Oh boy is this such a hot topic and filled with emotion! I feel that I should share the steps to take in appealing an insurance decision since I have dealt with this multiple times in the short time since Eldest was diagnosed with Type 1 Diabetes on 12/13/14! Just like with anything new, there’s a steep learning curve.
Prior Authorizations are Important
Most insurance companies will require a prior authorization for any major changes in medicine or for larger medical equipment items like insulin pump or CGM (continuous glucose monitor). If your doctor or endocrinologist tells you that you need to switch medications or is putting your Type 1 on new medication or medical equipment, ASK if that requires a PA! While it should be common practice for the medical staff to fill out and send in the needed PAs, they are often overlooked!
Our Endo’s office did NOT send in the correct information ( 3 months BG’s) when we went to get Eldest on the Dexcom. I was furious because that caused a denial which could have been prevented! This meant calling up the healthcare supplier to see what they were told, calling the insurance, and calling the Endo’s office NOT once mind you, but about 3 times each! You will quickly learn how incompetent the employees and the entire system is once you have to deal with multiple people at multiple offices!
Our insurance will allow a re-submission with the first denial before having to file a State Hearing. If you know that you or your child qualifies for the medicine (per your STATE Health Department) or medical equipment that you are requesting then an appeal is needed!
Steps to a Medical Appeal
- Make the appeal as the patient. I found out after the long wait of our first denial that a patient would get a response within 15 days but the doctor’s office would get a response up to 60 days later! Big difference in time frame.
- Be prepared for double talk! Your insurance company will say one thing and the pharmacy or medical supplier is told a different thing-ACK!! Write down the date, time AND person to whom you spoke each time you have to call about a medical order or medical decision. Trust me you will be so glad that you did!
- Be prepared to fight! It is exhausting to deal with PAs and denials when your prescription is about to run out on a Friday of a 3 day Holiday weekend- Yep, been there done that! 11 phone calls over a 7 hour period and a 11 pm dash to a 24 hour pharmacy so that my son would have enough test strips!
Keep Detailed Records
A lot of my headache would have been avoided had I documented each and every time I called our insurance and each time I called the healthcare supplier! If you need to file a formal complaint or an appeal it will be much better for you to have all these details handy AND accurate! While it would be a much easier process if you could just chat with one person from insurance and one person from doctor’s office and one person from the medical supplier that is often NOT the case. It would be much more efficient but unfortunately doesn’t work that way!