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IBD Payer-Provider Appeals Process ‘Sucks the Energy Out of You’
Although we have seen the issues of appeals and insurance coverage in areas like hepatitis C where overly expensive drugs needed for 12 weeks are denied on the basis of cost or prerequisites, inflammatory bowel disease presents an additional layer of administrative hardships in that by the time a patient needs a biologic, chances are they are going to need it for an extended period of time, sometimes indefinitely. Yet, the arduous process continues to be a barrier to care in IBD.
What we do need to remember is that the insurance companies, at least in the U.S. health care model, are commercial entities; they have to make money and be profitable. The denials in and of themselves – especially when we are applying to use off-label therapies – can be managed, but we as health care providers need to know the rules so we can follow them. Unfortunately, there is little transparency and no standards across the system.
By rights, with off-label use or differing doses, the payer is going to initially say it doesn’t fall within the approved criteria. We must be ready to respond. But being prepared is never as easy as it sounds. Too often, an insurer will ‘lose paperwork’ or there isn’t a set procedure to follow. Even in an area as specialized as this, we often face denials from someone who is not an expert in our field. It is frustrating for us. I would love to at least have the information reviewed by someone who can understand why you’re appealing. It would be ideal if it were an expert in IBD, of course.
At larger IBD centers, we have employees who spend a lot of time working through these issues. People on the team become experts at this. Here at Mayo, I have a fantastic secretary who understands and navigates this better than others, but why does it have to be that difficult? Why must we dedicate a person to this battle each day? And then there are those companies that require ‘peer-to-peer’ consult, which puts the onus on the physician to spend time on the phone (often on hold) to get what the patient needs.
In the end, this hurts our patients. Not all patients can go to a tertiary care center with volume and expertise. In a general GI practice or even a primary care office, maybe the office staff can’t navigate this process. Some may not realize you almost always appeal – sometimes twice. Some of the patients are probably not getting access to the most appropriate therapies or those at the best doses. Increasing the dosage of adalimumab, for example, sometimes takes a prior authorization and appeals.
Some of these hassles unfortunately drive patients to referral and larger volume centers because they feel the average physician isn’t going to bat for them. To keep patients within your practices, physicians should be aware that there are resources available for these appeals letters. On the Crohn’s and Colitis Foundation website, there are templated appeal letters for various scenarios.
What many patients and physicians don’t realize is that appeal letters need to cite specific studies. Although we may be invested personally in our patients, appeals don’t carry as much weight with only a personal story. Rather, we need to reference a study that contains the information to justify our approach. These templates – from off-label use to dose escalation to prior authorizations – approach the appeal in the manner where you should have the most success.
Maintain your personal investment in the patient when speaking to the patient. Reading through Dan Sharp’s testimony can help us remember the bigger picture. Having even more empathy will allow you to further fight for your patients.
Sadly, this process sucks the energy out of you and it’s enough to make some of us dream of a single payer system where there would be one set process with one set of rules to follow. There might be problems with a single payer system – but you wouldn’t have these.
Join myself @EdwardLoftus2 and experts like David Rubin, MD, @IBDMD, in the ongoing conversations on Twitter. Tag @HealioGastro to comment on our cover story.
Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, CVS Caremark, Celltrion Healthcare, and Napo Pharma; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Allergan, Genentech, and Seres Therapeutics.