DIY Your Medical Care

Prior authorization – denied.
Family Medical Leave Act (FMLA) – denied.
Patient-level authorization for higher quantity – denied.
Infusion treatment – denied.
American with Disabilities Act (ADA) accommodation – denied.
Social Security Disability – denied.

We’ve all been there, some of us repeatedly. Accommodations and treatments for migraine that would make our lives easier and possibly improve quality of life have been denied through any number of assistance programs and insurances.

The common denominator seems to be you, it’s normal to think it must be something about you that’s causing the denials. You’re not good enough. You’re not sick enough. No one understands you. In reality, there’s a more important common denominator – your doctor.

Get rid of the pedestal

Far too often in Western medicine people believe that what their doctor says and does is correct, and they have difficulty speaking up and asking questions. There is a cultural bias against questioning doctors in Western medicine. In my experience, I’ve learned that you need to get past this and take a good look at the care you’re receiving, not only during an office visit but by the required paperwork being handled on your behalf by your doctor and the office staff.

You need a partner

Never think that a medical degree makes someone better informed than you, the person living with a chronic condition. You each have a different perspective on the situation and should work in partnership. As part of this, you need to make sure your doctor is fully informed about your medical history, but you also need to make sure that history is being acknowledged and used.

I’ve worked for a prescription benefit management company for more than 20 years, and a quarter of those years were spent working with prior authorizations for medications. Most authorization denials I processed were denied for lack of information being provided by the doctor’s office. Questions are skipped or answered incompletely, requests for clinical information, such as lab results, are ignored, or incorrect information, such as the wrong diagnosis, is provided.

From what I’ve seen, a medication isn’t going to be approved for coverage unless it’s been prescribed for the correct condition. This is a safety net for you, the patient. It’s a way to catch errors and double-check standards of care. Along the same lines, your medical history is critical. If it’s not provided, what you want may not be approved. The same goes for other things like FMLA, disability, and medical procedures. There is a chance that absolutely nothing is going to be covered or approved if the doctor never responds to the request for information.

Get the facts

When you’re denied coverage, you have the right to know why. Get this information and review it closely. Never just accept the statement from your doctor, “Oh, that’s not covered”. Instead, go directly to the source. Call your insurance. Call social security. Call whomever is managing FMLA for your company. Get all the details and review them closely. This is your life, no one is going to care more about it than you. At the end of the day, it’s your responsibility to make sure the correct information is being provided for the coverage you would like to have approved.

Insider tip – handle documentation yourself

The paperwork needed for coverage doesn’t always have to be handled strictly by the doctor’s office. In fact, in most cases, the paperwork may be sent directly to you! I think it is beneficial to review it closely and fill out everything you can before going to your appointment. Not only does this save time for the office, but you’re guaranteed the information about you is correct because you provided it.

Often, particular pages will say “to be filled in by the office/doctor”. In some cases, it may be okay for you to fill out this information yourself. Your doctor will have to approve it and sign off on it but that shouldn’t be an issue, particularly since you’re saving the office so much time and work by having the forms ready to go.

You know you!

Remember, no one knows you better than you so take care of paperwork requirements yourself whenever you are able.