Health insurers offering Medicare Advantage plans, corporate health plans, health plans on the state insurance exchanges and elsewhere seem to deny care indiscriminately. Who hasn’t been faced with an inappropriate denial of care a treating physician says you need? You should know that in eight out of ten cases, fighting back and appealing the denial will get you the care you need.
The good news: The most recent data on Medicare Advantage reveals that 82 percent of appeals led to a reversal and either full or partial coverage for the care. The bad news: Insurers too often use prior authorization inappropriately to keep people from getting care.
Jackie Fortier and Lauren Sausser report for Kaiser Health News on how easy it is to fight the insurers when they deny you needed care. You don’t need a lawyer and it costs nothing but time. Here’s what you need to know:
- You always can challenge your health insurer’s denial of care. It is not a final decision. In fact most people who do challenge win.
- Appealing is easy. You simply need to ask your insurer to review your denial.
- Ask your doctor’s office for help. Your doctor’s letter explaining why the denied service is reasonable and necessary can help a lot.
- Act quickly. You usually have six months. And, keep track of the appeal.
- If you have Medicare, your State Health Insurance Assistance Program (SHIP) can provide free help with the appeal.
Even if you lose the initial appeal, you can appeal again. And, again, your likelihood of success is high, especially with a letter from your treating physician explaining why the service is reasonable and necessary.
Here’s more from Just Care:
- Prior authorization: How dangerous is it?
- Oncologists report excessive deaths from prior authorization
- Medicare Advantage inappropriate denials of care abound
- Health insurers increasingly deny coverage for critical care
- Medicare Advantage plans denied two million prior authorization requests in 2021
