Adverse Tiering – a method used to discourage patients with certain conditions from enrolling in a health plan by placing newer drugs for diseases like cancer and HIV on the highest copayment tier. A 2015 study in The New England Journal of Medicine found that some insurers participating in the state health exchanges placed all HIV therapies on the highest tier, meaning enrollees in these plans paid more than twice as much for their drugs as those in other plans.
Non-medical Switching – a practice where the health plan switches patients who are stable on a medication to a different treatment for nonmedical reasons by refusing to cover the therapy any longer or significantly increasing the copay. While insurers use this practice to control costs, patients may experience negative side effects of the new treatment regimen or become less responsive to treatment even if returned to their original medication.
Prior Authorization – a process requiring physicians and other health care providers to obtain advance approval from a health plan before a procedure, service, device, or medication is given to a patient and qualifies for payment coverage. Prior authorization can lead to delays in treatment. In a 2010 American Medical Association survey of 2,400 physicians, two-thirds reported waiting several days to receive authorization for drugs, while 10 percent waited more than a week.
Step Therapy – a policy sometimes referred to as “fail first” that requires the individual to try one or more less expensive treatments first and “fail” on them before the health plan will cover the one prescribed by the provider. Step therapy not only delays effective treatment, but multiple studies show the practice increases the costs to the health care system, particularly for hospital and emergency-room care.
Just Do It: Don’t take “No” for an answer
For most patients, the thought of fighting your health insurance company is daunting.
But, we’re not powerless. Regardless of where you live or which insurance roadblock you face, every patient has rights to fight back.
To help get you started, Aimed Alliance has launched “Know Your Health Insurance Rights” — a website that offers specifics steps to take if your insurer improperly delays or denies your coverage. That can include: filing an appeal directly with the insurance company, requesting an outside review by an independent third party, or filing a complaint with the insurance commissioner or attorney general in your state.
“Even as most Americans pay higher monthly premiums for their health insurance than a year ago, many are not receiving the type of care they pay for and deserve,” says Stacey Worthy, executive director of the Aimed Alliance. “This is why we launched the Know Your Health Insurance Rights campaign – to provide a roadmap so consumers will have the know-how to successfully navigate the insurance appeals process.”
GAO Report: Your odds are better than you think
Still skeptical of taking the time to fill out the paperwork?
Your odds of reversing your insurance company’s decision are better than you think. That goes for internal appeals directly with your insurance company and external appeals with an outside government agency.
According to a 2011 report by the Government Accounting Office, patients that filed internal appeals directly with their insurance company saw insurance companies reverse its initial denial 39 to 59 percent of the time. In 2009, 54 percent of patients in California succeeded in reversing or revising an insurance denial through the external appeal process.
In other words, it pays to fight your insurance company and file an appeal.
Health Insurance: How to request an internal appeal
If your insurer denies your claim, you have the right to an internal appeal. This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:
Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
Collect information. In addition to the determination letter, collect all documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
Request an expedited internal appeal, if applicable. If your case is urgent, you should contact your insurer and ask for instructions on how to apply for an expedited internal appeal. Your situation is urgent if waiting 30 days would seriously jeopardize your health, life, or ability to regain function.
Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.