Due to the increasing pressures of health care cost containment, health plans (both public and private) are demanding greater clinical justification for professional evaluations and diagnostics, medications, rehabilitation services, durable medical equipment and more. Common strategies for containing costs within both private plans AND public plans now include:
- Utilization review
- Drug formularies
- Denials of coverage for off-label use of FDA-approved drugs
- Step therapy
- Tiered drug benefits
Anecdotal reports show that delays or denials are most common for:
- Medications- dosages, quantities or routes of administration excluded from the formulary
- Off-label prescribing of medication or devices
- Services that are not covered, have exceeded coverage limits or were improperly authorized
- Supplies or equipment not covered or deemed “not medically necessary”
When a denial of coverage has been made, patients and/or healthcare providers should pursue an appeal when:
- Is the treatment, service or item medically necessary and indicated for this patient?
- Is the treatment, service or item a covered benefit under the patient’s plan? Note: If the desired treatment, service or item is clearly listed as an uncovered benefit, there is virtually no value in pursuing an appeal. However, if the plan materials are unclear or silent on the matter, an appeal is warranted.
- Is the denial based on a clerical error or missing information? If the denial has not already been provided in writing, request it immediately and examine it for errors, such as in the member’s ID number, diagnostic or service code, or date of service.
- Has the patient’s co-payment or co-insurance amount for a covered service, drug or item recently risen and become un-affordable to the patient? Note: If the denial for co-payment or costs of disease modifying therapies, prescription assistance programs are available through most pharmaceutical companies. A list of prescription assistance programs is available online.
Medicare prescription drug plan
By law, Medicare prescription drug plans must cover certain drugs, but are prohibited from covering many others. Drugs prescribed for off-label uses are likely to be denied unless its use is listed in one of three Medicare approved drug compendia. Requests for an exception (appeal) to a Medicare Prescription drug plan should be made under the following circumstances:
- The medically necessary drug, preferred route of administration or dose is not on the plan’s formulary
- The prescriber believes a generic substitution will be ineffective or cause harm
- The plan requires step therapy or limits the prescribed quantity
- The prescribed drug is in a higher “tier” than similar drugs on the formulary
Best practices and expert tips
Navigating the health insurance landscape for your patients can be challenging and time consuming. The following best practices/expert tips from healthcare providers will hopefully make this easier and more efficient:
- Partner with sub-specialists for symptomatic management authorizations and appeals. For example, a urologist may be more successful in achieving coverage of medications for bladder dysfunction.
- Be very detailed and thorough in your exam notes, particularly around symptom and disease management for which you are prescribing medication.
- Utilize your electronic medical record system’s functionality to the fullest potential. Many are equipped with letter templates that you can set up to automatically pull information from a patient’s record right into the letter.
- Use discount programs like Good RX or Needy Meds when appeals are likely to be denied, typically because a drug is not covered by the plan or being prescribed for an off-label use, like modafinil for MS fatigue.
- Use the most precise terms and assume the reader has limited knowledge when writing a letter of medical necessity. Start with the language written in the policy and make sure to include the policy number. Essential components of a letter of necessity include: goals, assessment of patient, treatment plan and medical history. To learn more about writing a letter of medical necessity for a wheelchair check out this presentation provided by the IOMSRT.
Template health insurance appeal letters developed by the Society are available to assist you with the appeals process. Healthcare providers using these templates should:
Step Therapy Appeal
- Include details from the patient’s chart to support the argument. Download this sample chart note as an example.
- Coordinate efforts directly with the patient before writing the appeal letter to avoid confusion and possible duplication of effort.
Disease Modifying Therapy Specific Appeals:
Symptom Management and Rehab