Patients and doctors should work together if insurance denies a claim, explains a Keck Medicine of USC expert.
Do you remember that Denzel Washington movie in which his character holds a hospital hostage because his insurance company won’t pay for his son’s heart transplant? Or what about that popular TV series in which a chemistry teacher turns meth dealer to afford his cancer treatment? Hollywood has made lots of money off storylines so farfetched they can’t possibly be real. Except they are. Many Americans’ healthcare treatments are stuck in limbo, waiting for prior authorizations.
What is a prior authorization?
Insurance companies use prior authorizations to determine medical necessity before a patient’s treatment can begin. A prior authorization can be required for anything from prescription drugs to life-saving surgeries.
After you meet with your physician and come up with a treatment plan, your physician and their team then reach out to your insurance company to start the prior authorization process. During this process, the insurance company wants to know your medical history, what symptoms you have, what test results verify your diagnosis and what other treatments you have tried. Your physician’s team must provide your insurer with all this information – and doing so is time-consuming.
An insurance reviewer will look at what treatments or medications are being requested and review the records submitted. The reviewer decides if the insurer will approve or deny the prior authorization.
So, we wait.
What to do if insurance denies a prior authorization request
Occasionally, before formally denying a request, the insurance reviewer will reach out for additional information or request a “Peer-to-Peer.” A Peer-to-Peer is when a medical physician from your insurance company wants to talk to your physician or provider before deciding whether to approve or deny a prior authorization.
So, we continue waiting.
In March 2024, Forbes reported that “on average, 6% of prior authorization requests are initially denied. Of those, 11% are appealed, and 82% are ultimately fully or partially reversed.”
If 82% of denials are reversed, why do only 11% of denials get appealed? Usually because the patient and/or their physician team don’t realize that appealing is an option. This article will help inform you of how you can partner with your provider to appeal prior authorization decisions.
How to appeal a prior authorization denial
The first step is understanding why your prior authorization was denied. Did the insurance reviewer feel that the treatment or medication wasn’t medically necessary? Is your provider or the servicing facility out of network and not covered by your insurance plan? To find out what the problem is, the first step is to call your insurance company and have them explain the reason for the denial.
Once you have a reason for the denial, it’s time to partner with your physician’s office. Give them the reason for the denial and see if there is any additional information they can provide to support the prior authorization request. Get copies of your consult notes, test results and any additional information needed. For example, we once had insurance deny a claim for a percutaneous surgery because percutaneous surgery wasn’t a covered benefit under the patient’s policy. Our office provided the insurance company with peer-reviewed sources citing the effectiveness and positive outcomes associated with percutaneous surgery.
From there, you will need to send a letter of appeal to your insurance company. This letter should include the previous prior authorization reference number, your diagnosis and the CPT codes associated with the requested procedure. Then state why you are requesting this appeal. Talk about things like your quality of life, the impact the requested service will have on your health and why your care team feels it’s necessary. These appeals must be in writing. Ask your insurance company where to send your appeal; it’s usually by fax.
Insurance companies usually allow themselves 30 days to review your appeal once it is submitted. Call your insurance company frequently to check on the status of the appeal. Ask them if they need any additional information to process to your appeal. Keep your physician’s office in the loop on the status of your discussions with your insurance company. Sometimes an insurance company will reach out to the physician’s office, so it’s important for everyone to be on the same page.
If you have an HMO plan and your medical group (or Individual Practice Association/IPA) denies your appeal, you can then send the same appeal to your health plan. Your health plan is the bigger insurance company that your medical group (or IPA) belongs to. The health plan can ultimately overrule the IPA and agree to authorize your treatment.
If you have a PPO plan and your appeal is denied, you can reach out to Consumer Assistance at the California Department of Insurance. They oversee California’s health care coverage and manage patient complaints.
Act as your own champion
The most important thing to remember is that your health requires advocacy. You, as a patient, need to partner with your physicians to advocate for timely and appropriate approvals from your insurance. You can also check whether your insurance company offers case workers or patient advocates who can help you navigate your health care.
Don’t forget that your insurance company works for you. You are their customer. So, if you aren’t happy with their service, let them know. File a complaint, ask to speak to a manager or change insurance companies. You have the right to do these things and should feel empowered to do so. After all, you are the most valuable member of your care team.
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