‘The System is Broken’ for IBD Insurance Denials, Appeals
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AUSTIN, Texas — In a cycle of physician prescriptions, payer denials and repeated appeals, gastroenterologists often become advocates for their patients, according to a presenter at the Crohn’s and Colitis Congress.
“I’m not anti-payer in many ways. I’m anti-medically irresponsible management and I recognize that we can’t do everything we want to do,” David T. Rubin, MD, of the University of Chicago, said during his presentation.
In an online survey Rubin presented in 2016, he showed that 67% of calls for authorization of biologics are made by health care providers and 9.35% are made by physicians themselves.
Looking at communications with payers, 73% of the responders said they communicated with payers more than five times per day and 63% spent a quarter of their time or more communicating with the payers.
“The amount of time, effort and money you spend in your offices to try to deal with this problem is not insignificant,” Rubin said. “Who takes the burden of that cost? The overhead comes to us. We have to shoulder that.”
Rubin detailed ways to avoid denials – know the labels and write to them, document everything, use clinical language, order all labs early, etc. – but admitted they will still happen.
“You will be denied. This happens all the time to all of us. There’s no recognition of expertise. There’s no recognition of where you are,” Rubin said. “But resistance is not futile.”
In the inevitable appeals to be filed, Rubin suggested inclusion of the following: a copy of the denial; a letter of medical necessity detailing all tried and failed therapies, rationale for requested regimen and summary of supporting evidence; emerging clinical literature, abstracts and articles; chart notes, recent labs, objective evidence of disease activity; and “Your direct contact information.”
“They may call you directly or that peer-to-peer call that you’re asking for may call you on your phone at the end of a long day,” he said. “You really need to answer your phone if you’re expecting these.”
In the back pocket, physicians should have the contact information for their state departments of insurance.
“This should always be your ace in the hole,” Rubin said, and it can be mentioned in an appeal as well.
Additionally, there are foundations and options for assistance to patients to fund the costs of medication, Rubin said.
Patients and physicians alike see Rubin as an advocate due to his social media presence, but “It doesn’t work anymore,” he said. “I don’t think it’s the right thing to do for the patient.”
What you can do is join advocacy networks and listservs, contact elected officials and participate in advocacy days, he said.
“This is all working around a broken system. I want to emphasize that. The system is broken. We need to figure out ways around it to treat the patients one by one, but we also need to work at a larger level to fix it,” Rubin said. – by Katrina Altersitz
Reference: Rubin DT, et al. Sp 62. Presented at: Crohn’s and Colitis Congress; Jan. 23-25, 2020; Austin, Texas.
Disclosures: Rubin reports acting as a consultant or receiving grant support from AbbVie, Abgenomics, Allergan, Arena Pharmaceuticals, Biomica, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Check-cap, Dizal Pharmaceuticals, GalenPharma, Genentech, Gilead Sciences, Ichnos Sciences SA, GlaxoSmithKline, Janssen Pharmaceuticals, Lilly, Mahana Therapeutics, Narrow River Managmeent, Pfizer, Prometheus Laboratories, Reistone, Seres Therapeutics, Shire, Takeda, Target PharmaSolutions and Techlab Inc.
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