One of the most frustrating things when you need care is to have the procedure you need performed… DENIED. In a recent article, actor Hilary Swank took to social media to express her concerns over denied coverage for treatment of ovarian cysts. Swank’s statement:
“I’m truly exhausted by the way women’s ovarian and cyclical health issues continue to be treated by healthcare insurance companies,” the 46-year-old actress began. “I have experienced it in my own life, and I continually read about it across social media and in the press.”
Swank continued, “Their policies are antiquated, barbaric and primarily view the role of women’s organs solely as a means for procreation. My hope is to create change for all woman suffering from women’s health issues that have to battle with insurance companies who diminish the significance of their problems, don’t believe the patient (or their doctor’s) explanations surrounding their suffering, and severely preclude coverage to only incredibly limited services and procedures. It’s painful enough having to deal with the nature of a female health issue, let alone having to wrestle with the stress of trying to get your insurance company to provide the coverage and care that their contract explicitly states they offer.”
Source: Yahoo – Hilary Swank Sues SAG-AFTRA Health Plan After Coverage is Denied for Ovarian Cysts: Barbaric
How is an Authorization Submitted to My Health Insurance Company?
Physician groups have contractual processes they must follow for submitting to a health insurance company an authorization—a request for a procedure to be performed and paid for. This is done usually via a secure online portal. A form is completed with the option for the physician to provide attachments for clinical data for review. The approvals usually take 1-3 days if urgent and 3-7 days if routine. If the authorization is denied, both you and the physician will receive a letter which is required to include the following information:
- Information on your right to file an appeal
- Specific reason your claim or coverage request was denied
- Detailed instructions on submission requirements
- Deadlines to submit your appeal
- Availability of a Consumer Assistance program, if available in your state.
Reasons for Denial:
- Services are deemed not medically necessary
- Services are no longer appropriate in a specific health care setting or level of care
- The effectiveness of the medical treatment has not been proven
- You are not eligible for the benefit requested under your health plan
- Services are considered experimental or investigational for your condition
Source: Patient Advocate Foundation: Where to Start if Insurance Has Denied Your Service and Will Not Pay
What Options Do I Have If Services Are Denied?
There are three levels of appeals if you wish to pursue:
First-Level-Appeal—The physician can contact the authorization department to ask for the authorization to be reconsidered. This is usually with a nursing team staffed to support approvals or denials. They may ask for clarification and or additional clinical data for consideration. If the authorization is still denied, you can proceed to the second-level-appeal.
Second-Level-Appeal—The physician has a right as stated in the letter to request for a “peer-to-peer” review. Most health insurance authorization departments have a medical director of the authorization department. This is usually the individual your physician meets with for the peer-to-peer review. This allows for a physician to physician clinical discussion regarding the request and why it should be overturned. Your physician has to prove that your service meets the insurance guidelines, and that it was incorrectly rejected. In many cases, this peer-to-peer review provides the adequate information, and the authorization is overturned… approved. If not approved, you can proceed to the third-level-appeal.
Third-Level-Appeal—this process may vary among health insurance companies, but an external review may be requested by you or your physician. If by you, this may be done by calling the member services number on the back of your health insurance card. There is typically a member services case resolution team to handle these types of requests. An external review is usually a team of medical directors, including a physician of the same specialty as your physician to consider the clinical data and request to overturn the authorization for approval.
Source: JDRF: Denials/Appeals: What to do When Insurance Company Denies Coverage
Authorization for Services—DENIED
If all three levels to overturn are unsuccessful, you can opt to have the services performed and pay via a Health Savings Account (HSA) should you have this option with your health insurance plan or speak with the physician group about self-pay options or finance plan.
Conclusion:
An important fact to keep in mind is if your authorization is approved, this does not always guarantee payment. The authorization teams are made up mostly of clinical staff and they approve or deny an authorization based on medical necessity and don’t review in detail your health insurance plan to confirm coverage. It is always important to review your benefits, deductibles and co-insurance so you don’t end up with a hefty out-of-pocket payment.
If you choose to appeal, your health insurance company cannot penalize you by dropping your coverage. An appeal is your right.
If you are experiencing a level of frustration, as Swank stated with ovarian cysts not covered, be mindful of the 2020 election. Health care is a big topic and will be impacted significantly based on which candidate ends up as our next president.
Vote and Be Informed: Savvy Health Care Consumer: Health Care Reform.