What Do You Do if Your Preauthorization is Denied?
Here's a look into the start of appealing your denial.
I’ve held off writing about this because it’s such a huge topic with many different factors involved. It’s daunting, and I could write an entire book about it. But instead, I really need to start giving you little tidbits of information.
Recently, I’ve had several, SEVERAL women ask me about how to handle their appeals. Each is a little different, but let’s look at where to start on your appeal process.
First, you have resources. If you dig deep enough, you can find them.
This resource is excellent, and you can get most of your information through here. It’s called The Patient Advocate Foundation. This site can give you a lot of starting information on appeals. An initial explanation they give is this:
Think of an appeal as a contract dispute over the interpretation of the plan coverage details. Your health plan language defines your contract.
Your job is to win the dispute, and you do this with as many facts as possible.
Review your denial carefully.
It will tell you about your next steps for appealing their decision. Your insurer must provide to you in writing:
Information on your right to file an appeal
The specific reason your claim or coverage request was denied
Detailed instructions on submission requirements
Key deadlines to submit your appeal
The availability of a Consumer Assistance program, if available in your state
These initial key factors will guide you on why they denied your preauth, the requirements for submitting your appeal, how much time you have (deadline), and a resource for you to refer to for help.
Investigate why your submission was denied
The most common reason we get denied is because, in insurance lingo, the treatment is not considered medically necessary. You can also contact your insurance if you have any questions. Whenever you call, make sure you write down all of the information you get and who you talk to. Make a log.
Filing a Formal Appeal
Each insurance has a process for appeals. You will get at least two appeals, and the first appeal will be an internal appeal. This means the appeal will be reviewed by one of their medical directors. If your first appeal is denied, you will likely get a second appeal. You won’t get an infinite amount of appeals, so use your appeals wisely. If your internal appeals are denied, you can usually get an external appeal. This is an external entity reviewing your appeal and making a final decision.
You can also file a compassionate appeal. Most of us have insurance through our employer group, which is self-insurance. This type of appeal requests that your employer overturn the decision. With self-insurance, the employer has the final say. I know a few women who have done this and have been successful.
Your formal appeal will involve providing information that disputes their decision. You can provide a long list of information, and plan to send in a large packet, maybe even more information than you had on your original submission.
Your Appeal Packet
The appeal packet is individualized, and you should gather everything you can to show your insurance that the proposed surgery is medically necessary. You should take two angles: you show that you, in fact, do have lipedema (some insurances will deny that you have the condition) and that you have severe pain and mobility issues that have exhausted medical care and can be relieved with surgery.
I know this sounds like a repeat of your original submission, but this is strategic documentation that uses supporting research and information to apply to your personal disease history and symptoms.
This is a general run-down of an appeal packet from the PAF:
DENIAL FOR NOT MEDICALLY NECESSARY
• Review the definition of medical necessity in your member handbook and show that the drug or treatment being requested meets the health plan’s definition
• Request a letter of medical necessity from your treating provider (if you have a second opinion or specialist report that supports the treatment include that as well) stating why the procedure is being recommended
• Prepare a detailed history that highlights previous treatments or therapy attempted as well as the results, did it work or not
• Search online in professional societies or disease associations for information about when the specific type of treatment being recommended is the best practice for your condition. Ideally, ask your prescribing provider’s office to provide some guidance
The most important points on your appeal process:
Use the Consumer Assistance Program (CAP) in your state. Many states help with managing medical insurance denials through their state Department of Insurance. You also have the option to reach out to your state legislators and request help (I think all of us should start doing this anyway).
Don’t give up. Your appeal letter will give you what you need for your next steps. Go through the process, keep on it. Document everything. If you are unsure, go to your resources and get help.
Don’t get discouraged. This is a tough process. It’s easy to feel like you have one issue after another and it can wear you down. Moving through the appeals process is the opportunity to advocate for yourself. You can do this.
Take care,
Michelle
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