Denied? How to Deal with a Health Insurance Denial.

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It’s that feeling of dread every time I open the letters from our health insurer. Is it going to be a denial? No matter how many times a denial happens, I go into panic mode. Instantly, I am calculating how many phone calls will be made, how many letters to write, how long will it take. These inevitably come on a Saturday so my panic gets to settle in all the way until Monday. 

Most of us parent-caregivers of kids that are either being treated for a brain tumor or are living with the effects have been through the den of denials — whether for treatments, medications, therapies or tests ordered by your child’s doctor. If you haven’t had the pleasure,  then it’s a good idea to expect them to come around a time or two or ten. Here are some of the ways that you can manage the denials and the panic.

1. Call the insurance company to confirm they denied. These letters tend to get automatically printed and mailed at the moment of denial so call to make sure the denial still stands. Sometimes, a simple change in diagnosis code from the doctor’s office or hospital clears the situation right up. That’s a good feeling.

2. Make sure the doctor issued a prior authorization for medications. This means that the physician has gotten approval from your health care provider prior to prescribing the medication. If the prior authorization hasn’t gone in but the prescription went to your pharmacy, you will likely get a denial.

3. File an appeal. If the denial continues to stand, your physician can file an appeal. You may also write a letter to personally speak to need for the treatment or medication. 

4. Have your doctor arrange a peer-to-peer. Your child’s physician can ask to have a peer-to-peer review. This is often necessary in particularly rare medical conditions and is usually a phone conversation between the health insurance’s medical director (the one saying no to a medication or treatment) and the treating physician. When a denial gets to this point, the phone call can be vital in changing the outcome.

Expensive medications or those used off-label usually get denied immediately – its like a really pesky health insurance formality. Many times one round of appeals reverses the decision. Denials are painful but part of the process health insurance companies employ to control costs but usually they get reversed. For help with navigating health insurance challenges, visit the Patient Advocate Foundation. This organization can help you with health insurance appeals for free.