When Sally Nix found out that her health insurance wouldn’t cover the costly treatment her doctor suggested for her nerve pain, she braced herself for a fight.
After years filled with mixed decisions and changing insurance companies, she finally received approval in January. Now, she dedicates her time to assisting other patients in their battles against denial.
“I always tell those who come to me, ‘Don’t panic. This isn’t a final no,’” Nix, 55, from Statesville, North Carolina, shared.
To keep expenses down, most health insurers implement a prior authorization system. This process requires patients or their healthcare providers to get approval before certain tests, procedures, or medications.
While denials can be contested, a recent survey by KFF found that nearly half of insured adults who faced a prior authorization denial in the last two years felt that the appeals process was either somewhat or very complicated.
“It’s designed to be overwhelming,” Nix mentioned, noting that insurance companies rely on confusion and fatigue to encourage people to give up. “That’s exactly what they want.”
If you find yourself facing a prior authorization denial, here are a few suggestions.
Understand your insurance plan
Is your insurance obtained through your employer? Or is it from Healthcare.gov, Medicare, or Medicaid?
Various types of health insurance come under different regulations, and pre-approval requirements can vary.
Federal marketplace plans, Medicare, and Medicare Advantage plans are overseen by the U.S. Department of Health and Human Services. Employer-sponsored plans fall under the Department of Labor’s jurisdiction, while state-administered Medicaid plans are subject to both state and federal regulations.
Get familiar with the terminology related to your insurance policy. Different health insurance providers don’t uniformly apply prior authorization. So, it’s essential to read your policy closely to check if the insurer is adhering to the state and federal rules.
Collaborate with your provider to dispute
Before she retired in 2014, Kathleen Lavancie communicated extensively with health insurance companies on behalf of patients.
Lavancie suggests that before reaching out to your insurance company, contact your healthcare provider to speak with the medical care manager or someone in the office responsible for prior authorization applications.
You or your healthcare provider might want to request a “peer-to-peer” review during the appeal, allowing your doctor to discuss your case directly with a clinical professional from the insurance company.
Keep organized
Many patients and hospitals utilize a platform called MyChart to manage medical records and communications. Similarly, individuals should maintain a thorough record of everything related to their insurance claims, including phone calls, emails, letters, and in-app messages.
“Maintain a comprehensive paper trail,” Nix advocated. “Document every call, every letter, every name.”
Linda Jorgensen, who leads the nonprofit Special Needs Resource Project, advises those dealing with denials to keep everything in writing. “If it’s not documented, it didn’t happen,” she stated.
Jorgensen, who assists her adult daughter with special needs, has even created a free printable form to log notes during conversations with insurance representatives. She recommends asking for the representative’s “ticket number” and name before diving into the discussion.
Appeal promptly
On the bright side, a significant number of denials are overturned during the appeal process.
KFF’s January report on Medicare Advantage indicated that about 82% of prior authorization denials from 2019 to 2023 were either partially or fully reversed on appeal.
However, most health plans allow just six months to submit an appeal, per the Affordable Care Act.
“Don’t procrastinate,” Jorgensen stressed, particularly regarding mailing appeals and other documents via the U.S. Postal Service. She suggests filing at least four weeks before the due date.
Seek assistance
If your health insurance is through your employer, it’s likely self-funded. This means the employer contracts a health insurance company to manage benefits, while the employer covers healthcare expenses.
With self-funded plans, your employer determines what services are covered.
For instance, if your doctor recommends surgery but the insurance company deems it unnecessary, and your plan is self-funded, you can appeal to your employer’s human resources department since your employer is the one paying for your healthcare, not the insurance company.
Many states also offer free consumer assistance programs to help with appeals, explaining your benefits and intervening when the insurance company fails to comply.
Nonprofit organizations like the Patient Advocate Foundation can also provide support.
Sometimes, denials can be reversed if a patient or physician raises awareness online regarding the insurance company.
Engaging with lawmakers can also create pressure, as state laws control certain types of health insurance, and legislators can hold these companies accountable. It may not guarantee a result, but it’s worth considering.
