Hurdles in health care: Navigating insurance approvals

For patients with chronic diseases such as inflammatory bowel disease (IBD), new drugs such as biologics are highly effective, but also very expensive.

As a result, many insurance companies have limited access to these medications, forcing doctors and families to jump through hoops to obtain coverage. According to a recent article in ProPublica, insurance companies sometimes force doctors to deny claims without reading them.

To address these challenges, Atos Bousvaros, M.D., vice director of clinical operations at the Boston Division of Pediatric Gastroenterology, Hepatology, and Nutrition, is calling for change and developing the necessary tools to navigate the increasingly difficult approval process. Providing tools to professionals. This research Journal of Pediatric Gastroenterology and Nutrition.

snapshot of what’s happening

In a recent paper, Bousvaros and colleague Dr. Stacy Kahn detail how complex the process of approving and denying certain medicines has become.

They say the market is mainly Monopolized by three specialty pharmacies, and these three companies account for approximately 80% of the overall insurance industry market. So, if your doctor fills out paperwork with one of these three major insurance companies but doesn’t prescribe the drug accurately according to FDA guidelines, you’ll be instantly denied. (It is unclear whether pharmacy benefit managers are denying medications after proper medical review or through software.)

These denials pose a particular challenge in pediatric medicine because many of the drugs used to treat the same conditions in adults have not yet been approved by the FDA for use in children and are prescribed “off-label.” ing.

“Two pressing issues emerge here,” Bousvaros explains. “First, patients are not getting the medicine they need to treat their illnesses. Second, it means more paperwork for health care providers and less time with patients.”

So what do you do if the prescription you wrote for a patient is refused?

What you can do now

While these challenges show no signs of resolving, Bousvaros recommends three ways pediatric specialists can help their patients get the medications they need.

1. Leverage your resources. If you work within a large hospital or health system, you may have access to resources to deny insurance. For example, Boston Children’s Hospital has a dedicated team that helps doctors pre-authorize, limiting the amount of time they spend away from patient care.
2. Perfect your letter writing skills. Another paper by Bousvaros and Kahn shares details on how to write a letter indicating medical necessity. The purpose of a medical necessity letter is to argue why the prescribed drug will benefit the patient. “Writing these letters can be very emotionally taxing, but it’s absolutely critical to doing it right when fighting for your patients,” says Bousvaros.
3. I will stand on the witness stand. Bousbaros encourages doctors to be advocates for their patients. For example, Boston Children’s Hospital has had great success advocating for patient access to scarce services by treating payers as partners. “We also encourage professionals to work with professional and patient organizations to launch additional advocacy efforts to help patients get the care they need,” he says. “Advocacy is critical if we want to improve this process in the future.”