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Posted on 16. February 2017

The Pre-Approval Blues

By Abbie Cornett

Every year, I dread the new year! That sounds odd until you consider what the new year means to those of us with a chronic illness. It means the dreaded pre-approval and coordination of benefits, which translates into hours on the phone with people who have little or no understanding of chronic conditions, and trying to get approved for medications or treatment we need to survive and, frequently, have been taking for years.

Even though I am a patient advocate, and I work with insurance pre-approvals every day, I will admit I am not a patient person when it comes to my own healthcare. So for the preservation of my sanity, and the safety of all people concerned, I gave up on the whole process personally years ago. Instead, I abdicate the headache to my husband, who for some reason has the patience of Job when dealing with insurance companies. Whenever I ask him how he stands dealing with them, he says someone has to do it.

This year, though has tested even his limits so far. Both of our health insurance companies changed Jan. 1, which means he has to get pre-approval for everything all over again and fill out the coordination of benefits forms. It also means he is still submitting thousands of dollars of bills from last year to companies who we are no longer with, and who are in no hurry to pay.

Trust me, I am grateful to have good insurance when so many people either don’t have coverage or their coverage is inadequate, but that doesn’t make the process any less frustrating. Over the years, I have learned a few things that make the whole process a little easier to bear:

  1. Remember, it isn’t personal. When an insurance company requires a pre-approval, it is trying to control healthcare costs by ensuring the medication or treatment you are seeking approval for is medically necessary and appropriate for your condition.

  2. Be proactive. If changing insurance companies, don’t wait until it’s time for your next treatment to start the pre-approval process. Start submitting medical documentation as soon as you know who your provider is.

  3. Read your insurance policy from cover to cover. Frequently, you will know your benefits better than the person you are speaking to.

  4. Be patient. Remember, you have a rare disease. This means the person you are talking to may never have heard of it! Be ready to explain what your disease is and what the treatments are.

  5. Be prepared for denial. Many times, treatments that are expensive or long-term are denied on the first request. This means you and your physician need to be ready to file an appeal that includes all of the available documentation and lab work. The appeal process is another subject that is at least as frustrating as pre-approval.

  6. Don’t give up! No matter how frustrating the pre-approval process is, you can’t give up. If you can’t handle the process yourself, reach out to a family member or a patient support group.

As the patient advocate for IG Living, I work with patients and their families every day that need help with the pre-approval process and appeals. If you need any help or have been denied insurance, please contact me at acornett@igliving.com.

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Comments (2) -

Joy Kiser
7:34 AM on Saturday, February 18, 2017

Thank you got this timely message.  I have spent hours on the phone because the hospital did not bill correctly.
Joy

April
6:59 PM on Thursday, March 23, 2017

My philosophy is NEVER GIVE UP! Tenacious is my middle name. I have had my share of denials from Insurance companies... some denied claims took 16-18 months of continual appeals and resubmitting information time and time again before the insurance company finally reversed the denial and paid a "prior authorized" claim. I've heard them all, denial for no prior authorization (Wrong - I have the prior authorization letter from the insurance company in hand), denial because it was not emergent (I have a prior authorization letter approving this medication), denial because I'm not using an in network provider (umm... Yes I am, I checked with the insurance company and the specialty pharmacy BEFORE I received the medication). There are insurance companies that have been a JOY to work with and some that have NOT. Do your homework ahead of time and be SURE to read your policy thoroughly. You are your BEST healthcare advocate to ensure you receive the care needed. If you are having trouble reach out to a trusted friend or family member to assist you in the process.

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