It’s tough enough that there are no drugs on the market yet specifically FDA-approved for the treatment of Raynaud’s, but when trying to explain why pills for erectile dysfunction can be medically necessary, we’re often entering new territory for most claims processors.
Now there are more options and support for appealing denied medical claims: The Affordable Care Act includes new rights for policyholders to demand reconsideration. And if those efforts fail, there’s now the option to take the case through an independent third party whose decision can override the one from an insurance company. For patients requiring immediate care, they can file both appeals together to speed up the process.
While it may feel like a long-shot, external third-party reviews can be worth the effort. We found this research statistic in a recent article on the Fox Business web site: ” A 2006 study by the industry group America’s Health Insurance Plans found external reviewers decide in favor of the consumer about 40% of the time.”
The article also suggests getting professional help with the appeals process from state insurance departments or specific consumer assistance programs. Here’s the full article on the Fox Business site with lots of useful information about the appeals process and stats that are encouraging for keeping up the fight: Health Insurance Claim Denied? Appeal!
If you’re feeling defeated, check out this article on a patient with MS who was denied insurance coverage for costs associated with his participation in stem-cell transplant trials that were so successful, he now snowboards! He spent years working on the appeals, to the point where he covered the walls of his garage with the rejection letters. But in the end, he not only recovered his out-of-pocket costs, he received double the amount when factoring in interest. Here’s the story in the NY Times: Dogged Persistence Pays Off, With Interest. Sometimes there are happy endings!