7 Ways To Fight Back When Your Health Insurance Says ‘no’ To Prior Authorization

When Sally Nix recovered retired that her wellness security institution wouldn’t salary for an expensive, doctor-recommended curen to easiness her neurological pain, she prepared for battle.

It took years, a concatenation of conflicting decisions, and a wellness insurer move earlier she yet won approval. She started curen successful January and now channels clip and power into helping different patients conflict denials.

“One of nan things I show group erstwhile they travel to maine is: ‘Don’t panic. This isn’t a last no,’” said Nix, 55, of Statesville, North Carolina.

To power costs, astir each wellness insurers usage a strategy called anterior authorization, which requires patients aliases their providers to activity support earlier they tin get definite procedures, tests, and prescriptions.

Denials tin beryllium appealed, but astir half of insured adults who received a anterior authorization denial successful nan past 2 years reported nan appeals process was either somewhat aliases very difficult, according to a July canvass published by KFF, a wellness accusation nonprofit that includes KFF Health News.

“It’s overwhelming by design,” because insurers cognize disorder and fatigue origin group to springiness up, Nix said. “That’s precisely what they want you to do.”

The bully news is you don’t person to beryllium an security master to get results, she said. “You conscionable request to cognize really to push back.”

If you are dealing pinch bills that look to beryllium retired of statement aliases a denial of coverage, attraction aliases repairs, whether for health, location aliases auto, please email NBC News astatine Costofdenial@nbcuni.com.

Here are tips to see erstwhile faced pinch a anterior authorization denial:

1. Know your security plan.

Do you person security done your job? A scheme purchased done healthcare.gov? Medicare? Medicare Advantage? Medicaid?

These distinctions tin beryllium confusing, but they matter a awesome deal. Different categories of wellness security are governed by different agencies and are truthful taxable to different anterior authorization rules.

For example, national marketplace plans, arsenic good arsenic Medicare and Medicare Advantage plans, are regulated by nan U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by nan Department of Labor. Medicaid plans, administered by authorities agencies, are taxable to some authorities and national rules.

Learn nan connection circumstantial to your policy. Health security companies do not use anterior authorization requirements uniformly crossed each plans. Read your argumentation intimately to make judge your insurer is pursuing its ain rules, arsenic good arsenic regulations group by nan authorities and national government.

2. Work pinch your supplier to appeal.

Kathleen Lavanchy, who retired successful 2024 from a occupation astatine an inpatient rehabilitation infirmary successful nan Philadelphia area, spent overmuch of her profession communicating pinch wellness security companies connected behalf of patients.

Before you interaction your wellness insurer, telephone your provider, Lavanchy said, and inquire to speak to a aesculapian attraction head aliases personification successful nan agency who handles anterior authorization appeals.

The bully news is that your doctor’s agency whitethorn already beryllium moving connected an appeal.

Medical staffers tin enactment arsenic “your voice,” Nix said. “They cognize each nan language.”

You aliases your supplier tin petition a “peer-to-peer” reappraisal during nan appeals process, which allows your expert to talk your lawsuit complete nan telephone pinch a aesculapian master who useful for nan security company.

3. Be organized.

Many hospitals and doctors usage a strategy called MyChart to shape aesculapian records, trial results, and communications truthful that they are easy accessible. Similarly, patients should support way of each materials related to an security entreaty — records of telephone calls, emails, snail mail, and in-app messages.

Everything should beryllium organized, either digitally aliases connected paper, truthful that it tin beryllium easy referenced, Nix said. At 1 point, she said, her ain records proved that her security institution had fixed conflicting information. The records were “the point that saved me,” she said.

“Keep an astonishing insubstantial trail,” she said. “Every call, each letter, each name.”

Linda Jorgensen, executive head of nan Special Needs Resource Project, a nonprofit offering online resources for patients pinch disabilities and their families, has advised patients who are fighting a denial to specifically support insubstantial copies of everything.

“If it isn’t connected paper, it didn’t happen,” she said.

Jorgensen, who serves arsenic a caregiver to an big girl pinch typical needs, created a free form you tin people to thief guideline you erstwhile taking notes during telephone calls pinch your security company. She advised asking nan security typical for a “ticket number” and their sanction earlier proceeding pinch nan conversation.

4. Appeal arsenic soon arsenic possible.

The metallic lining is that astir denials, if appealed, are overturned.

Medicare Advantage data published by KFF successful January recovered that astir 82% of anterior authorization denials from 2019 done 2023 were partially aliases afloat overturned upon appeal.

But nan timepiece is ticking. Most wellness plans springiness you only six months to entreaty nan decision, according to rules laid out successful nan Affordable Care Act.

“Don’t dillydally,” Jorgensen advised, particularly if you’re sending a insubstantial appeal, aliases immoderate supporting documents, done nan U.S. Postal Service. She recommends filing quickly, and astatine slightest 4 weeks earlier nan deadline.

For nan liking of speed, immoderate group are turning to artificial intelligence for thief crafting customizable entreaty letters.

5. Ask your HR section for help.

If you get your wellness security done an employer, there’s a bully chance your wellness scheme is “self-funded” aliases “self-insured.” That intends your employer contracts pinch a wellness security institution to administer benefits, but your employer shoulders nan costs of your care.

Why does that matter? Under self-funded plans, decisions astir what is aliases isn’t covered yet remainder pinch your employer.

Let’s say, for example, your expert has recommended that you acquisition surgery, and your insurer has denied anterior authorization for it, deeming nan process “not medically necessary,” a building commonly used. If your scheme is self-funded, you tin entreaty to nan quality resources section astatine your job, because your employer is connected nan hook for your wellness attraction costs — not nan insurer.

Of course, there’s nary guarantee your employer will work together to pay. But, astatine nan very least, it’s worthy reaching retired for help.

6. Find an advocate.

Many states run free consumer assistance programs, disposable by telephone aliases email, which tin thief you record an appeal. They tin explicate your benefits and whitethorn intervene if your security institution isn’t complying pinch requirements.

Beyond that, immoderate nonprofit defense groups, specified arsenic nan Patient Advocate Foundation, mightiness help. On nan foundation’s website is guidance astir what to see successful an entreaty letter. For those battling terrible disease, instauration staffers tin activity pinch you one-on-one to conflict a denial.

7. Make noise.

We’ve written astir this before. Sometimes, erstwhile patients and doctors shame insurers online, denials get overturned.

The aforesaid holds erstwhile patients interaction lawmakers. State laws modulate immoderate categories of wellness insurance, and erstwhile it comes to mounting policy, authorities lawmakers person nan powerfulness to clasp security companies accountable.

Reaching retired to your legislator isn’t guaranteed to work, but it mightiness beryllium worthy a shot.