Deborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of Umbra Health Advocacy, a marketplace for patient advocacy services, and co-director of the Alliance of Professional Health Advocates, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in healthcare leadership roles, including chief marketing officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill and Managed Care Magazine. She earned a BA in bioethics from Brown University and an MBA with distinction from Harvard Business School.Full Bio
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You might think that your healthcare decisions are between you and your healthcare provider (HCP). But your health insurer can have a lot to say about which treatments you can get.
When your dermatologist prescribes a treatment for a skin condition, for example, there’s a chance your insurance plan won’t pay for it. Arm yourself with information to increase the chances that you can get the treatments you need.
What skin treatments are likely to be covered by insurance?
Medically necessary care to diagnose, treat and prevent skin disorders is more likely to be covered by insurance. Examples include screening, diagnosis and treatment for:
- Skin cancer
- Skin infections
What skin treatments are unlikely to be covered by insurance?
Cosmetic dermatology to improve skin appearance is not likely to be covered by insurance. Examples include services to address the effects of:
- Sun damage
What is medical necessity?
In deciding what treatments to cover, insurers look for evidence that the service, treatment or medication is medically necessary.
Medical necessity refers to services or treatments that are:
- Needed to diagnose, treat, cure or relieve a health condition, illness, injury or disease
- Consistent with medical standards or guidelines
- Not considered experimental or investigational (or not proven or standard)
- Not for cosmetic purposes or only for a patient’s convenience
Common reasons for insurance denials
Insurers may still deny treatments that your HCP prescribes for medical reasons. Common denial reasons include:
- The claim has errors.
- Coding errors – Insurers can deny claims if they aren’t coded correctly.
- Missing information – Insurers can deny claims if certain information isn’t included, such as dates or other details about the services, HCP or patient.
- Late filing – Insurers set limits on how long HCPs have to submit claims for reimbursement. If the HCP submits the claim late, the insurer can deny it.
- Duplication – Sometimes HCP offices will mistakenly bill more than once for the same service.
What can you do?
Often, your HCP can fix these types of mistakes (unless the filing window has closed). Ask your HCP to fix the errors and resubmit the claim.
- The service, treatment or HCP is not covered under your health insurance plan.
- If your HCP prescribes a drug that isn’t on your plan’s list of approved drugs (called a formulary), the insurer can deny the claim or request for approval.
- If the service itself is not covered, such as a cosmetic procedure, the insurer will likely deny the claim or request for approval.
- If the HCP doesn't participate in your health plan’s network, the plan will likely deny coverage even if the service or treatment itself is covered.
What can you do?
You may be able to request an exception to these rules. If you can prove that a specific treatment or HCP is the only way to treat your condition, the insurance company may make an exception to cover the service or treatment.
- The health plan requires you to get permission first before they’ll cover a treatment or service.
- Insurers require that you get permission, called prior authorization, before they’ll pay for some services or medications. If you don’t get that approval, the insurer will probably deny the request.
- In a prior authorization request, you’ll have to explain why you need this treatment.
- Even if you request prior approval, the insurer may still deny your request.
What can you do?
You have rights in the prior authorization process, including several levels of appeal. Your HCP may be able to help. Though it’s the patient’s responsibility to get prior approval, HCPs can prepare the paperwork to support your request.
- The insurer requires you to try other treatments first.
- Sometimes, insurers want you to try a cheaper treatment before they’ll pay for a more expensive one. This process is called step therapy.
- If you haven’t tried the cheaper options first, the insurer can deny your claim until you have tried those and proved that they don’t work for you.
What can you do?
You may have to go through the insurer’s required steps, but your HCP can try arguing that the specific treatment he or she is prescribing is medically necessary and that the alternatives would be a risk to your health. For example, if you’ve had a bad reaction in the past to a drug the insurer wants you to try first, your HCP can document that experience. Or, the HCP may be able to show that delaying your access to the treatment by trying others first could be dangerous.
How to avoid an insurance denial
You may not be able to avoid getting denied for skin treatments, but these steps may give you a better chance of getting coverage:
- Read your health plan documents. No one wants to wade through the member handbook or coverage policies your health plan publishes, but these materials spell out the rules you need to follow to get your care covered. Understanding the rules can help you avoid preventable mistakes.
- Request prior authorization if it’s required. It’s technically your responsibility to get prior approval for specific treatments, but most HCPs will help you make prior authorization requests. Your HCP can include the medical reason for the requested treatment and speak directly with a medical peer who works for the health plan.
- See HCPs who participate in your health plan network. See an HCP who works with your health insurer. If you can’t find one, ask for approval to see an HCP who does not participate, called out-of-network. You’ll have to show that the plan has no one in your area with the right expertise.
- Focus on medical necessity. The stronger the evidence of medical necessity, the more likely it is that the insurer will cover it.
- Stick with it. Just because your insurer denies your request for coverage doesn’t mean you won’t be able to get them to pay for it eventually. Follow the rules for filing appeals and don’t give up. Patients who appeal denials win as much as 4 out of 10 times.
If you can’t get your insurer to approve a treatment, you may still have options.
- Request a cash-pay discount for the treatment from your HCP.
- Use a pharmacy discount card, which sometimes even makes drugs cost less than if you use insurance.
- Check with the drug maker for a coupon or financial assistance.
This resource was created with support from Eli Lilly.