getting services covered led him to found his business, SJ Health Insurance Advocates, which now has a staff of 19. He works on a contingency basis — his customers pay only when his team succeeds.
But the best way to advocate for yourself is simply to be a doctor. When my son was born eight years ago, a series of errors left my wife unmedicated for 18 hours following a C-section. Furious, I fastened my medical school faculty badge to my collar, hoping to send the message: I'm watching you. We got an apology and a private room.