Dealing with insurance denials is a critical part of removing barriers to care.
No patient dealing with a serious illness or disease wants to hear that their insurer will not cover a needed aspect of their care. Whether the denial is for a specific medication, a round oftreatment, or an imaging procedure to check the progress of their disease, a coverage denial can feel like an insurmountable hurdle on the journey to better health. Many patients do not realize they can appeal a denial, and many are so overwhelmed that they struggle to compile the information and documentation necessary to submit an effective appeal.
The case managers at PAF have helped tens of thousands of patients over the years to successfully navigate the appeals process. In 2013, 23.7% of the issues faced by PAF’s insured population revolved around insurance access issues. One recent example is Lisa W. who described her father's situation in a letter to Patient Advocate Foundation this spring.
"I'm not sure what I expected when I contacted your company. But I can tell you that I had been tirelessly researching available treatment options, and companies that provide patient advocacy. I had made numerous phone calls, and spent many hours to no avail. So I guess you could say that I was in complete shock when I contacted your company and you were able to submit an expedited appeal and facilitate my father's new medication being approved all within two weeks. My case manager accomplished what I thought was to be impossible in the approval of Medicare covering this medication that cost over $9,000 each month out of pocket.
Our family cried tears of joy. It was just one more option that provided my father hope. Hope to spend additional time with his family, hope for a better quality of life, just plain old hope."
For many patients, the stress and uncertainty that is inherent in the process of submitting an appeal can divert physical and emotional energy away from their recovery. That is why the work our case managers do on behalf of patients facing a coverage denial is critical. They submit the appropriate paperwork and documentation needed to support the case for an appeal, including insurance denials for treatment and pharmaceutical needs.
As Rochonda F. from Florida explained:
“My assigned case manager was a delight to work with. Because of her strong initiative and desire to provide the best service one could ask for, she was able to get my insurance company to approve paying for my medication. She jumped through hoops and did what it took to get the results we needed.“
I am inspired by the work done every day by our case management team, and it is my honor to share with you how PAF is taking the time to make a difference in the lives of patients.