Tips to Avoid Common Access Barriers

Tips to Avoid Common Access Barriers

Stacey Butler, LCSW, Support Program Manager, Sharsheret

Navigating health insurance coverage can be challenging and confusing. The following tips will help you learn more about how to be prepared and understand your coverage, and avoid some common access barriers.

  1. Before speaking with anyone about your health insurance coverage, have a pen/pencil and paper ready. Be prepared to take many notes, and ask the representative to repeat items you are unclear about. Make sure to document what phone number you called, and who you spoke with.
  2. When you call your health insurance company, make sure that you have the right contact phone numbers, mailing addresses, and your personal codes (i.e. ID number, group number, Rx) ready.
  3. When you are facing a health crisis, speak with your health insurance company and learn more about your benefit package. Health insurance companies can send you a copy of your benefit information via email or postal-service. It is important to know what is covered, what is not covered, is you have an out-of-network benefit and what it is, what requires prior authorization, the process for prior authorization, your pharmacy benefit, your reconstruction benefit, your deductibles, policy limits, etc. (Other services to consider inquiring about coverage for include: home health visits, palliative care, physical therapy and rehabilitation, and mental health care and counseling). If the health insurance company uses terms or concepts that are not clear to you – ask. The representative will take the time to answer them, as many times as is necessary. Have them repeat any items you are unclear about.
  4. Speak with your health care professional’s billing office before any procedures to confirm that they are aware of your insurance and the requirements. If you have questions, ask.
  5. If you have concerns about having enough coverage, The Cancer Support Community has partnered with other cancer organizations to create The Cancer Insurance Checklist which can help guide you in choosing an additional plan on the Health Insurance Marketplace.
  6. Many health insurance companies have case managers who can be a regular point of contact and help you navigate your care and questions. Case managers can be referred to in many different ways, including: case manager, nurse case manager, telephonic case manager, or cancer support program. If your health insurance company is not clear what you are asking for, explain how the individual will help you (i.e. being a regular point of contact, assist you in navigating care questions and insurance questions, etc.).
  7. If you do not presently use your online health insurance account, you can request assistance from customer service in setting up an account, and learn how to access your information through the online website. Health insurance company websites can have a great deal of information, which can be helpful in managing your care and health insurance needs throughout your treatment.
  8. Always confirm with your health insurance company – and your health care professional’s office – whether providers are in-network or out-of-network prior to making any appointments. Confirm with your health insurance company whether you have any out-of-network benefits, and what those are. Confirm the covered treatment addresses of all providers (for example, procedures completed in the hospital may be in-network, while a breast center affiliated with the hospital may not be in-network).
  9. Confirm with your health insurance company which in-network radiology and laboratory center you can access. Confirm covered treatment addresses for all providers. Remember, a test completed in a hospital versus in a satellite office may or may not be covered depending on your benefit package.
  10. Confirm all copayments and co-insurances prior to appointments, with both your insurance company and your health care professional’s billing office.
  11. Keep copies of all requests, reports, receipts, letters, bills, documents, and notes from calls with your insurance company and health care professional offices.
  12. Keep a detailed record of your appointments, amounts paid, and claims you submit.
  13. If a claim is denied, speak with your insurance company (or insurance case manager if you have one) to understand why the claim was denied, and what the appeal process is. You can also speak with the health care professional’s billing office to assist you in appealing the denied claim. Make sure to keep records of all communications in the appeal process.

Another important aspect of treatment is your Medication Formulary. These are lists of what are considered “covered” medications by your insurance. These vary depending on your insurer and benefit plan. These are available to you either through direct discussion with a pharmacy representative (from your insurance company), or on the website of your insurer (once you log into the online system.)

Once you have located your formulary (in either print or online format – your preference), your will notice that there are “steps” or “tiers”. These are categories of medications. The categories generally relate to the cost to the insurance carrier for providing pharmacy coverage for that identified medication to those who are covered members (i.e. you.) You should review your formulary with your physician, so that medications being prescribed can be considered based upon your coverage/benefit.

Depending on your insurance plan and/or benefit plan, you may be required to go through the “step” or “tier” process. To put this into easy language, if the medication your physician is prescribing is considered a Step or Tier 4 medication – you may be required to have utilized a similar medication and demonstrated it to be medically non-beneficial. Therefore, you must first utilize the most similar medication to that which your doctor would prescribe in Step or Tier 1 -3 before being able to have a Step or Tier 4 medication covered.

If you decide that you will not accept the medication from the prior Step or Tiers, then you have a few options.

  1. Discuss the insurance recommended medication (from the prior steps/tiers) with your doctor – perhaps he/she feels this would be as efficacious as the one initially discussed.
  2. If your physician still feels that you should utilize the specific medication he/she is recommending, inquire whether there is a generic available for the medication. With this information, then you should contact your insurance plan – speak with a pharmacy representative – and find out what the cost will be to you for that medication as it presently stands. Additionally, during that call confirm if there is a generic, and what the cost will be.
  3. If your physician feels that the prescribed medication is the only medically necessary and appropriate option based upon his/her medical assessment as your physician, then you and your physician can file a request with the pharmacy department to utilize – and have covered – a medication that is out of step or out of tier. There will be a form for you and your physician to complete. The form is usually completed by the Billing Office or Nurse Navigator at your physician’s office – in conjunction with the physician. (They should be familiar with this process.)
  4. If, after you and your physician have submitted the request for covering a medication that is out of step or out of tier, has been denied. You should utilize your Appeal Rights. It is recommended that you speak with a nurse case manager or pharmacy case manager through your insurance to inquire about specific steps for a pharmacy appeal process. Here again, there is usually a portion for you – as the patient and insured person – to complete, and a portion for your physician to complete.

Regardless of insurance carrier or benefit package, generally there are many levels of appeal available. Usually, the first is where you and your physician submit documentation to support why this specific medication – and no other generic or similar – is the only medically necessary option for your medically appropriate treatment. This is then reviewed by a physician from your insurance company for a medically necessary determination to be made. If the request is denied at this level, most insurance companies have a second level appeal – where a different physician (i.e. not the same physician who previously denied under your first level appeal) must speak doctor-to-doctor live. This is usually arranged by your insurance company directly with your physician. During this call, your physician will make the clinical case for why you need this specific medication at this specific time given your particular medical presentation. If your second level appeal is denied, you and your physician can request an external appeal. This appeal goes to an outside company who will then have what is sometimes called a “Fair Trial Hearing.” The purpose is to determine whether the insurance company provided appropriate medical coverage to you (the insured), and whether the physician’s request is medically appropriate – and therefore the original denial would need to be overturned – ultimately allowing you to receive the medication ordered as a covered medication at the benefit plan appropriate rate for that step or tier.

During the appeals process, no matter which level you are on, it is important to have a Nurse Navigator or a Peer Navigator through your insurance. It is also critical to be in direct discussion with your physician, and their support team, for updates on the status of the process. Keep organized and clear records – it is encouraged to keep them in chronological order – and read each and every line. If there are terms or concepts that you are uncertain about, call your insurance and speak with your Nurse Navigator or Case Manager to have them clarify – ask them the same question multiple times if necessary until you are absolutely certain that you understand what your paperwork states.

If you or someone you know is struggling with health insurance, check out these helpful Sharsheret partners.


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