Kff Health News
When Sally Nix learned that his medical insurance company would not pay an expensive treatment recommended by his doctor to relieve his neurological pain, he prepared for battle.
He took years, a series of contradictory decisions and a change of insurer to finally achieve approval.
The treatment began in January and now dedicates their time and energy to helping other patients to fight against these denials. “Something that I tell people when they go to me is: ‘Do not be scared. It is not a definitive one,” says Nif, 55 years old, from Statesville, in North Carolina.
To control costs, almost all insurers use a system called prior authorization, which requires patients or their suppliers to request approval before being able to perform certain procedures, tests and recipes.
Denegations can be appealed, but almost half of the insured adults who received one in the last two years say that the process was something or very difficult, according to a survey published in July by KFF, a non -profit organization dedicated to health information that includes .
“It is designed to be overwhelming,” because insurers know that confusion and fatigue make people surrender, said Nix, “that is exactly what they want you to do.”
The good news is that it is not necessary to be an insurance expert to achieve results, he said, “you just have to know how to defend yourself.”
Here are some tips to face a denial of prior authorization:
1. Know your plan
Do you have insurance for your job? A plan hired through Healthcare.gov? Medicare? Medicare Advantage? Medicaid?
These distinctions can be confusing, but they are very important. The different categories of medical insurance are regulated by different agencies and subject to different norms of prior authorization.
For example, the plans of the Marketplace Federal, as well as those of Medicare and Medicare Advantage, are regulated by the Department of Health. Those sponsored by the employer are regulated by the Labor Department. Those of Medicaid are administered by state agencies, and are subject to state and federal norms.
(Federal Judge orders the Department of Health to stop sharing Medicaid data with ICE officials)
Medical insurance companies do not apply prior authorization requirements in a uniform way. Read their policy carefully to make sure that the insurer complies with her own norms, as well as the regulations established by the state and federal government.
2. Work with your supplier to appeal
Kathleen Lavanchy, who retired in 2024 of his work at a rehabilitation hospital in the Philadelphia area, spent much of his career communicating with medical insurance companies on behalf of patients.
Before contacting the medical insurer, call her supplier, advise Lavanchy, and ask to speak with a medical care administrator or someone in charge of prior authorization appeals.
The good news is that your doctor could be working on an appeal. Medical staff can act as “your voice,” he says, Nix, “they know language.”
You or your supplier can request a “peer” review during the appeal process, which allows your doctor to discuss your case by phone with a medical professional from the insurance company.
3. Be organized
Many hospitals and doctors use a system called Mychart to organize medical records, results of tests and communications, so that they are easily accessible. Patients should keep a record of all material related to an appeal to insurance: telephone call records, emails and messages in the application.
Everything must be organized, either in digital or paper format, so that it can be easily consulted, Nix suggested. His own records showed that his insurance company gave him contradictory information and it was “what saved me,” he explained.
“Save all documents,” he insisted, “every call, every letter, every name.”
Linda Jorgensen, executive director of the Special Needs Resource Project, a non -profit organization that offers online resources for patients with disabilities and their families, advises to save copies on paper of everything.
“If it’s not on paper, it didn’t happen,” said Jorgesen. She takes care of her adult daughter with special needs and created a free form that can be printed and serves as a guide to take notes during telephone calls with the insurance company. He advises asking for the name of the insurer and a “ticket number” before continuing with the conversation.
4. Appeals fast
Most of the denials, if appeal, are revoked. Medicare Advantage data, published by KFF in January, revealed that almost 82% of prior authorization denials between 2019 and 2023 were partially or totally revoked after the appeal.
But time runs. The majority of health plans only give him six months to appeal the decision, according to the norms established in the affordable health care law.
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“Do not waste time,” Jorgensen advised, especially if he sends a written appeal or any support document through the mail. Recommends presenting the rapid appeal, and at least four weeks before the deadline.
To gain time, some people turn to artificial intelligence to write personalized appeal letters.
5. Ask Human Resources for help
If you have medical insurance through your employer, it is likely that your health plan will be “self -financed” or “self -assured.” This means that your company assumes the expense of your medical care although it hires an insurance company to manage benefits.
Why does it matter? In self -financed plans, decisions about what is covered and what does not fall at the end of your employer.
Suppose, for example, that your doctor recommended undergoing surgery and your insurer has denied prior authorization by considering that the procedure “is not medically necessary”, a phrase that is usually used. If your plan is self -financed, you can appeal to your company’s human resources department.
Of course, there is no guarantee that your employer accepts to pay. But, at least, it is worth asking for help.
6. Look for a defender
Many states have free consumer assistance programs, available by phone or email, which can help you appeal. They can explain their benefits and intervene if their insurer does not meet the requirements.
In addition, some non -profit organizations, such as the Patient Advocate Foundation, usually help. On the website of the Foundation you will find guidance on what to include in an appeal letter and, for those who fight against serious illness, work individually to reverse a denial.
7. Do not stay silent
Sometimes, when patients and doctors criticize insurers on the Internet, denials are reversed.
The same happens when patients contact their legislators. State laws regulate some categories of medical insurance, and when it comes to establishing policies, state legislators have the power to demand responsibilities from insurance companies.
Contact them does not guarantee that it works, but it is worth it.
