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- What Does It Mean When Your Insurance Denies Medical Claims?
- Health Insurance Claim Denied? Fight Back, Possibly Win By Filing Appeal: Here’s How
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What To Do When Insurance Denied Medication – Have a medical test or procedure denied by insurance? How to Appeal Consumer Reports explains how to appeal if your insurance denies a prescribed treatment, test or medication
What do you do if your health insurance provider refuses to cover a test, treatment or medication that your doctor says you need? Before you dig into savings and pay out of pocket, Consumer Reports says you have a guaranteed right to appeal. And the good news is that it’s not that hard to do.
What To Do When Insurance Denied Medication
About 18% of in-network claims by people insured through an Affordable Care Act plan were denied in 2020, according to a Kaiser Family Foundation report.
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But that doesn’t mean you should immediately pay for the treatment yourself, or worse, go without care. Consumer Reports says you have the right to appeal the decision, and that applies to Medicare or private health insurance.
Step one: Call your insurance company to make sure there was nothing wrong with your claim. Mistakes can and do happen at several points in the claims or pre-authorization process, and they are often relatively easy to fix once you identify them.
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If there is nothing wrong, ask to speak to the reviewer behind the decision and request an explanation. You need this information for your next step: file a formal appeal, specifically stating that you disagree with the decision.
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Ask your doctor to write a letter explaining the necessity of the procedure. They are used to this, so don’t be afraid to ask. Gather copies of as many other supporting documents as possible, such as your medical records, treatment studies, and any previous communications with the insurance company.
The next step may be the hardest: waiting. It may take 30 days or longer for a response, but if you need the denied treatment right away, be sure to request an expedited review.
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If you get a letter saying the insurer still chooses to deny the claim, both Medicare and private insurance companies are required by law to give you the reasons in writing and tell you how to appeal the decision for an independent third-party review.
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If you get your insurance through your employer, consider asking your company’s human resources department for help. If your claim was denied by Medicare, you may want to consider getting legal help to get your case heard in front of a judge.
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About Us Our News Standards Submit a Consumer Complaint Submit Photo and Video Contests Our Apps Newsletter Cozi TVOral vancomycin can be extremely difficult for PSC patients to access. It is quite common for insurance companies to deny coverage – even if the patient has been taking oral vancomycin for years! (There are some political motives behind this, which you can read more about here.)
In today’s post, I will share with you exactly how to prepare an appeal if your insurance company has denied coverage of oral vancomycin for you or your loved one’s PSC.
Consumer Reports: How To Appeal A Denied Insurance Claim
Never forget that you, as a patient, have power. If your insurance denies coverage of oral vancomycin for PSC, you don’t have to accept that as an answer. You can file an appeal and fight to get access to oral vancomycin.
And buckle up, because there is PLENTY of evidence as to why insurance could cover it. Let’s dive into it now!
It may take some time to prepare your appeal package. It is okay. Take a deep breath. My PSC advocates and I have gathered all the documents, templates and supporting evidence you need.
Below is a list of required and suggested documents you should include to create an effective oral vancomycin appeal. Further down I will go into detail about each document.
Health Insurance Claim Denied? Fight Back, Possibly Win By Filing Appeal: Here’s How
The foundation of an effective appeal is a strong appeal letter. This appeal letter is a request to your insurance company to reconsider their decision and cover oral vancomycin for your PSC. The purpose of your appeal letter is to provide evidence, reasons, and data to prove why your insurance should cover oral vancomycin.
You MUST adapt the parts highlighted in yellow to your unique situation. And remember to remove the yellow marks before submitting your appeal. Wherever it says “Insurer” please enter your policy name there. And of course, feel free to add anything else about your improved symptoms, test results, etc. that supports your case.
Disclaimer: Please remember that using this appeal template and following the process described in this post does not guarantee that your insurance will agree to cover oral vancomycin for PSC.
To save and edit this template, first click on this link or the image above. Then you have two options. You can either edit as a Google document or as Microsoft Word.
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To edit as a Google Doc: First, sign in to your Google account. Then go to File > Make a copy. Now you are free to edit it in your new, copied version.
To edit as a Microsoft Word document: Just click File > Download > Microsoft Word (.docx). Then you are free to edit it in your own Word document.
Please remember that this appeal letter is a template. You MUST edit it to reflect your own test results, symptoms and experiences. I have marked in bright yellow where you need to edit the template before sending it to your insurance.
A letter of medical necessity is a letter written by the doctor who prescribes your oral vancomycin. The purpose is to show your insurance that you have medical support and support to access oral vancomycin.
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Below is my own medical necessity template. You must edit the parts marked in yellow. Or, if your doctor has a different format, they are welcome to write their own from scratch.
Published research papers are some of the most crucial documents for you to include in your appeal package. Why? Because they present data and evidence showing the effectiveness of oral vancomycin in the treatment of PSC.
In the letter of appeal above. But including the research papers themselves can only help your case. You want to give your insurance as much readily available evidence as possible.
Below are three great pieces of paper that you can print and include in your appeal package. Note that you do NOT need to include all of them. Pick and choose which one(s) you want to include.
Examining Prior Authorization In Health Insurance
This is the essay included in my annual prior authorization to request an additional year of access to oral vancomycin for my PSC. It’s only 10 pages and you can download it here.
This is another good paper to include because it shows that oral vancomycin is effective in treating children as well as adults. It is 11 pages long and you can download it here.
3. A triple-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy and safety of oral vancomycin in primary sclerosing cholangitis: a pilot study
This paper is amazing because it shows that in this pilot study there were ZERO side effects or adverse reactions from taking oral vancomycin for PSC. The “risk” of side effects is a common argument raised by some doctors, and so can insurance. It is 8 pages long and you can download the magazine here.
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P.s. Did you know that I have an entire web page dedicated to research articles and other resources on my website PSC Hub? Check out medical literature and resources here.
This letter to the editor (LTE) was written by Cynthia Buness—a prominent advocate for PSC and oral vancomycin—and a handful of amazing, supportive physicians. LTE was published in the medical journal Hepatology (run by the American Associated for the Study of Liver Diseases (AASLD).
If you want to read my in-depth article on what an LTE is and why it is important, click here.
The two key facts you need to know are that: 1) this LTE is titled “Insurance Should Cover Vancomycin for Primary Sclerosing Cholangitis” and 2) because it was published in AASLD’s journal, AASLD publicly supports that insurance should cover oral vancomycin for PSC. This should help support your appeal package!
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The AASLD Support Statement is a mandatory document. It is written in pleasant, neutral language and states “Although there is insufficient evidence to make a formal recommendation regarding the use of vancomycin for PSC, it should not be used as justification for limiting coverage of this treatment if a physician believes that it’s the right approach.”
This is another public statement that AASLD declares oral vancomycin for PSC should be covered by insurance.
Your insurance company may require you to complete their appeal form. This can vary between insurance companies, so be sure to check your insurance’s website or call them to find out exactly what documents you may need to fill out.
These forms should also tell
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