Your Insurance and Our Rheumatology Office

Feb 19, 2015

This sample letter explains to rheumatology patients how denials happen and how they can help.

As you know, health care has changed dramatically in the last several years. The Affordable Care Act is just one of many regulatory changes that directly impact our ability to treat your illness.

Many of these changes actually limit our ability to treat you by creating bureaucratic obstacles such as formulary restrictions (insurance will not pay for some medicines at all) or prior authorizations (we must complete burdensome paperwork to ask your insurance company to decide whether you can receive the medicine we prescribe). Sometimes patients are not allowed to see us at all without getting permission from their insurance company first.

This is frustrating for all of us. It limits your treatment options and delays your treatments. It burdens us with complicated paperwork that insurance companies create to meet their own needs, and then they tell you that it is our fault when you don’t receive your medicine because of some problem with their paperwork.

When you have difficulties with your insurance coverage, please remember the following FACTS:

  • We prescribe the treatments, services, and tests that we feel are medically appropriate, that meet current guidelines published by the American College of Rheumatology or other medical societies, and that we feel are best for you and your individual situation. Sometimes there is only one “best” treatment, and other options are not advisable. We will discuss this with you before selecting a treatment or test option.
  • We complete all the forms and papers to get your medicines and tests, as required by your insurance companies. We have NO control over the outcome of THEIR decisions.
  • If your insurance company does not want to give you a medicine we prescribe or to cover a test that we order, please remember that this office cannot control their list of approved drugs or tests.  We will be your advocates, but we cannot force insurance to do anything and we will not substitute what we feel to be an inappropriate medicine to treat you simply because it is on their “preferred” list. We always recommend treatment based on what we believe is best for you.
  • Your health coverage is between you and the insurance company. If you have a dispute with them, we have no legal ability to intervene for you.

We work very hard as your advocate to convince insurance companies to provide the care we have recommended and we appeal their denials when we can, but sometimes they still say “no.” At that point, there is nothing further we can do. But there are still important things you can do:

  • You can contact your local Congressman’s office for Medicare or Federal health insurance coverage. (Although your doctors do try to send these messages to Congress, elected officials are far more likely to listen to you!)
  • For Medicaid or other policies issued by your state, please contact the director of your state program or your state insurance commissioner.
  • For private insurance with Blue Cross, Aetna, Humana, United Health, or other companies, consider contacting the state insurance commissioner’s office after you have exhausted your options by dealing with the company’s representatives directly.