Lauren Sausser
When Sally Nix came upon that her medical insurance firm wouldn’t pay for an costly, doctor-recommended remedy to ease her neurological ache, she ready for battle.
It took years, a series of conflicting decisions, and a well being insurer swap earlier than she lastly gained approval. She began remedy in January and now channels time and power into serving to different sufferers struggle denials.
“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” mentioned Nix, 55, of Statesville, North Carolina.
To management prices, almost all well being insurers use a system referred to as prior authorization, which requires sufferers or their suppliers to hunt approval earlier than they will get sure procedures, assessments, and prescriptions.
Denials could be appealed, however almost half of insured adults who obtained a previous authorization denial prior to now two years reported the appeals course of was both considerably or very troublesome, in line with a July poll published by KFF, a well being data nonprofit that features KFF Health News.
“It’s overwhelming by design,” as a result of insurers know confusion and fatigue trigger folks to surrender, Nix mentioned. “That’s exactly what they want you to do.”
The excellent news is you don’t must be an insurance coverage knowledgeable to get outcomes, she mentioned. “You just need to know how to push back.”
Here are tricks to contemplate when confronted with a previous authorization denial:
1. Know your insurance coverage plan.
Do you’ve got insurance coverage by means of your job? A plan bought by means of healthcare.gov? Medicare? Medicare Advantage? Medicaid?
These distinctions could be complicated, however they matter an important deal. Different classes of medical insurance are ruled by totally different companies and are due to this fact topic to totally different prior authorization guidelines.
For instance, federal market plans, in addition to Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state companies, are topic to each state and federal guidelines.
Learn the language particular to your coverage. Health insurance coverage firms don’t apply prior authorization necessities uniformly throughout all plans. Read your coverage intently to verify your insurer is following its personal guidelines, in addition to rules set by the state and federal authorities.
2. Work together with your supplier to enchantment.
Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital within the Philadelphia space, spent a lot of her profession speaking with medical insurance firms on behalf of sufferers.
Before you contact your well being insurer, name your supplier, Lavanchy mentioned, and ask to talk to a medical care supervisor or somebody within the workplace who handles prior authorization appeals.
The excellent news is that your physician’s workplace could already be engaged on an enchantment.
Medical staffers can act as “your voice,” Nix mentioned. “They know all the language.”
You or your supplier can request a “peer-to-peer” assessment through the appeals course of, which permits your physician to debate your case over the cellphone with a medical skilled who works for the insurance coverage firm.
3. Be organized.
Many hospitals and docs use a system referred to as MyChart to arrange medical information, check outcomes, and communications in order that they’re simply accessible. Similarly, sufferers ought to hold observe of all supplies associated to an insurance coverage enchantment — information of cellphone calls, emails, snail mail, and in-app messages.
Everything ought to be organized, both digitally or on paper, in order that it may be simply referenced, Nix mentioned. At one level, she mentioned, her personal information proved that her insurance coverage firm had given conflicting data. The information had been “the thing that saved me,” she mentioned.
“Keep an amazing paper trail,” she mentioned. “Every call, every letter, every name.”
Linda Jorgensen, government director of the Special Needs Resource Project, a nonprofit providing on-line assets for sufferers with disabilities and their households, has suggested sufferers who’re preventing a denial to particularly hold paper copies of every little thing.
“If it isn’t on paper, it didn’t happen,” she mentioned.
Jorgensen, who serves as a caregiver to an grownup daughter with particular wants, created a free form you’ll be able to print to assist information you when taking notes throughout cellphone calls together with your insurance coverage firm. She suggested asking the insurance coverage consultant for a “ticket number” and their title earlier than continuing with the dialog.
4. Appeal as quickly as attainable.
The silver lining is that the majority denials, if appealed, are overturned.
Medicare Advantage data published by KFF in January discovered that almost 82% of prior authorization denials from 2019 by means of 2023 had been partially or absolutely overturned upon enchantment.
But the clock is ticking. Most well being plans provide you with solely six months to enchantment the choice, in line with rules laid out within the Affordable Care Act.
“Don’t dillydally,” Jorgensen suggested, particularly should you’re sending a paper enchantment, or any supporting paperwork, by means of the U.S. Postal Service. She recommends submitting rapidly, and a minimum of 4 weeks earlier than the deadline.
For the sake of velocity, some individuals are turning to artificial intelligence for assist crafting customizable enchantment letters.
5. Ask your HR division for assist.
If you get your medical insurance by means of an employer, there’s an excellent probability your well being plan is “self-funded” or “self-insured.” That means your employer contracts with a medical insurance firm to manage advantages, however your employer shoulders the price of your care.
Why does that matter? Under self-funded plans, choices about what’s or isn’t lined finally relaxation together with your employer.
Let’s say, for instance, your physician has really useful that you just endure surgical procedure, and your insurer has denied prior authorization for it, deeming the process “not medically necessary,” a phrase generally used. If your plan is self-funded, you’ll be able to enchantment to the human assets division at your job, as a result of your employer is on the hook on your well being care prices — not the insurer.
Of course, there’s no assure your employer will comply with pay. But, on the very least, it’s value reaching out for assist.
6. Find an advocate.
Many states function free consumer assistance programs, obtainable by cellphone or e-mail, which may help you file an enchantment. They can clarify your advantages and should intervene in case your insurance coverage firm isn’t complying with necessities.
Beyond that, some nonprofit advocacy teams, such because the Patient Advocate Foundation, would possibly assist. On the muse’s web site is guidance about what to include in an appeal letter. For these battling extreme illness, basis staffers can work with you one-on-one to struggle a denial.
7. Make noise.
We’ve written about this before. Sometimes, when patients and doctors shame insurers online, denials get overturned.
The identical holds when sufferers contact lawmakers. State legal guidelines regulate some classes of medical insurance, and in the case of setting coverage, state lawmakers have the facility to carry insurance coverage firms accountable.
Reaching out to your legislator isn’t assured to work, but it surely is likely to be value a shot.
Finally, should you’re fascinated with sharing your experiences with a journalist, fill out this form. We’d like to listen to from you.
KFF Health News is a nationwide newsroom that produces in-depth journalism about well being points and is without doubt one of the core working packages at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Learn extra about KFF.
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