Insurance providers make money by attracting and keeping beneficiaries and by controlling the benefits they pay out. Insurance plans control costs in many ways that may affect your coverage. For example, they might refuse to cover or pay only a portion of some medications and services. Or they might limit how much medication or services they cover each year and delay payment for an expensive therapy by requiring you to try a less-expensive option first.
By carefully reviewing and understanding your benefits before receiving treatment, you can troubleshoot insurance problems if they arise. Many pulmonary hypertension (PH) medical teams also have staff dedicated to navigating insurance problems. If you encounter insurance challenges, this information can help you partner with your care team or advocate for yourself to resolve them.
When your health insurance plan requires approval for medical services or treatments before you receive those services or treatments, you need what’s known as prior authorization. Not all services require prior authorization. But depending on the treatment, you might need one. Here’s what to know about obtaining prior authorization.
Step therapy is a requirement that you must try one medication and do poorly on it before your health insurance will cover the therapy prescribed by your physician. Many step therapy requirements can be appealed so you can get the treatment your doctor prescribed right away. Learn more about step therapy.
While specialty pharmacies try to ensure prescription refills are delivered promptly, problems sometimes arise. Each pharmacy has a PH team to address refill delays and options to avoid emergencies such as medication disruptions. Find out what resources are available when you face prescription refill challenges.
Insurance Claims and Appeals
Whenever you receive treatment, you or your medical provider must file a claim for the insurance company to pay for the service. In the claim, you provide the insurance company with detailed information about the services you received. Learn more about filing a claim.
If your insurance company refuses to pay for a treatment or service, you can appeal. An appeal is a request for a re-evaluation of a claim or service that the insurance company denied. You can appeal a denial of a treatment or service that you believe your health insurance plan is obligated to cover. You can also appeal for coverage of a product or service that is not normally covered by your health plan if your physician believes it is essential to your health care. Learn more about appeals.
A grievance is a formal complaint about something other than a coverage decision. A grievance can be filed as a formal complaint with an insurance company or State Insurance Commission regarding any aspect of the services provided by a health care plan.
Resource: Medical Billing & Coding Certification (MB&CC) offers several health insurance guides to help you understand your medical bills, health insurance, the Affordable Care Act and Medicaid. Visit the MB&CC page here.