September 5, 2021

State of Denial

When you submit an insurance form for coverage, have you ever been denied?   What should you do if you’ve already received a denial of service or medication?

Here are examples of denials that may happen:  

• Your health insurance company won’t let you be seen at a hemophilia treatment center (HTC) for comprehensive care because the HTC isn’t “in-network.”

• You can’t go to an HTC because you’re in a health maintenance organization (HMO). Your managed care company doesn’t have any physical therapists in-network experienced with bleeding disorders.

• Your HTC doctor prescribed a brand of factor replacement therapy, and your insurance company won’t approve it.

What can you do about these denials?

Typically, people tell me they’ve just accepted the insurance company’s decision and denial. But you need to be proactive. Did you or your healthcare provider ask the insurance company to reconsider? Did you file a complaint? You have a right to challenge the decision. You’ll likely get help from your provider, and you may enlist the help of your local hemophilia organization. Consider asking for an appeal even if you have Medicaid. Sometimes, people with Medicaid feel they are getting “free” healthcare and don’t want to rock the boat. No matter what type of healthcare coverage you have, you have the right to ask the company to reconsider.

Is this “appealing”?

Here are some ideas on getting what you need, if you need to appeal:

• Insurance companies are in the business of providing care that leads to good medical outcomes for their members. If you and your healthcare providers can show why something is medically necessary, your chances of getting the insurance company to cover it will increase.

• If an HTC isn’t in-network, ask the insurance company to make an exception. When you call the number on the back of your insurance card, be prepared to tell them why you need this service. You’ll probably have to ask the HTC or provider to write a letter to the insurance company. If the insurance company still says no, you can file an appeal.

• If your insurance company doesn’t agree with the treatment plan that you and your healthcare provider have agreed on, you may need a letter of medical necessity. For example, if your treatment plan includes a prescription for a different factor replacement therapy than you currently use, a prior authorization may be required. If the insurance company still doesn’t approve it, you can appeal that decision.

• You’ll need to follow the processes for complaints and appeals that your insurance company requires, so keep good records of phone calls and correspondence (emails, letters, forms).

• You can get the details on the company’s process by calling the number on the back of your insurance card or going to the insurer’s website.

Bottom line: If you and your healthcare team think that you’re not getting medically necessary treatment approved, you’ve got to speak up!

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