Sally Nix braced herself for battle when she learned that her health insurance company would not cover the cost of a costly, physician-recommended procedure to relieve her neurological discomfort.
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Years passed, a series of difficult choices, and a change of health insurance before she was eventually approved. After beginning therapy in January, she now devotes her time and efforts to assisting other patients in overcoming rejections.
Don’t panic is one of the things I tell folks when they approach me. Nix, 55, of Statesville, North Carolina, stated that this is not a definitive no.
Prior authorization is a mechanism used by almost all health insurance to limit costs. It requires patients or their doctors to obtain approval before they may obtain specific operations, tests, and medicines.
Denials can be challenged, but according to a July survey by KFF, a nonprofit organization that provides health information, including KFF Health News, almost half of insured persons who had a prior authorization refusal within the previous two years said the appeals procedure was either somewhat or extremely challenging.
According to Nix, insurers know that consumers give up due to uncertainty and exhaustion, which is why it’s intentionally overwhelming. They want you to do precisely that.
“The good news is that you can get results without being an expert in insurance,” she stated. All you have to do is learn how to push back.
Email NBC News at [email protected] if you are facing expenses that don’t seem to be in line or if you are being denied coverage, care, or repairs for your house, automobile, or health.
When a previous authorization request is denied, keep the following advice in mind:
She ended up with a wild bat in her mouth and a large medical bill problem
Health insurers promise changes to prior authorization process. What to know
1. Know your insurance plan.
Does your employer provide insurance for you? A plan that you bought on healthcare.gov? Medicare? Advantage of Medicare? Medicaid?
Although these differences can be perplexing, they are quite important. Prior permission regulations vary depending on the agency that oversees the various types of health insurance.
The U.S. Department of Health and Human Services, for instance, regulates Medicare and Medicare Advantage plans, as well as federal marketplace plans. The Department of Labor regulates employer-sponsored programs. Both state and federal laws apply to Medicaid plans, which are run by state agencies.
Get familiar with the terminology used in your policy. Prior authorization rules are not consistently applied by health insurance companies across all policies. Make sure your insurer is adhering to state and federal standards as well as its own by carefully reading your policy.
2. Work with your provider to appeal.
A large portion of Kathleen Lavanchy’s employment was interacting with health insurance companies on behalf of patients. She resigned in 2024 from her position at an inpatient rehabilitation hospital in the Philadelphia area.
Lavanchy advised calling your clinician and asking to talk with a medical care manager or an office representative who handles prior authorization appeals before contacting your health insurance.
The good news is that an appeal might already be in the works at your doctor’s office.
According to Nix, medical staff members can speak for you. They are fluent in every language.
During the appeals process, you or your provider can ask for a peer-to-peer review, which enables your physician to speak with an insurance company medical professional over the phone about your case.
3. Be organized.
To make medical information, test results, and correspondence conveniently available, many hospitals and physicians utilize a system called MyChart. In a similar vein, patients ought to maintain a record of all correspondence pertaining to an insurance appeal, including phone conversations, emails, snail mail, and in-app messaging.
According to Nix, everything should be arranged, whether digitally or on paper, for easy reference. She said that her own documents at one point demonstrated that her insurance provider had provided contradictory information. She claimed that it was the documents that saved her life.
She advised keeping a fantastic paper trail. Every phone call, letter, and name.
individuals battling a denial have been told to explicitly preserve paper copies of everything, according to Linda Jorgensen, executive director of the Special Needs Resource Project, a nonprofit organization that provides online services for individuals with disabilities and their families.
“It didn’t happen if it’s not on paper,” she remarked.
In order to assist you in taking notes during phone conversations with your insurance company, Jorgensen, who is the caregiver for an adult daughter with special needs, developed a free form that you can print. Before continuing the chat, she suggested getting the insurance representative’s name and ticket number.
4. Appeal as soon as possible.
The good news is that most denials are reversed upon appeal.
Nearly 82% of prior authorization denials from 2019 through 2023 were partially or completely overturned following appeal, according to Medicare Advantage statistics released by KFF in January.
However, time is running out. According to guidelines outlined in the Affordable Care Act, the majority of health plans only allow you to appeal the decision within six months.
Jorgensen cautioned against wasting time, particularly if you were mailing a paper appeal or any supporting documentation via the USPS. She advises filing as soon as possible, ideally four weeks before to the due date.
Some people are using artificial intelligence to help them create personalized appeal letters in order to save time.
5. Ask your HR department for help.
It’s likely that your health plan is self-funded or self-insured if you obtain it via your job. In other words, your employer pays for your care even though they have a contract with a health insurance provider to manage benefits.
Why is that important? Your employer has the final say over what is and isn’t covered under self-funded plans.
Consider the following scenario: your doctor has advised you to have surgery, but your insurer has refused to provide prior authorization for it, stating that the procedure is not medically required. You can make an appeal to your employer’s human resources department if your plan is self-funded, as your employer bears the financial responsibility for your medical expenses rather than the insurance company.
Naturally, there is no assurance that your company will make the payment. However, it’s worth asking for assistance at the very least.
6. Find an advocate.
You can file an appeal with the use of free consumer support organizations offered by several states, which can be contacted by phone or email. They can clarify your benefits and take action if your insurance provider isn’t following the law.
Beyond that, the Patient Advocate Foundation and other nonprofit advocacy organizations may be able to assist. Advice on what to include in an appeal letter can be found on the foundation’s website. Foundation employees can help you combat a denial one-on-one if you are suffering from a serious illness.
7. Make noise.
We have previously written about this. Denials are occasionally reversed when physicians and patients humiliate insurers online.
The same is true when patients get in touch with legislators. Certain types of health insurance are governed by state legislation, and state legislators have the authority to hold insurance firms responsible for policy decisions.
Although it’s not a certainty, contacting your legislator could be worthwhile.
