You have cancer and now you need to add a new battle, with your insurance company because they have denied your request to cover a certain drug or a treatment. Going to your health insurer is always frustrating and time-consuming. They don’t care if what you need will extend your life or make living better, they don’t want to pay. Yes, you pay absorbent premiums each month, but they don’t want to part with your money.
Sometimes you need to appeal a coverage denial. Appealing their decisions, as they are the initial judge and jury, can make you want to tear your hair out, but it is what you need to do to protect yourself and get what you need. There are several strategies that can bolster your case and improve your chance to beat them.
The very easiest problem to solve comes from your doctor’s error when a wrong code on a claim form is entered. This type of error can be resolved with a phone call. This is the easiest issue to solve; other issues can be more difficult.
These more difficult issues bring in complex medical questions like whether a certain cancer treatment is appropriate for you and if one treatment may be superior to another.
Your first task is to learn your insurer’s procedure for appeals and to specifically find out what led to the denial. Calling your insurer on the phone is best. Always take notes, include the names of everyone who speaks with you and what they tell you.
Request some key documents to reconstruct what led to the denial. Get a copy of the denial letter, a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Also, get a copy of the insurance companies policies for filing exceptions and appeals, pay special attention to filing deadlines as they are very strict.
Set a strategy and make a plan.
You must develop a plan to get a negative decision reversed. Your appeal could simply be based on showing that your treatment qualifies for coverage under your plan’s “Evidence of Coverage” benefits and rules that they supplied. Show this by zeroing in on the plan’s own language and figure out why the procedure or drug you are seeking fits into a category of care that the insurer has already agreed to pay.
Your appeal could hinge on whether a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf showing the efficacy of the treatment for your situation as well as why it is medically necessary for your care.
You should supplement your doctor’s letter by researching your own scientific evidence from online on sites like pubmed.gov, sponsored by the National Library of Medicine. Make it a point to find studies that demonstrate that the treatment you want has worked in cases similar to yours. The strongest evidence comes from large, randomized, controlled trials, but anything published in a reputable medical journal could support your cause. You should show your findings to your doctor, ask them to integrate anything important into their letter to the insurer.
Don’t be shy, seek help from researchers who worked on the cutting-edge studies you find. Ask them to help a patient (you) with an urgent case that is consistent with their research findings. They might even review your medical records and submit be willing to submit a backup letter on your behalf, which can add weight to your own doctor’s views.
If your appeal is rejected you still could have other options. Those of us who have a policy provided by an employer who has a self-funded health plan, administered by a private insurer but is backed by the employer, you can sue in federal court. However, this can be long, expensive and tough process.
If your coverage is with an insurance company, either through your employer or an individual policy, you can opt for your state’s appeals process, an easier task. Often, these are handled through the state’s insurance regulator, but if not, this agency should at least be able to tell you where to go. Make sure you check with the agency, because the 44 states that offer independent reviews won’t handle all kinds of issues, and each has its own rules.
For Medicare beneficiaries, there is a separate, federal appeals-review process that you can learn about at Medicare
Usually a best place to start is by seeking help from one of the nonprofit and for-profit entities that offer advice on insurance appeals. Many states have health insurance consumer advocates. The advocacy group Families USA offers a list of state resources.
Another key resource is the nonprofit Patient Advocate Foundation, which handles health-insurance appeals for free. Other organizations and companies can be found at the following Web sites:
Don’t just lie down and accept a bad decision from your insurance carrier, use the available exceptions and appeals process in a smart fashion to get the drugs and treatments you need.
Joel T. Nowak, M.A., M.S.W.