Depending on your health insurance policy, you may have noticed that you need to get permission from your insurer before it will pay for a medication, treatment or procedure your doctor prescribes — even if it’s covered by your plan.
This extra step, called prior authorization, is becoming more common with most types of health insurance, including Medicare Advantage, employer coverage and individual plans sold through HealthCare.gov or your state health insurance marketplace.
When your health plan requires prior authorization, your doctor must provide evidence that the specific care is medically necessary and is the best course of action in your situation.
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Prior-authorization requirements have increased significantly over the past few years. For example, virtually all enrollees in Medicare Advantage plans are required to obtain prior authorization for some services, and these insurers made nearly 50 million prior-authorization determinations in 2023, up from 37 million in 2021, according to health policy research organization KFF.
Insurers don’t always approve these requests. In 2023, for example, Medicare Advantage insurers fully or partially denied 3.2 million prior-authorization requests, according to KFF.
Insurers say that prior authorization provides a vital screen to ensure patients receive safe, evidence-based care and to reduce low-value and inappropriate services so that coverage is as affordable as possible.
‘An overused process’
The American Medical Association, however, calls prior authorization “an overused process that interferes with patients receiving timely care, or even any care at all.”
More than one in four physicians report that delays or denials related to prior authorization have led to a serious adverse event, such as hospitalization, disability or even death for a patient in their care.
And prior authorization isn’t the only obstacle you may encounter. You may face a denial of your claim after you receive a procedure or treatment if the insurer decides that your coverage doesn’t include it, or you didn’t get the necessary prior authorization first.
Insurers of health plans sold on HealthCare.gov denied 19% of in-network claims and 37% of out-of-network claims in 2023, according to KFF.
But you don’t have to take no for an answer, and perseverance often pays off. Less than 12% of Medicare Advantage prior-authorization denials were appealed in 2023, but more than 81% of the appealed denials were partially or fully overturned, KFF found.
Only 1% of the in-network denials were appealed for the policies sold on HealthCare.gov, but 44% of the denials were overturned at the first level of appeal, KFF found.
You may also be able to successfully appeal denials from employer health insurance plans or traditional Medicare — whether for prior authorization or for a service you already received — although few people know their appeal rights.
“Never accept the first denial letter you get, because it is often just the default reaction to treatment protocols, especially if it’s something new,” says Suzanne Garner, 47, of San Diego, who was first diagnosed with breast cancer seven years ago.
“It doesn’t matter if the treatment is fully FDA-approved and, in the case of oncology care, even if the National Cancer Coalition and ASCO [the American Society of Clinical Oncology] have endorsed it to be a piece of standard of care,” she says. “If it’s new, for a while, it’s likely to be denied.”
By appealing, Garner has successfully reversed more than 20 prior-authorization denials and five denials for claims after receiving a bill.
“At the beginning, I was very intimidated when I would get these denials and big cost estimates, and I remember crying and saying to my husband that we would have to go into our daughter’s college fund or our retirement fund,” Garner says. “For the most part, we figured it out, but it took being brave, advocating for myself and waiting on hold a lot. Don’t be afraid to appeal, and don’t be afraid to ask a lot of questions.”
Here’s what you need to know to appeal a health insurance denial, whether it involves a prior authorization request or a big bill following a procedure or treatment that you believe your insurance should cover.
Help from your doctor
The procedure for appealing a denial varies depending on the type of health insurance.
“You have to follow the time line and the instructions on the explanation of benefits or the Medicare summary notice,” says Tatiana Fassieux, education and training specialist for California Health Advocates. She helps people with all levels of appeals through HICAP, the state’s health insurance assistance program.
Whatever the appeals process, you should contact your doctor’s office right away after you receive a denial.
“There’s a certain amount of time to appeal — sometimes it’s 30 to 60 days, depending on the insurance. But we might not be alerted to that denial until 21 days have passed, and sometimes it’s a fight against time,” says Michelle Vanderwaall, who spent more than 20 years as an operations manager for several surgical specialties in a San Diego hospital system.
Your doctor’s office can help you determine how urgently you need care. When you’re diagnosed with a major disease, you might feel as though you have to rush to get treatment, with no time for appeals, Garner says.
“Oftentimes, when you’re told you have cancer, it feels like a medical emergency. But you may have weeks or a month or two where you can take a breath and make sure everything is lined up before you have that surgery or scan or treatment.”
