While access to health insurance is a critical component of finding good care and making the most of it, being insured is often just the starting point for frequent users of health care services.
What follows is an example of what people with chronic conditions must do to get the care they need in a situation they frequently face: disputes with their health plan about what will be covered by insurance and what they must pay for themselves. Too often, we get calls from people whose insurer has denied coverage of a test or treatment who have used up all of their appeals and get to us when it's too late for us to do anything other than deliver the bad news that there's nothing more that can be done. So that individuals are better prepared in the future, this is the information we offer on how to handle disputes with one's insurance company:
First, your insurance company will tell you that if you want to appeal, you can just call them. Never do this. If you don't provide the insurer with new information, there's no reason to think that, if they review the same information they already had, they will reach a different result. You have to give them something that will change their minds.
Similarly, resist the urge to sit down and write a letter saying your doctor says you need the test or treatment and you pay your premiums, so they should cover it. Your insurer already knows your doctor ordered the test or treatment. When an insurance company denies coverage, it's usually because they believe it's not medically necessary or it is experimental / investigational, so these are the concerns you must address.
To appeal a coverage denial successfully, the first thing to do is to collect your medical records. You need objective evidence test results, labs, doctors' office notes to establish your diagnosis and medical necessity. Things like pain and fatigue are subjective; they can't be proven, and insurance companies discount these symptoms, though they are less likely to do so if they are documented by your physician in your record. Proving that there's a source of the pain is best demonstrated with an abnormal x-ray or imaging study, colonoscopy with biopsies, for example.
Often, a medical necessity denial is really a denial of an expensive test or treatment when the insurance company thinks there's a less expensive, medically equivalent alternative. A medical record that shows you've tried all the alternatives is the best way to address this, but sometimes the problem is that their suggested alternative really isn't medically equivalent. In that case, the best thing to do is get a letter from your doctor explaining why it's not medically equivalent for you.' For example, a generic drug may not work as well for you as a brand name. But it will require that your doctor explains why.' This is one of the few instances when a letter from a doctor is essential.
If you receive a denial on the ground that the test or treatment is experimental or investigational, you have a more difficult task. You still have to collect all of your medical records to prove your diagnosis and the fact that you've tried all of the more traditional treatments. However, in addition, you have to gather medical journal articles that support the safety and effectiveness of the treatment in question. You can search for abstracts or summaries on www.pubmed.gov, which is the library of the National Institutes of Health. So, for example, if your doctor thinks you need a new drug called Stelara to treat your Crohn's disease, you search for 'Stelara Crohn's' and all of the relevant articles will come up.' If you are near a medical library and can get the full text of articles rather than abstracts, do it. If there are one or two articles that seem really important, you can buy the full text on the internet they're expensive, but spending $50 to get a treatment that costs thousands of dollars is a good investment. If you can only get the abstracts, that's better than nothing.
Once you have the medical records and the medical journal articles, you need to write a cover letter detailing ' with dates -- how the medical records establish your diagnosis and all of the treatments you've already tried, and how the medical journal articles establish the safety and effectiveness of the treatment in question. The more detailed your letter, the better.' You can find samples of good appeal letters on our website. Attach your records with relevant sections highlighted and the abstracts or articles you refer to in your letter.
Generally, 70 percent of insurance appeals are successful. We encourage people to not give up, to take the time to collect the necessary documentation and organize it in a convincing way. And we offer free assistance for people who request it.
I am impressed with the persistence and commitment of people who take on the chores of contesting the denial of a claim.' Some of them must do it repeatedly as they change health plans and as new evidence for treatments and tests influences a plan's coverage decisions. I am also impressed with the considerable barriers they face in doing so: the continuing lack of easily accessible medical records, the demands individuals must make on their busy physician, the expense of obtaining articles from medical journals not to mention the skills and judgment required to put together a compelling case.
It is worth pointing out that these barriers constitute real limits to access to needed care, especially since many people with chronic conditions lack the wherewithal time, skills, resources to overcome them.