"When Sally Nix found out that her health insurance company wouldn't pay for an expensive, doctor-recommended treatment to ease her neurological pain, she prepared for battle. It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials."
"To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests, and prescriptions. Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to a July poll published by KFF, a health information nonprofit that includes KFF Health News."
Sally Nix endured years of denials before a health insurer switch led to approval, and she now helps other patients appeal denials. To control costs, nearly all insurers require prior authorization for many procedures, tests, and prescriptions. Denials can be appealed, but nearly half of insured adults who faced prior authorization denials found the appeals process somewhat or very difficult. Approval systems can create confusion and fatigue that lead people to give up, so persistence matters. Patients do not need to be insurance experts to succeed; understanding how to push back and knowing which agency governs a plan are crucial. Federal marketplace, Medicare, and Medicare Advantage plans are regulated by HHS, and different plan types are subject to different prior authorization rules.
Read at The Mercury News
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