Plus, your medical team may regularly deal with appeals, developing expertise in navigating them. The staff at the office of Garner’s oncologist were instrumental in overturning denials for PET scans, breast MRIs, an oophorectomy (ovary removal surgery) and other procedures.
“My oncologist and her team have gone to bat for me. I’ve had so many scans denied,” she says. “I had a number of PET scans because I also have an autoimmune disease that will show up on these imaging studies.”
The insurer initially denied the requests for PET scans and wanted her to have CT scans instead. Several of the denials were reversed after her oncologist got on the phone with a doctor at the insurance company and explained her specific needs, a step called a peer-to-peer review.
Bruce A. Brod, a physician and clinical professor of dermatology at the University of Pennsylvania Perelman School of Medicine, says that he sometimes can get a denial reversed through a peer-to-peer review.
But the conversation isn’t necessarily with other dermatologists, so he may need to take extra time to explain the patient’s needs. “Oftentimes, I’m talking with a nurse practitioner who was involved in primary care, or a primary-care physician. Or sometimes I talk to an OB/GYN or internist who works for the insurance companies,” says Brod.
Another reason to contact your doctor’s office after a denial: It may be a simple mistake.
Garner received a bill for the full cost of a re-excision surgery for her lumpectomy. “When I got the notice, it looked as though insurance covered $0, and I didn’t understand,” she says. “I was stressed out about it, and I brought all the paperwork to my next visit and had my team look at it.”
They discovered that the wrong number/letter combination had been typed in for the surgical code. After they submitted the claim with the correct code, the insurance company covered it.
Other sources of assistance
Some doctor’s offices are more helpful with appeals than others, and you may need to advocate for yourself. But that can be difficult to do when you’re learning new medical terminology while dealing with a major diagnosis.
“I’m aggressive and pretty educated in my diagnosis,” says Garner. “When you get a cancer diagnosis, you have to learn a new language, and it’s super overwhelming.”
Garner learned a lot from other cancer survivors in support groups, and she shares the knowledge she has collected, too.
For example, she helped a neighbor who was diagnosed with breast cancer get 14 months of coverage for an infusion her oncologist recommended. The insurance company wanted to pay for only eight months, citing an older study that suggested eight months of treatment could be just as effective as 14 months.
Garner used Outcomes4Me, a cancer-support app that aggregates medical research for patients based on their specific diagnosis (Garner now works for Outcomes4Me), and they looked through PubMed (a resource of medical literature from the National Institutes of Health) and Google Scholar to find newer studies.
“We were able to pull together a compelling case with numerous studies that showed it was more effective to have the full 14 months,” she says.
You may get help from a nurse navigator or a social worker at the hospital or your doctor’s office. Additionally, nonprofits and advocacy groups specializing in your disease may provide resources and help with claims.
Cancer-focused groups include the American Cancer Society, the Susan. G. Komen Foundation, which focuses on breast cancer, and Triage Cancer, a national nonprofit that provides education on the legal issues after a cancer diagnosis.
Among other disease-specific organizations are the American Diabetes Association, the American Kidney Fund and the National Kidney Foundation.
The Patient Advocate Foundation and Triage Health help people with a variety of serious conditions navigate insurance and financial issues.
“I think one of the major challenges is that there is an overarching lack of awareness about the appeals process,” says Monica Bryant, a cancer-rights attorney and chief operating officer for Triage Cancer.
“This is a lot to put on the shoulders of someone who already has a too-full plate. However, when we’re talking about access to care issues and how to avoid financial hardship after a cancer diagnosis, the appeals process is an incredibly important tool.”
Bryant has helped reverse denials in a variety of situations. She has been able to get coverage for oral chemotherapy when the insurer wanted to cover only IV chemo, or for cancer screenings outside of the usual guidelines — for example, for a person younger than the standard age who needed the screening for a medical reason.
She has also helped get coverage for off-label drugs prescribed by the doctor. “The science moves faster than insurance companies and the law, and the science might indicate that a drug that is approved for one type of cancer is really effective in treating another type and is being prescribed off-label,” she says.
She helps gather the evidence to build the patient’s case, which can include medical records, test results, literature, clinical trial results, a personal narrative or a letter from the doctor, she says.
Prior authorization is much less common for original Medicare than it is for Medicare Advantage plans, but you can get help navigating the appeals process for either type of coverage from your State Health Insurance Assistance Program, the Center for Medicare Advocacy and the Medicare Rights Center.
Your insurance broker may also be able to assist, says Craig Wilcox, a Medicare insurance broker in Northern Nevada.
