I have written about topics including access to medicines, patient advocacy, child welfare, and the healing role of music.
APPEALING INSURANCE DENIALS
If there is one thing I learned in my multiple battles for treatment access, it's this: it's an endurance game. Insurers want to save money. They try to tire you out. They want you to give up. Don't.
It's often the patient and their family who have to do the legwork. The doctors are on your side, but they don't always have the time to fight every insurance company for every patient. If you provide the ammunition, a lot more can be accomplished.
Unfortunately, it can take anywhere from two to six months to win an approval, so the appeal strategy will depend on the patient's condition and whether he or she is able to wait.
10 WAYS TO MAKE YOUR CASE
- Contact the Oncology Social Worker or hospital patient advocate.
- Study your insurer's coverage policy for your specific diagnosis code. Many insurers post their CPBs (Clinical Policy Bulletins) online.
- Work through insured person's employer (Benefits Department). Most larger employers have a dedicated insurance representative, who can help broker your case.
- Involve your local elected official(s).
- Contact your state's Insurance Commissioner.
- Review recent scientific data on the treatment under discussion (see Google scholar) and use it to support your case.
- Find out who manufactures your drug and search their website for patient assistance programs.
- Talk to your doctors about the possibility of participating in a clinical trial. You can search clinical trials for your condition and in your area at clinicaltrials.gov.
- Find out if your medication qualifies for FDA's 'expanded access/compassionate use' program (read about it here.)
- Research recent legal action against your insurer involving treatment denials (caselaw.findlaw.com) and refer to it in your appeal.
The fact is this: most people don't appeal at all; even a smaller percentage appeal more than once. It might take three, four, even five appeals, but most insurers eventually approve the coverage.
Enlist your family and friends if you need to and brace yourself for a battle. You owe it to yourself and to all those who love you.