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Medication authorization for patients is a standard process where your insurer reviews whether the treatment or medication you need is necessary and can be covered by your plan. But it can be really frustrating when an insurance company denies your PA request.
Based on the analysis done by KFF in 2023, Medicare Advantage (MA) insurers made 50 million prior authorization requests, out of which approximately 3.2 million (or 6.4%) requests were fully or partially denied in 2023.
This number clearly shows that prior authorization denials are common and it’s important to know what steps to take if it happens to you.
But first, let’s look at the common reasons that lead to prior authorization rejections.
What are the Most Common Reasons for Prior Authorization Denials?
If your medication authorization for patients is denied, you’re not alone. Many patients face the same issue. The good news is that denials often happen for reasons that can be fixed or appealed. Here are some common reasons why these rejections happen:
1. Missing Documents: If your doctor or care team fails to include lab results, past treatment history or a clear explanation of medical necessity, insurers may reject the request.
2. Not Medically Necessary: Even if your doctor believes the treatment is the best option, the insurance company may not agree. They review your case against their guidelines and if they don’t see enough evidence that the treatment is medically necessary for your condition, they can issue a denial.
3. Not Meeting the Necessary Criteria: Sometimes, not every treatment is included in every insurance plan. Some medications, therapies or procedures might be entirely excluded, even if your doctor recommends them. This can also lead to denial of the authorization.
7 Steps to Take If Your Prior Authorization Request is Denied
Getting a denial can be disheartening, especially when you’re counting on that treatment or medication. But don’t give up, many denials can be fixed with a few simple steps. It might be a paperwork issue, a missing detail or something your doctor can clear up. Here’s what you can do next to get things back on track:
1. Review and Analyse the Reason for Denial: Start by carefully reviewing the denial letter that you received from your insurance company. It will tell you why they said no. Common reasons include missing information, the treatment not being covered or the insurance company thinking it’s not medically necessary.
2. Talk to Your Doctor: Your doctor or their office staff can be a big help. They might be able to provide more medical information, correct any errors or send in a new request with stronger support.
3. Request an Internal Appeal: If you still get a “no,” you can challenge the decision by filing an appeal. This means asking the insurance company to take another look at your case.
4. Consider Peer-to-Peer Review: Sometimes, your doctor can speak directly with the insurance company’s doctor on a phone call, which is called a peer-to-peer review. This gives your doctor a chance to explain why the treatment is necessary.
5. Explore Patient Assistance Programs: If your insurance company still doesn’t approve the treatment, look for patient assistance with prior authorization programs, as they may help cover the cost. These are often run by drug companies, hospitals or nonprofit groups.
6. Check for Errors: Sometimes denials happen because of simple mistakes, like a wrong code, a missing document or a mix-up with your insurance info.
7. Document Everything: Keep track of every letter, phone call and email related to your case. Write down names, dates, and what was said.
Conclusion
A prior authorization denial can be frustrating, but it doesn’t have to be the final word. Stay calm, stay organized and speak up. Whether it’s through appealing, correcting errors or turning to EPA support programs for patients, there are many ways to move forward. By following the above steps and getting the right support, you can often get the care or medication you need.
