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The recent and tragic attack on Brian Thompson, CEO of United Healthcare Group, has once again brought attention to the pervasive issues surrounding healthcare insurance practices, particularly delays and denials of care deemed necessary by healthcare providers. While violence is never an acceptable way to express frustration, the incident highlights growing concerns among patients about navigating the barriers to timely and essential care.
This is a significant issue in musculoskeletal care, where prior authorization requirements and outright denials are especially common. Services such as advanced imaging (e.g., MRIs), physical therapy, and surgical treatments are frequently delayed or denied, creating frustration for both patients and the clinicians who care for them. While health insurance companies claim to be addressing these challenges, denials of care remain a primary cost-saving mechanism.
However, patients can take proactive steps to reduce the likelihood of delayed or denied care by partnering effectively with their healthcare providers.
1. Understand Your Insurance Coverage
Patients must take an active role in understanding their insurance policies, as healthcare providers cannot track the specifics of the countless plans available in the market.
• Review Your Policy Annually: Familiarize yourself with what is covered, what requires prior authorization, and your financial responsibilities for testing and surgeries.
• Know the Limits: Understand coverage limits, in-network providers, and the criteria for “medical necessity,” though this can be challenging to interpret.
2. Work Collaboratively with Your Healthcare Provider
Healthcare providers often face challenges in navigating complex insurance requirements, and the documentation insurers demand may not always align with optimal patient care.
• Provide Input: Use your medical records portal to monitor notes and ensure all necessary documentation is included, especially details about failed treatments and the risks of delaying care.
• Flag Potential Issues: If you notice gaps in documentation that might trigger a denial, proactively bring them to your provider’s attention.
3. Advocate for Yourself if Care is Denied
If your request is denied, take the following steps to appeal and address the issue:
• Seek Assistance: Ask your provider’s office to help file an appeal, ensuring all required forms are submitted to your insurance carrier.
• Contact Your Insurer Directly: Speak with the authorization department to confirm the status of your request and address any missing information.
• Request an Expedited Review: If your care is time-sensitive, request a faster review process, providing evidence of urgency.
• Understand the Denial: Carefully review the denial letter to identify the reasons behind it. File an appeal with additional documentation to address the insurer’s concerns.
• Keep Records: Document the names, titles, and contact information of everyone you speak with at the insurance company to track your case effectively.
Conclusion
The challenges of navigating insurance roadblocks are real, but by staying informed, advocating for your care, and working closely with your clinician, you can reduce delays and increase the likelihood of receiving necessary treatments. While the broader system needs reform, proactive patient involvement can make a significant difference in the short term.