Next levels of appeal
If the first stage of your appeal is unsuccessful, you can request an external appeal, in which someone from outside the insurance company reviews the evidence.
“We gather all the medical records, and we make sure it’s a complete story and time line of what happened,” says Christine Huberty, an attorney with the Center for Medicare Advocacy.
If that appeal is denied, the next steps vary depending on the type of insurance. For Medicare Advantage plans, you can request a hearing with an administrative law judge. (The case must meet a minimum dollar amount of $190 to be eligible in 2025.) “You don’t need an attorney, but people assume you do,” says Huberty.
She has assisted several people in getting denials overturned at this third level, especially for rehabilitation in a skilled nursing facility.
For example, your doctor may say you need six to eight weeks of rehabilitation after a stroke, but after two weeks of rehab, you get a surprise denial for further care, she says. “The people who fight the denial often get it overturned, but they may have to do it five or six times over the course of their treatment.”
Huberty recently helped Rosemary Perry and Lisa Strelecky with a claim involving their mother’s skilled nursing facility in Hartford, Conn.
Their mother had a severe laceration on her leg from a chair lift footrest and needed 21 stitches. Three days later, she fell on the stairs in her garage and couldn’t walk. After four days in the hospital, she was transferred to a skilled nursing facility for rehab.
“I thought she was going to be there for six to eight weeks to do the physical therapy and get this wound under control,” says Strelecky, who is a neonatal nurse. But nine days after she was admitted, she received a notice that the insurance was going to stop paying for the care.
The sisters called the insurance company to appeal and let them know their mother needed daily nurse care, complicated wound care and physical therapy. The coverage was extended.
Then, six days later, the insurer said the coverage was going to end again. They appealed and got coverage extended for four more days. After that, their appeal was denied.
They wrote a letter explaining that she continued to need physical therapy and nursing care, but the insurer also denied the next level of appeal. Keeping their mother at the facility cost $700 daily without insurance coverage.
They were billed the full cost for a week before moving her to another facility, and she passed away the same day she was transferred.
Shortly after the funeral, Perry and Strelecky contacted the Center for Medicare Advocacy and connected with Huberty, who agreed to accept the case. She gathered the evidence explaining why their mother continued to need skilled nursing facility care during that time and sent it to the insurance company and the administrative law judge.
The day they were scheduled to have a hearing before the administrative law judge, the insurer agreed to pay out for the week of care that was unpaid, which Huberty says is common.
“Had I known that Christine’s department existed, would she have been able to help us sooner?” asks Strelecky. “That would have been amazing.”
Tips for getting out-of-network coverage
The plot of the hit TV show Breaking Bad revolves around Walter White’s scheme for earning money to pay for his out-of-network lung cancer treatments. But rather than cooking meth for the cash, you may be able to get an insurer to cover out-of-network care if you can build a strong enough case that your policy doesn’t include an in-network specialist who provides the specialized care.
“There are network exceptions, and if a patient can show that seeing a provider is medically necessary, that would be a reason to appeal,” says Bryant of Triage Cancer.
In breast reconstruction after a mastectomy, she sees this happen frequently for those who want a procedure known as a DIEP flap reconstruction but have no access to in-network plastic surgeons who perform it. But the exceptions can vary a lot by insurer, she says.
Sometimes your doctor’s office will do the legwork.
Michelle Vanderwaall frequently needed to get out-of-network coverage for patients when she managed an ENT (ear, nose and throat) office. Before ear surgery, for example, sometimes patients have to get a special hearing test with an audiologist, and there may be no in-network specialists who do it, she says.
She would get the names of audiologists in the plan’s network and ask each one whether they could do the test. When she had exhausted all the options, the insurer would usually cover the out-of-network audiologist.
Get a reference number or written letter from the insurance company verifying the extra coverage, she says.
If you’d like to use a doctor who isn’t covered by your plan, you could also switch plans during open enrollment, which is usually in the fall for employer plans, individual plans sold through HealthCare.gov or your state health insurance marketplace, and Medicare Advantage plans (original Medicare lets you see any doctor who participates in the Medicare program).
Even if the doctor you prefer isn’t in a plan’s network, you could get some extra coverage by switching from a health maintenance organization (HMO) to a preferred provider organization (PPO). PPOs usually cover out-of-network providers, but you may need to pay a higher deductible and co-payments than for in-network care.
Note: This item first appeared in Kiplinger Personal Finance Magazine, a monthly, trustworthy source of advice and guidance. Subscribe to help you make more money and keep more of the money you make here.