Learn how to appeal a health insurance company’s denial | WFAE 90.7

Following our series The Price We Pay, WFAE has partnered with Jeanne Pinder, CEO and founder of media company Clear Health Costs, on a series of columns to help readers find ways to manage their own healthcare costs. health.

Your insurance company has therefore refused treatment or medication in advance and you want help. Here are some steps:

  1. Understand the reason for the refusal. Ask that this be clearly stated in writing and that the appeal process for this particular type of refusal be clearly explained to you. Quite often, the insurance company seems to hope that by saying “no” and offering no further information, they can end the conversation. Insurers respond that it is their responsibility not to spend money on unproven or excessive treatments and that providers are willing to take their money. Insurers and providers can sometimes accuse patients of being irresponsible. All three will accuse Big Pharma of being there to take their money. Either way, when a denial occurs, it will likely be up to you to reverse it.
  2. Start a call. In this step, you will have to follow the procedures established by your insurer and/or provider. These rules aren’t consistent, but you basically need to follow them and get the insurer and provider to talk to each other as quickly as possible. (If the doctor prescribed something that the insurance company won’t pay for, then the doctor should step in and plead your case.) See David Belk here and here for how a doctor can help with these issues. Suggest your doctor watch this short video on what to do in case of refusal.
  3. If it’s an employer-sponsored policy, get the human resources department involved. Encourage them to speak to their insurance broker or other contact, if available. The employer is actually footing the bill here, in a sense, so they can fuss and say they think this should be paid. Often HR departments will be responsive to an employee’s call and they may use their broker or other insurer contacts to bolster the call. Of course, it’s difficult and complicated – I’m not saying it’s not – but if you’re focused on canceling a call, you have to go all out.
  4. Get a second opinion. Some insurance policies, including policies from many large employers, have a second opinion service to assess a doctor’s recommendation. It could be useful.
  5. If it’s a drug, there may be a patient assistance plan that will cover some of the costs. The best way to find out is to google medications and “patient assistance plan”. For more details on what a patient assistance plan is and if it’s a good idea, see our How to Save Money on Prescriptions page. There are many – and they have different rules. Some will take part of the cost if insurance approves the treatment, for example, but not if it was declined for coverage. For a really complicated case of drug refusal, take a look at this post on The Health Care Blog, by an assistant professor of medical ethics at New York University.
  6. Ask how much the medication or procedure will cost in cash. An acquaintance told me that the declined drug would cost $36,000 per year, but when she asked for the cash price, it was $24,000. It was through a specialty pharmacy. It’s still out of reach, but…
  7. Do your homework. If it’s a drug, go to the ProPublica Dollars for Docs search tool and see if the supplier is receiving payments from the drug company. In general, be aware of doctors’ prescribing habits for ordering medications.
  8. Is there a generic or old generation drug Does it work as well, or almost as well? Is there an over-the-counter version? Sometimes new drugs bring a lot of hope, but older generations or generics can be just as good, or almost as good. Talk to your doctor about generic options. Does the insurer reject an injectable drug in favor of a pill version of the same drug, or vice versa? We have also heard of this.
  9. Is there an online patient group? Many conditions and diseases are associated with a non-profit foundation that has information on its website – Susan G. Komen for Breast Cancer, Leukemia & Lymphoma Society, etc. There might even be a patient relief plan posted on the site – after all, many of these nonprofit foundations get a lot of money from Big Pharma.
  10. Separately, is there a patient group on Facebook or elsewhere, like Psych Central or Smart Patients? Not everyone wants to share a lot of personal details on Facebook or other public sites, but hundreds of thousands of people do, especially in patient-focused groups. You might find people with similar issues.

A member of our community added on Facebook: “If it’s a whole procedure or treatment that was denied, ask for the qualifications of those on the committee who rejected it. It could be only those who have finished high school and have NO medical training.

We periodically hear of people called “patient advocates” or “medicine advocates” who will advocate for you. We don’t know enough about this particular industry to recommend people. We understand that some operate for a fee; Also, some people called “medical billing advocates” will help you argue a claim denial or bill (see Part 2 of this series). If you have a good experience with someone, please let us know by emailing us at info@clearhealthcosts.com.
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We often hear about an insurance company tactic called “step therapy.” Under this practice, the patient must try and fail conservative or less expensive treatments before receiving approval for a more complicated or more expensive treatment. Example: For back pain, you have to try physiotherapy for a while and get no relief until you get cleared for surgery. For some conditions, you have to try generic drugs for a while and get no relief until you get approval to use more expensive, newer drugs. Here is a description of step therapy from the Pfizer website. Sounds pretty benign – unless you’re the parent of a child who has to “fail” several medications for a mental health issue before you get clearance for the proper medication that’s already been prescribed by another doctor and insurer and which proved effective work.

Be persistent: call back and keep track of who you talked to. It’s unlikely to be resolved overnight, but if you keep going, you just might win.

Be polite no matter how irritated you are.

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