Hurdles in health care: Navigating insurance approvals

For patients with chronic conditions, including inflammatory bowel disease (IBD), newer drugs like biologics can be very effective—but also very expensive.

As a result, many insurance companies have limited access to these medications—and physicians and families are forced to jump through hoops to obtain coverage. According to a recent story from ProPublica, insurance companies sometimes have their physicians reject claims without even reading them.

To address these challenges, Athos Bousvaros, MD, MPH, vice chair of clinical operations in Boston Children's Division of Gastroenterology, Hepatology and Nutrition, is calling for change—and providing specialists with the tools they need to navigate an increasingly difficult approval process. The study is published in the Journal of Pediatric Gastroenterology & Nutrition.

A snapshot of what's happening

In a recent paper, Bousvaros and his colleague Stacy Kahn, MD, detail how complicated the approval and denial process has become for certain drugs.

They point out that the market is largely dominated by three specialty pharmacy companies, and those three companies hold about 80% of the entire insurance industry market. Therefore, if a physician fills out the paperwork for one of these three big-box insurance companies but doesn't prescribe the medication exactly according to FDA guidelines, they're instantly denied. (It is unclear if the pharmacy benefit manager is denying medication after a proper medical review or if the denial is happening through software.)

These denials pose a particular challenge in pediatric medicine because many of the medications used to treat the same illnesses in adults are not yet FDA-approved for use in children and are prescribed "off-label."

"Two immediate problems emerge here," explains Bousvaros. "The first is that your patient won't get the medication they need to treat their illness. The second is that there is now a lot more paperwork for the provider, which means less time is being spent with patients."

So, what can be done if the prescription you write for your patient is denied?

What you can do now

While these challenges show no signs of going away, Bousvaros recommends three ways that pediatric specialists can help patients access the medications they need.

1. Draw on resources. If you work within a larger hospital or health system, you may have access to resources for insurance denials. For example, Boston Children's has a dedicated team that assists with prior authorizations for physicians, limiting the amount of time spent away from patient care.
   
2. Perfect your letter writing. In another paper by Bousvaros and Kahn, they share specifics of how to write a letter of medical necessity. The goal of a letter of medical necessity is to make the case for why a patient will benefit from the drug being prescribed. "It can be really emotionally taxing to write these letters, but they are absolutely crucial to get right when you're fighting for your patient," says Bousvaros.
   
3. Take a stand. Bousvaros encourages physicians to advocate for their patients. At Boston Children's, for example, there has been great success in advocating for patients to gain access to rare services by treating payors as partners. "We also encourage specialists to collaborate with professional and patient organizations to initiate additional advocacy efforts so that our patients get the treatments they need," he says. "Advocacy is incredibly important if we want to make any improvements to this process in the future."