For many patients, arriving at a diagnosis can be a long journey. Even after being prescribed a treatment, though, their hardship may not be over.
Endless Denials
Each year, insurance companies deny 850 million claims.
Pharmacy claims are particularly likely to be denied, as insurers weigh short-term costs against the long-term benefits of certain medications for managing complex conditions. Innovative medications, such biologic treatments that treat conditions like autoimmune disorders and some cancers, are often denied. These denials are frustrating, confusing and often dangerous for patients.
Persistence Pays Off
But for the few who appeal, 80% are successful in getting their insurer’s decision reversed.
This success rate fuels advocates’ efforts to increase awareness about methods for challenging denials. The right information about how to appeal a denial can help put an end to what may seem like a nightmare. State regulators, clinician societies and advocacy organizations like the Alliance for Patient Access provide resources and guidance for overcoming medication access challenges.
Breaking Through the Roadblocks
Patients and providers should understand their chances of getting a denial overturned are high and be encouraged to file an appeal. If they are unable to resolve the issue directly, they can file a complaint with their state insurance department.
State governments – who regulate health care coverage for in-state plans and handle complaints or requests for review – may also provide recourse in the event of a denial. Direct engagement with the state office of insurance may provide an additional avenue for patients dealing with inappropriate denials.
Provider Advocates
Clinicians have a critical role to play in challenging restrictive insurance policies. The high rate of overturned appeals is an important statistic they use in their calls for reforms.
By understanding appeal processes, seeking support from patient advocacy organizations and pushing for policy reforms, health care providers have the power to improve access to the treatment they’ve prescribed to their patients.
While the burden of navigating this process remains high, securing the most appropriate care can measurably improve patients’ outcomes and quality of life – and is worth the fight.
