Duplication \u2013 Sometimes HCP offices will mistakenly bill more than once for the same service. <\/li>\n<\/ul>\n<\/li>\n<\/ul>\nWhat can you do?<\/em><\/p>\nOften, your HCP can fix these types of mistakes (unless the filing window has closed). Ask your HCP to fix the errors and resubmit the claim. <\/p>\n
\n- The service, treatment or HCP is not covered under your health insurance plan.<\/strong>\n
\n- If your HCP prescribes a drug that isn\u2019t on your plan\u2019s list of approved drugs (called a formulary), the insurer can deny the claim or request for approval.<\/li>\n
- If the service itself is not covered, such as a cosmetic procedure, the insurer will likely deny the claim or request for approval.<\/li>\n
- If the HCP doesn’t participate in your health plan\u2019s network, the plan will likely deny coverage even if the service or treatment itself is covered. <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n
What can you do?<\/em><\/p>\nYou may be able to request an exception to these rules. If you can prove that a specific treatment or HCP is the only way to treat your condition, the insurance company may make an exception to cover the service or treatment. <\/p>\n
\n- The health plan requires you to get permission first before they\u2019ll cover a treatment or service.<\/strong>\n
\n- Insurers require that you get permission, called prior authorization, before they\u2019ll pay for some services or medications. If you don\u2019t get that approval, the insurer will probably deny the request.<\/li>\n
- In a prior authorization request, you\u2019ll have to explain why you need this treatment.<\/li>\n
- Even if you request prior approval, the insurer may still deny your request. <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n
What can you do?<\/em><\/p>\nYou have rights in the prior authorization process, including several levels of appeal. Your HCP may be able to help. Though it\u2019s the patient\u2019s responsibility to get prior approval, HCPs can prepare the paperwork to support your request. <\/p>\n
\n- The insurer requires you to try other treatments first.<\/strong>\n
\n- Sometimes, insurers want you to try a cheaper treatment before they\u2019ll pay for a more expensive one. This process is called step therapy.<\/li>\n
- If you haven\u2019t tried the cheaper options first, the insurer can deny your claim until you have tried those and proved that they don\u2019t work for you. <\/li>\n<\/ul>\n<\/li>\n<\/ul>\n
What can you do?<\/em><\/p>\nYou may have to go through the insurer\u2019s required steps, but your HCP can try arguing that the specific treatment he or she is prescribing is medically necessary and that the alternatives would be a risk to your health. For example, if you\u2019ve had a bad reaction in the past to a drug the insurer wants you to try first, your HCP can document that experience. Or, the HCP may be able to show that delaying your access to the treatment by trying others first could be dangerous. <\/p>\n<\/div>\n
\n
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How to avoid an insurance denial<\/p>\n<\/h3>\n
You may not be able to avoid getting denied for skin treatments, but these steps may give you a better chance of getting coverage:<\/p>\n
\n- Read your health plan documents. <\/strong>No one wants to wade through the member handbook or coverage policies your health plan publishes, but these materials spell out the rules you need to follow to get your care covered. Understanding the rules can help you avoid preventable mistakes.<\/li>\n<\/ul>\n
\n- Request prior authorization if it\u2019s required.<\/strong> It\u2019s technically your responsibility to get prior approval for specific treatments, but most HCPs will help you make prior authorization requests. Your HCP can include the medical reason for the requested treatment and speak directly with a medical peer who works for the health plan.<\/li>\n<\/ul>\n
\n- See HCPs who participate in your health plan network.<\/strong> See an HCP who works with your health insurer. If you can\u2019t find one, ask for approval to see an HCP who does not participate, called out-of-network. You\u2019ll have to show that the plan has no one in your area with the right expertise.<\/li>\n<\/ul>\n
\n- Focus on medical necessity. <\/strong>The stronger the evidence of medical necessity, the more likely it is that the insurer will cover it.<\/li>\n<\/ul>\n
\n- Stick with it.<\/strong> Just because your insurer denies your request for coverage doesn\u2019t mean you won\u2019t be able to get them to pay for it eventually. Follow the rules for filing appeals and don\u2019t give up. Patients who appeal denials win as much as 4 out of 10 times. <\/li>\n<\/ul>\n
If you can\u2019t get your insurer to approve a treatment, you may still have options.<\/p>\n
\n- Request a cash-pay discount for the treatment from your HCP.<\/li>\n
- Use a pharmacy discount card, which sometimes even makes drugs cost less than if you use insurance. <\/li>\n
- Check with the drug maker for a coupon or financial assistance. <\/li>\n<\/ul>\n
This resource was created with support from Eli Lilly.<\/em><\/p>\n<\/div>\n<\/div>\n
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