Medical Necessity: Advocating For Needed Treatments

By: Meagan Freeman

As a Nurse Practitioner, I became extremely familiar with dealing with the often-frustrating denials by insurance companies, particularly when it comes to prescription drugs. After all, I am the one who holds the professional medical degree, and I am the one who should be determining what treatments my patients required, not an insurance adjuster.

The problem is, insurance companies often have a policy of “automatic denial” for expensive prescription drugs. This policy means that no matter what the circumstance might be, they will always issue a denial when an expensive medication is ordered. This policy may be a deterrent for new providers and patients, and may lead to an unnecessary change in treatment, opting for a less expensive drug that is less effective.

When dealing with insurance companies, my experience has led me to realize that it is incredibly important for providers to immediately argue the case, rather than to simply accept this automatic denial of needed treatment. I often find that a simple phone call to the insurer, with my insistence that the treatment was a medical necessity, and that no other alternative would be acceptable, is all that is needed for an eventual approval. These automatic denials are in place in order to save unnecessary expenses for insurers, whose main focus is always the bottom line. These are not medical professionals on the other end of the phone, and their opinion is not more important than your treating provider’s.

With the new affordable care act, all insurers are required to offer at least one covered medication in each disease category, and cannot deny patients needed medical treatments. Thankfully, no patient can be denied for coverage any longer due to a pre-existing condition such as MS. Our illness is one of the most expensive diseases to treat, with drug prices often exceeding $50,000 per year. This means that we need to become very skilled at advocating for ourselves as patients. If you are told that a necessary treatment was denied by your insurer, let your provider know that you would like them to make a call and argue the medical necessity of the treatment. A simple phone call is often enough to sway the initial opinion, and this simple step is well worth the time if it leads to coverage for a needed multiple sclerosis treatment. If your provider will not take the time to appeal a denial, you may need to consider finding a new provider. Your provider should always be your advocate, no matter what the circumstance may be.

*Meagan Freeman was diagnosed with RRMS in 2009, at the age of 34, in the midst of her graduate education. She is a Family Nurse Practitioner in Northern California, and is raising her 6 children (ranging from 6–17 years of age) with her husband, Wayne. She has been involved in healthcare since the age of 19, working as an Emergency Medical Technician, an Emergency Room RN, and now a Nurse Practitioner. Writing has always been her passion, and she is now able to spend more time blogging and raising MS awareness. She guest blogs for Race to Erase MS, Modern Day MS, and now MSAA. Please visit her at: http://www.motherhoodandmultiplesclerosis.com.

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If you need health insurance…

Don’t forget that Open Enrollment for purchasing health insurance through the new Health Insurance Marketplace ends this year on March 31st. 

If you need health insurance_blog

If you need health insurance and have not already visited the website www.healthcare.gov or called an Insurance Navigator at (800) 318-2596, do it now! Give yourself time to make an informed decision about the best options for you. Five million Americans have already enrolled.

Remember, once the 2014 Open Enrollment period closes, you will not be able to purchase insurance until 2015 Open Enrollment begins, unless you have a qualifying life event (such as the loss of a job or the birth of a new baby). 

Need more information? You can also review MSAA’s website for important information about how the ACA impacts you.

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Need health insurance? Join MSAA for our live webinar:

Don’t forget to sign up and attend MSAA’s live webinar, “The New Insurance Marketplace and MS” tomorrow evening 11/19 from 8PM – 9PM EST.  The webinar provides the ins and outs of the Marketplace, explaining everything from common insurance terms down to MS specific policy pitfalls.  So, register today and come find out what the insurance Marketplace means for you.

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If you have Medicare, get the information you need to know:

Tomorrow, October 15th, is the first day of Medicare Open Enrollment for plan year 2014. The plan that you select now will impact your medical coverage and costs for an entire year. Don’t forget to tune in to our live Webinar tomorrow evening from 8-9PM EST for important information on Medicare Open Enrollment and specific tips for people living with MS.

To register for the Webinar, go to the following link: support.mymsaa.org/aca1

If you cannot attend the live program, don’t worry, you will be able to watch the archive and download the presentation slides from our MSi page after the live program:  http://mymsaa.org/manage-your-ms/videos/.

This year, be prepared. Learn from Medicare experts who can try to help you understand what questions to ask and how to select your best options.

 

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The Affordable Care Act and Multiple Sclerosis

The Patient Protection and Affordable Care Act (PPACA or ACA for short) passed in Congress as a landmark piece of legislation with the intent of securing more accessible healthcare for all Americans. At MSAA, we often receive calls with clients curious and/or concerned about what these changes to the healthcare landscape may entail for them. The Affordable Care Act has enacted numerous changes to both private and public health care coverage (this includes Medicare and Medicaid).

On the private insurance side, here is a short list of just a few reforms that will be enacted starting October 1st:

1. Pre-existing condition exclusions have been eliminated, and insurers can no longer deny applicants based on their MS disease status.
2. Insurers must justify any monthly premium increase of 10% or more before it can take effect.
3. No consumer will be subject to yearly or lifetime benefit caps, which was a major issue for those with MS.
4. If you need to purchase a private plan insurance, it will now be offered through an Enrollment Marketplace in each state.

For Medicare and Medicaid:

1. The percentage for what you pay inside the Medicare Donut Hole will be decreasing every year until it is closed in 2020 and the out of pocket expense will be 25% of the plan’s medication cost.
2. Medicare beneficiaries will receive free wellness exams every year to ensure adequate preventative care.
3. As for Medicaid, for those states that elected to participate, the eligibility criteria will expand to 138% of the Federal Poverty Level or $32,499 for a household of four, for example.

These are just a few of the major reforms that will be taking place under the provisions of the ACA. MSAA has enacted a new initiative to expand education on this topic, including webinars that will focus individually on the changes to Medicare and private insurance.
The first webinar, “Understanding Medicare in the New Era” will take place on October 15th at 8 pm and will be presented by Katherine Fitzpatrick of the Medicare Rights Center and MSAA Client Services Manager, Margaret Weisser and registration is currently open. Registration information for the second webinar on the new State Marketplaces and Private Insurance is forthcoming.

You can register for the Medicare Webinar at: support.mymsaa.org/aca1
We look forward to “seeing” you there!

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