Welcome back! This blog provides financial resources and information for people living with cancer. In this post, I want to focus on prior authorization denials and how to appeal them with your health insurance company. When you are waiting for cancer treatment or diagnostic testing, the sense of urgency can be overwhelming. The last thing that you want to hear is that your health insurance plan will not pay.
Prior authorization (PA) (aka pre-certification) is a process where your cancer treatment team must obtain approval from your health insurance plan before a specific medical service or medication is provided to you. Typically, commercial insurance and Medicare Advantage plans require PAs for expensive health care services. Denials are common for MRIs, PET scans, and some chemotherapy drugs. The usual time frame to receive a PA is 5-10 days.
Why are PAs denied?
The first response to a denied authorization may be that the insurance company does not want to pay for your services. However, many factors can lead to a denial. Incorrect forms, incomplete paperwork, wrong ID number, or lack of supporting evidence for the service can all be reasons that your prior authorization is denied. It has been my experience that even when the extensive paperwork is submitted correctly, services can still be denied.
How to appeal a denied PA:
Take a deep breath and talk with your cancer treatment team. Is there another service/medication that would give you the same benefit? If not, you or your doctor can submit an appeal to your insurance company. Your doctor’s office or treatment center probably has someone on staff that works directly with prior authorizations and denials. If they do, let them handle the appeal. Often appeals are successful if the denial was a result of incomplete paperwork or incorrect forms. Instead of appealing the decision, sometimes it is easier to submit a whole new request.
If you want to submit the appeal yourself, contact the member services phone number on your insurance ID card. Anticipate a 30–40-minute phone call.
- Ask to talk with a representative at your health insurance company.
- Once you have a human being on the line, ask for the contact information for the prior authorization department. Many insurance companies subcontract this service, so write down the contact info before asking to be transferred.
- Ask to be transferred to the prior authorization department. After being transferred, you may be asked to leave a detailed message. If you do not receive a call back from the PA department in 48 hours, call them back.
- Once you have a prior authorization representative on the phone:
- Write down their name and direct phone number/extension.
- Ask them why your request was denied.
- If they are using medical terms that you do not understand, tell them and ask them to explain.
- Ask what is needed to have your request approved. It may be something as simple as asking your doctor’s office to fax an additional code or clinical note.
- Acknowledge that it’s possible that the requested services are being denied for a valid reason, such as an out of network provider or medications that are not FDA approved. In this case, you will need to discuss options with your cancer treatment team.
- Avoid drama. Depending on the reason for the denial, it is easy to get angry and raise the volume of your voice when speaking to the representative. This will not help your case. If you think you may not be able to remain calm during this call, ask a family member or trusted friend to make the call with you. The insurance company representative will ask to speak to you to obtain a verbal agreement that he/she can discuss your medical information with another person.
What if it is more complicated?
Often denied PA’s are a result of an administrative issue. However, there are other factors that are more complicated, such as when the requested service is determined not to be “medically necessary.” If this is the reason for your PA denial, it is difficult to successfully appeal this decision on your own. Often you physician needs to request a “peer to peer” call with your insurance company medical director. If denied, you can request a second level appeal and an independent external review.
If your PA continues to be denied, you may need to contact a health or insurance claim ombudsman. This is a state appointed advocate that works with insurance denials. For state information, go to State Web Map (naic.org). Once you open your state’s insurance website, click on the consumer tab for details. Information on Medicare ombudsman services can be found at Medicare Beneficiary Ombudsman (MBO) | CMS
For More Information:
Prior Authorizations and How to Get Your Medication Covered (goodrx.com)
I hope this information is helpful. If you would like to continue this conversation, please click on the Subscribe button at the top of the Blog page. I would love to hear your comments as well as resources that have worked for you. Please share this information with your family and friends.
Keeping you in my prayers,
Jackie
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