When Sally Nix discovered that her insurance company would not pay for a treatment recommended by her doctor to relieve her neurological pain, she began a years-long battle. After several denials, insurance company changes and multiple appeals, she finally got approval and in January began therapy. Today she dedicates part of her time to helping other patients face the same situation.
The Nix case reflects a problem experienced by millions of people in the United States: the prior authorization system applied by insurance companies. This policy requires patients or their physicians to ask for permission before certain procedures, tests or even access to certain medications can be performed. Refusals are not always final. However, nearly half of insured adults who received one in the past two years acknowledge that appealing was a complex process, according to data from KFF Health News.
What to do if your health insurance denies you treatment and applies prior authorization?
The first thing is to know the type of plan you have.
Employer-sponsored insurance is not the same as a Medicare Advantage plan or one purchased on the federal health care marketplace.
Each category is regulated by different agencies and has different rules on pre-approvals.
For example, Medicare and Medicare Advantage are under the federal Department of Health, while plans offered by companies are under the supervision of the Department of Labor.
In the case of Medicaid, regulation falls to state and federal agencies, creating a patchwork of rules.
Reading the policy in detail is key, as many times insurers do not apply their own requirements uniformly.
Understanding what the plan covers and what the limits are is the first step to a successful appeal.
How to act
The recommendation from specialists such as Kathleen Lavanchy, who has extensive experience in rehabilitation hospitals, is to talk to the health care provider first.
Many doctors have administrative staff who specialize in appeals, which can save time and stress for the patient.
Sometimes the physician himself may request a “peer review,” a process in which he talks directly with another professional from the insurer to justify the need for treatment.
This strategy usually increases the likelihood that the decision will be reversed.
In addition, keeping a detailed record of all communication with the insurance company is essential.
Keeping copies of e-mails, letters, names of representatives and reference numbers can become the best defense in an appeal.
As patient advocate Linda Jorgensen explains, “If it’s not on paper, it didn’t happen.”
Remedies available if your health insurance denies you treatment
Although the process may be time consuming, there are multiple resources available to facilitate the appeal.
According to Medicare Advantage data, between 2019 and 2023, more than 80% of prior authorization denials were partially or fully reversed following a formal appeal.
The key is not to waste time.
Most plans allow a maximum of six months to appeal, although it is recommended that the request be submitted several weeks in advance.
Some patients even turn to artificial intelligence tools to write personalized appeal letters and increase their chances.
Those who have a health plan offered by their employer should be aware that, in many cases, these plans are self-funded.
This means that the company bears the medical costs directly and, therefore, Human Resources can intervene when a prior authorization is rejected.
In addition, several states have free consumer assistance programs that advise patients of their rights and assist them in pursuing legal remedies.
Organizations such as the Patient Advocate Foundation also provide individualized accompaniment to those facing serious illness and encountering unjustified refusals.
Do not remain silent
Public pressure can make a difference.
On more than one occasion, insurers have reversed decisions after receiving criticism on social media or being questioned by state legislators.
Congress and local parliaments have the power to regulate the practices of insurance companies in certain categories.
Therefore, contacting political representatives does not guarantee immediate change, but it does help to make the problem visible and increase pressure on companies to respond.
The central message is clear: if your health insurance denies you treatment, it doesn’t mean the door is closed.
There are mechanisms, deadlines, legal and social support to appeal. The key is to be informed, organized and, above all, not to give up.
This article was published by Nueva News.
