Empowering people affected by MS to live their best lives

Overview

Due to the increasing pressures of health care cost containment, health plans (both public and private) are demanding greater clinical justification for professional evaluations and diagnostics, medications, rehabilitation services, durable medical equipment and more. Common strategies for containing costs within both private plans AND public plans now include:

Prior-authorization
Utilization review
Drug formularies
Denials of coverage for off-label use of FDA-approved drugs
Step therapy
Tiered drug benefits

Anecdotal reports show that delays or denials are most common for:

Medications- dosages, quantities or routes of administration excluded from the formulary
Off-label prescribing of medication or devices
Services that are not covered, have exceeded coverage limits or were improperly authorized
Supplies or equipment not covered or deemed “not medically necessary”

Prior-authorization
Utilization review
Drug formularies
Denials of coverage for off-label use of FDA-approved drugs
Step therapy
Tiered drug benefits

Anecdotal reports show that delays or denials are most common for:

Medications- dosages, quantities or routes of administration excluded from the formulary
Off-label prescribing of medication or devices
Services that are not covered, have exceeded coverage limits or were improperly authorized
Supplies or equipment not covered or deemed “not medically necessary”

When to File an Appeal

pursue an appeal when:

Is the treatment, service or item medically necessary and indicated for this patient?
Is the treatment, service or item a covered benefit under the patient’s plan? Note: If the desired treatment, service or item is clearly listed as an uncovered benefit, there is virtually no value in pursuing an appeal. However, if the plan materials are unclear or silent on the matter, an appeal is warranted.
Is the denial based on a clerical error or missing information? If the denial has not already been provided in writing, request it immediately and examine it for errors, such as in the member’s ID number, diagnostic or service code, or date of service.

Has the patient’s co-payment or co-insurance amount for a covered service, drug or item recently risen and become un-affordable to the patient? Note: If the denial for co-payment or costs of disease modifying therapies, prescription assistance programs are available through most pharmaceutical companies. A list of prescription assistance programs is available online.
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When a denial of coverage has been made, patients and/or healthcare providers should pursue an appeal when:

Is the treatment, service or item medically necessary and indicated for this patient?
Is the treatment, service or item a covered benefit under the patient’s plan? Note: If the desired treatment, service or item is clearly listed as an uncovered benefit, there is virtually no value in pursuing an appeal. However, if the plan materials are unclear or silent on the matter, an appeal is warranted.
Is the denial based on a clerical error or missing information? If the denial has not already been provided in writing, request it immediately and examine it for errors, such as in the member’s ID number, diagnostic or service code, or date of service.

pursue an appeal when:

Is the treatment, service or item medically necessary and indicated for this patient?
Is the treatment, service or item a covered benefit under the patient’s plan? Note: If the desired treatment, service or item is clearly listed as an uncovered benefit, there is virtually no value in pursuing an appeal. However, if the plan materials are unclear or silent on the matter, an appeal is warranted.
Is the denial based on a clerical error or missing information? If the denial has not already been provided in writing, request it immediately and examine it for errors, such as in the member’s ID number, diagnostic or service code, or date of service.

When a denial of coverage has been made, patients and/or healthcare providers should pursue an appeal when:

Is the treatment, service or item medically necessary and indicated for this patient?
Is the treatment, service or item a covered benefit under the patient’s plan? Note: If the desired treatment, service or item is clearly listed as an uncovered benefit, there is virtually no value in pursuing an appeal. However, if the plan materials are unclear or silent on the matter, an appeal is warranted.
Is the denial based on a clerical error or missing information? If the denial has not already been provided in writing, request it immediately and examine it for errors, such as in the member’s ID number, diagnostic or service code, or date of service.

Medicare Prescription Drug Plan

Best Practices and Expert Tips

GoodRx or Needy Meds when appeals are likely to be denied, typically because a drug is not covered by the plan or being prescribed for an off-label use, like modafinil for MS fatigue.

Use the most precise terms and assume the reader has limited knowledge when writing a letter of medical necessity. Start with the language written in the policy and make sure to include the policy number. Essential components of a letter of necessity include: goals, assessment of patient, treatment plan and medical history. To learn more about writing a letter of medical necessity for a wheelchair check out this presentation provided by the IOMSRT.

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Navigating the health insurance landscape for your patients can be challenging and time consuming. The following best practices/expert tips from healthcare providers will hopefully make this easier and more efficient:

Partner with sub-specialists for symptomatic management authorizations and appeals. For example, a urologist may be more successful in achieving coverage of medications for bladder dysfunction.
Be very detailed and thorough in your exam notes, particularly around symptom and disease management for which you are prescribing medication.
Utilize your electronic medical record system’s functionality to the fullest potential. Many are equipped with letter templates that you can set up to automatically pull information from a patient’s record right into the letter.
Use discount programs like GoodRx or Needy Meds when appeals are likely to be denied, typically because a drug is not covered by the plan or being prescribed for an off-label use, like modafinil for MS fatigue.
Use the most precise terms and assume the reader has limited knowledge when writing a letter of medical necessity. Start with the language written in the policy and make sure to include the policy number. Essential components of a letter of necessity include: goals, assessment of patient, treatment plan and medical history. To learn more about writing a letter of medical necessity for a wheelchair check out this presentation provided by the IOMSRT.

GoodRx or Needy Meds when appeals are likely to be denied, typically because a drug is not covered by the plan or being prescribed for an off-label use, like modafinil for MS fatigue.

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Partner with sub-specialists for symptomatic management authorizations and appeals. For example, a urologist may be more successful in achieving coverage of medications for bladder dysfunction.
Be very detailed and thorough in your exam notes, particularly around symptom and disease management for which you are prescribing medication.
Utilize your electronic medical record system’s functionality to the fullest potential. Many are equipped with letter templates that you can set up to automatically pull information from a patient’s record right into the letter.
Use discount programs like GoodRx or Needy Meds when appeals are likely to be denied, typically because a drug is not covered by the plan or being prescribed for an off-label use, like modafinil for MS fatigue.
Use the most precise terms and assume the reader has limited knowledge when writing a letter of medical necessity. Start with the language written in the policy and make sure to include the policy number. Essential components of a letter of necessity include: goals, assessment of patient, treatment plan and medical history. To learn more about writing a letter of medical necessity for a wheelchair check out this presentation provided by the IOMSRT.

Healthcare Appeals

Overview

When to File an Appeal

Medicare Prescription Drug Plan

Best Practices and Expert Tips

Health Insurance Appeal Letters

Additional Resources