Being denied by your insurance company for coverage of a treatment, procedure or medication can leave you feeling helpless.
It feels as though insurance companies have all the power and as patients we have no choice but to accept their decisions and work around them.
The reality is that by empowering yourself with knowledge about how to ask them to reconsider their decisions, you can take back some power and ask for what you need.
I recently consulted with a family trying to get coverage of the medication Ketamine for intravenous treatment of a patient with various headache disorders. Although the patient has received the treatment before and responded well, and many clinics have had good luck treating headache disorder patients with this medication, her insurance company does not want to pay for it. The patient’s mother utilized many of the techniques I discuss here to appeal that decision. No decision has been made yet on their claim, but I’m hopeful the insurance company will see the light. You can take control and do the very same thing.
Prior Authorization: One important concept to familiarize yourself with is known as Prior Authorization. A Prior Authorization is a request made by your doctor to the insurance company stating it is a medical necessity for you to have access to a treatment, procedure and medication. Doctors and pharmacies are very familiar with this process. If they don’t offer to do this for you, don’t hesitate to ask them what you need to do to get this process started. In particular doctors who perform many expensive procedures or administer expensive medications like Botox are highly familiar with Prior Authorizations and will be able to walk you through the process step by step. In fact, they’ll often do most of the work for you.
To help them make the best case for coverage of the procedure or medication in the Prior Authorization request, you can help by making sure they have all the details about your history with migraine disease, including symptoms, treatments and preventive therapies you have tried and why they did not work for you (usually either you couldn’t tolerate the treatment or it didn’t work for you – or both). If you can provide details about how long you tried the medications and what your doses were, that’s even better.
Informal Request: If your Prior Authorization request is denied, you might consider asking your doctor to informally contact the insurance company to advocate in favor of the treatment or medication on your behalf. If he or she can convince them at this point, it will save all of you a lot of time and hard work.
Formal Written Appeal: If you and your doctor’s office have submitted a Prior Authorization request and that request is denied and your doctor has informally contacted the insurance company to no avail, your next step is to appeal that decision. You should receive a written denial of benefits in the mail. If you don’t, you have the right to request a written notice. You’ll want to carefully review the information contained in that denial letter for details about how long you have to tell them you intend to appeal (generally must be in writing within 30 days), where to send that appeal, etc.
In preparing your appeal you may very well likely end up submitting the same information all over again. This may sound like a waste of time, but the truth is that the same arguments and information about why you need this treatment may get a more thorough review at this level than it did at the Prior Authorization level. Further, chances are good someone else will be reviewing your appeal than who reviewed your Prior Authorization, and that may make all the difference.
I will address the topic of preparing a written appeal letter in depth in a separate article.
Other Steps: If your written appeal is unsuccessful, you may have the right to submit a second appeal. Furthermore, you may also have the right to have your appeal addressed by a committee of people chosen by the insurance company. Also, under the 2010 Affordable Care Act, a federal law, patients now have the right to a review of their appeals in front of an external committee (people outside the insurance company. Some plans previously provided for this type of review, but now all companies are required to submit to it. Finally, after you have exhausted all these options you may be able to ask your state insurance department to intervene on your behalf or choose to file a lawsuit against your insurance company. If you reach the point where you are considering filing a lawsuit, please seek legal representation right away so you don’t inadvertently sabotage your chances of wining your case and getting the treatment you need.