(Updated 2021) So your insurance company denied a treatment or a medication in advance, and you want help. This is part of our series on billing advice (see below for other entries.)
Here are a few steps.
- Understand the reason for the denial. Ask that it be clearly stated, in writing, and that the appeal process for this particular kind of denial be made clear to you. Quite often the insurance company appears to hope that by saying “no” and offering no further information, it can stop the conversation. Insurers reply that it is their responsibility not to spend money on unproved or excessive treatments, and that providers are out to take their money. Insurers and providers may sometimes accuse patients of being irresponsible. All three will blame Big Pharma for being out to take their money. In any case, when a denial happens, it’s probably going to be up to you to overturn it.
- Start an appeal. In this step, you will need to follow procedures set forth by your insurer and/or provider. There is no consistency to these rules, but essentially you need to follow them — and get the insurer and provider talking as quickly as possible. (If the doctor prescribed something the insurance company won’t pay for, then the doctor should step up and argue your case.) See David Belk here and here for how a doctor can help sort through these issues. Suggest that your doctor watch this short video about what to do about a denial.
- If it’s an employer-sponsored policy, get the human resources department involved. Urge them to talk to their insurance broker or other contact if applicable. The employer is actually footing the bill here, in some sense, so they can raise a fuss and say they think it should be paid. Often the HR departments will be sensitive to an employee’s plea, and they can use their broker or other insurer contacts to bolster the appeal. Of course this is hard and complicated — I’m not suggesting that it isn’t — but if you’re focused on overturning an appeal, you need to pull out all the stops.
- Get a second opinion. Some insurance policies, including many big employers’ policies, have a second opinion service to assess a doctor’s recommendation. This might be useful.
- If it’s a medication, there may be a Patient Assistance Plan that will pick up part of the cost. The best way to find out about this is to Google the medication and “patient assistance plan.” For details about what a Patient Assistance Plan is, and whether it’s a good idea, check out our How to save money on prescriptions page. There are a lot of them — and they have different rules. Some will pick up a portion of the cost if insurance approves the treatment, for example, but not if it’s been denied for coverage. For a really convoluted case of denial of medication, take a look at this post on The Health Care Blog, by a New York University assistant professor of medical ethics.
- Ask how much the medication or procedure will cost on cash. An acquaintance told me the denied medication would cost $36,000 a year, but when she asked for the cash price, it was $24,000. This was through a specialty pharmacy. It’s still out of reach, but …
- Do your homework. If it’s a medication, go to the ProPublica Dollars for Docs search tool and see if the provider is getting payments from the drug company. In general, be aware of doctors’ prescribing patterns for ordering medications.
- Is there a generic or an older-generation drug that works as well, or nearly as well? Is there an over-the-counter version? Sometimes new drugs bring lots of hope, but older generations or generics are as good, or almost as good. Is the insurer rejecting an injectable drug in favor of a pill version of the same drug, or vice versa? We’ve heard about this too.
- Is there a patient group online? Many conditions and illnesses have a nonprofit foundation attached to them that has information on its website — Susan G. Komen for breast cancer, the Leukemia and Lymphoma Society and so on. There might even be a Patient Assistance Plan billboarded on the site — after all, many of these nonprofit foundations get a lot of Big Pharma money.
- Separately, is there a patient group on Facebook or elsewhere, like Psych Central or Smart Patients? On the official foundation websites, any forum conversation can be pretty buttoned up, especially if the foundation gets a lot of drug money. But a patient group on Facebook or elsewhere may not be governed by a foundation, and so conversation can be much looser. You might find people with similar problems. Not everyone wants to share a lot of personal detail with Facebook or other public sites, but hundreds of thousands of people do.
Go to our blog page and search for your procedure or medication. You might find information about what others have paid for a colonoscopy, a gall bladder removal, a sleep study, a blood test, a medication.
A member of our community added on Facebook: “If it’s a procedure or full treatment that has been denied, ask for the qualifications of those on the committee that has rejected it. It could be just those out of high school with NO medical education.”
We do hear periodically of people called “patient advocates” or “medical advocates,” who will argue a case for you. We don’t know enough about this particular line of business to recommend people. We understand that some work on a fee level; also, some people called “medical billing advocates” will help you argue a claim denial or a bill (see Part 2 of this series). If you have a good experience with someone, please do let us know.
We often hear about an insurance company tactic called “step therapy.” Under this practice, the patient needs to try and fail conservative or less expensive treatments before receiving permission for a more complicated or more expensive treatment. Example: For back pain, you need to try physical therapy for a certain amount of time, and receive no relief, before getting permission for surgery. For certain ailments, you need to try generic drugs for a certain amount of time, and receive no relief, before getting permission for more expensive, newer drugs. Here’s a description of step therapy on the Pfizer website. It seems fairly benign — unless you are the parent of a kid who needs to “fail” several medications for a mental health issue, before receiving permission for the proper medication that has previously been prescribed by a different doctor and insurer, and that has been shown to work.
Be persistent: Call back, and keep track of who you talked to. This is unlikely to resolve itself overnight, but if you keep at it, you may well win.
Be polite, no matter how irritated you are.
Check out our “useful links” page.
Google around: You might find someone in a similar position.
When you’ve finished the process, let us know what happened.
Add at end: Negotiating a bill.