This is often called a denial of service.
Biologicsare the latest class of medication to be approved to treat IBD.
As the patents for some biologic medications expire, other versions, called biosimilars, are becoming available.
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Health insurance plans mayrefuse to cover the cost of a medicationeven when it is prescribed by a physician.
However, medications for IBD are not always interchangeable.
They have different mechanisms of action and are given in different ways.
Often, what is recommended is a less expensive treatment.
This could mean not only an uptick in symptoms but also in potential complications and, therefore, costs.
The majority of the states have enacted legislation that helps patients and physicians in the appeal process.
What Physicians Can Do
Physicians report spending a significant portion of their time on paperwork.
This is often called a peer-to-peer review.
The medical director may have a background in any specialty, not necessarily from gastroenterology.
Unfortunately this can be time-consuming and physicians often carry the burden of lost productivity this process.
What Patients Can Do
Patients may also appeal the decisions made by health plans.
Patients can, however, file a written appeal.
This may mean filling out the paperwork that is determined by the health plan.
A denial of service is often described in a written letter that is sent to the patient.
That letter will also describe the appeal process and what paperwork needs to be filed.
This is why keeping notes from every doctors visit and call to the insurance company is important.
These notes will be extremely useful when communicating with payers about why a medication should be approved.
If this appeal, which is called an internal appeal fails, an external review can be requested.
CMS.gov has a list of states that conduct an external appeals review process.
Summary
A denial from a payer is often a frustrating experience for both physicians and for patients.
Keeping good notes about every step of the process can help patients when talking to the health plan.
2017;23:853857. doi:10.1097/MIB.0000000000001153
StepTherapy.com.Step Therapy Legislation by State.
KFF.org.2024 Employer Health Benefits Survey.
CMS.gov.Affordable Care Act: Working with States to Protect Consumers.
HealthCare.gov.Appealing a health plan decision, External Review.
Healthcare.gov.How to appeal an insurance company decision.
