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When Sally Nix found out that her health insurance company wouldn’t pay for an expensive, doctor-recommended treatment to ease her neurological pain, she prepared for battle.
It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials.
“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville, North Carolina.
To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests, and prescriptions.
Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to a July poll published by KFF, a health information nonprofit that includes KFF Health News.
“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”
The good news is you don’t have to be an insurance expert to get results, she said. “You just need to know how to push back.”
Here are tips to consider when faced with a prior authorization denial:
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1. Know your insurance plan.
Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicare Advantage? Medicaid?
These distinctions can be confusing, but they matter a great deal. Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.
For example, federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.
Learn the language specific to your policy. Health insurance companies do not apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.
2. Work with your provider to appeal.
Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital in the Philadelphia area, spent much of her career communicating with health insurance companies on behalf of patients.
Before you contact your health insurer, call your provider, Lavanchy said, and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.
The good news is that your doctor’s office may already be working on an appeal.
Medical staffers can act as “your voice,” Nix said. “They …