Hurdles in Healthcare: Navigating Insurance Approvals

If you’ve ever had problems with your patients’ insurance company when it came to getting the prescription, you’re not alone. For patients with chronic conditions, including inflammatory bowel disease (IBD), newer medicines such as biologics can be very effective but also very expensive. As a result, many insurance companies have limited access to these drugs and doctors and families are forced to jump through hoops to get coverage. According to a recent ProPublica article, insurance companies sometimes make their doctors reject claims without even reading them.

To address these challenges, Athos Bousvaros, MD, MPH, vice president of clinical operations at Boston’s Division of Gastroenterology, Hepatology and Children’s Nutrition, is calling for change and equipping specialists with the tools they need to navigate an ever-changing approval process. harder.

A snapshot of what is happening

In a recent article, Bousvaros and his colleague Stacy Kahn, MD, detail how complicated the approval and rejection process for some drugs has become. They point out that the market is largely dominated by three specialty pharmaceutical companies and these three companies hold about 80% of the entire insurance industry market. Therefore, if a doctor files paperwork for one of these big three insurance companies but doesn’t prescribe the drug exactly according to FDA guidelines, they are immediately denied. (It’s unclear whether the drug benefits manager is withholding drugs after proper medical review or if the withholding is done through software.) These denials present a particular challenge in pediatric medicine because many of the drugs used to treat the same diseases in adults are not yet approved by the FDA for use in children and are prescribed off-label.

Two immediate problems arise here, Bousvaros explains. The first is that your patient will not receive the drugs he needs to treat his disease. The second is that there is now a lot more provider paperwork, which means less time to spend with patients.

So, what can you do if the prescription you write for your patient is denied?

What can you do now

While these challenges show no signs of disappearing, Bousvaros recommends three ways pediatric specialists can help patients access the medicines they need.

1. Tap into resources. If you work within a hospital or larger healthcare system, you may have access to insurance waste resources. For example, Boston Childrens has a dedicated team that assists physicians with pre-approvals, limiting the amount of time spent away from patient care.

2. Perfect your letter writing. In another article by Bousvaros and Kahn, they share the details of how to write a medical necessity letter. The goal of a medical necessity letter is to demonstrate why a patient will benefit from the prescribed medication. It can be really emotionally taxing writing these letters, but they’re absolutely crucial to being right when you’re fighting for your patient, says Bousvaros.

3. Take a stand. Bousvaros encourages doctors to stand up for their patients. At Boston Childrens, for example, great success has been achieved in supporting patient access to rare services by treating payers as partners. We also encourage specialists to work with professional and patient organizations to launch further advocacy efforts so our patients get the treatments they need, she says. Advocacy is incredibly important if we are to make improvements to this process in the future.

Find out more about our Division of Gastroenterology, Hepatology and Nutrition.