By Dr. Anthony Policastro

Recently I attended a committee meeting. I am the secretary taking minutes for the meeting. The treasurer was having problems contacting a company. The automated attendant did not let her talk to someone and when it did, the individual couldn’t help her.

I asked her to let me try. When I got home from the meeting I went online, looked up the parent company and found the individual in charge of what we were trying to ask about. There was a phone number there. It was after hours but I dialed it anyway. The message I got was the answering machine of the individual herself.

Some of that was related to experience. I had many chances to deal with insurance denials. One of the basic things to remember is that every one that gets frustrated with the system and does not  appeal a denial is a win for the insurance company. 

The denial stays in effect. The person does not get approval. The system is set up to frustrate people so they give up.

I had to face this every January. The Medicaid contract would switch to a different insurer. They had a different drug list. They wanted me to switch my ADHD patients who were not on a drug on their approved list to something else. That something else might not work as well and it would take months to find the right drug and dose.

The result was that every year, I had to appeal to keep my patients who were doing well on their medications to stay on the medication that they were already taken. Sometimes this was easy, other times it wasn’t.

There was one year that I had some patients on a long acting preparation of meditation that was specifically for ADHD. The new insurer wanted me to switch all of the patients on that medication to the short acting version which did not work for ADHD.

I called them up to appeal the list of my patients on the medication. They initially refused. So I had to make them an offer they couldn’t refuse (that’s the Italian way). They told me I had to change the medication. 

So I simply told them that they were forcing me to document it in each patient’s medical record. I planned on writing in each record that the patient was on a medication that was approved by the FDA for ADHD. Then I would write that the current insurer insisted that I put the patient on a medication that was not approved by the FDA for ADHD. Lo and behold, they approved all my patients to take the FDA approved medication.

The process is the same for all insurance denials. Most of them will be overturned on appeal. The company is expecting that many people will not bother with the appeal and just accept the decision. Every time that happens, the insurance company saves money. 

If they wait for an appeal and then approve it, the only extra cost to them is the salary of the person in the appeals department. The bottom line is that if you are the patient and you get an insurance denial, you should always try and appeal it. The squeaky wheel often gets the oil in this situation.