What To Do When You Need Treatment, But Insurance Won't Pay

What To Do When You Need Treatment, But Insurance Won't Pay
| by Dr Elena Borrelli

So you're excited that after dealing with symptoms for some time and searching for a treatment, you and you have finally found treatment for your symptoms. Perhaps you have been suffering from back pain and have seen various doctors and specialists and you finally are offered a treatment to alleviate your pain. Just when you feel a sense of relief, your hopes come crashing down because, unfortunately, you are informed that your insurance is refusing to approve the treatment. Sound like a familiar scenario? It does to us at Pathway Patient Advocates. This scenario is similar to one we are approached with very frequently. So what do you do? Fortunately, there are many different ways to tackle this problem. As patient advocates, we often are able to help turn this negative situation into a positive outcome for our clients.

Potential Solution Number One — Fixing an Error in the Submission

In these scenarios, it is not always the insurance company that is the issue. Sometimes it's the mere process of what information is submitted to the insurance. Often the coding may be an issue, or the insurance just simply needs more information. A patient advocate can review the information and help determine the submission error. In some situations, it may just be a change in diagnostic coding that is needed, or perhaps an extra piece of information that the insurance company needs, in order to complete the process and get you approved for the treatment that you need.

Potential Solution Number Two — Submitting an Appeal

It is possible that the insurance company is in fact denying the initial request for payment for the procedure. In this situation, an appeal can often be filed depending on the insurance options. The appeal process and the number of appeals allowed do vary by insurance, but almost all insurances do allow for appeals at least one appeal to be filed. In addition, it's essential to talk to different people in the insurance company to really understand what your policy entails. This really goes along with understanding your policy.

This brings us to…

The Importance of Understanding Your Health Insurance Policy

There are two big initial challenges with this task right from the start -1)actually finding the details of what is covered by your insurance policy, and 2)What it actually means! A patient advocate can review your policy and if needed discuss specifics with your healthcare insurance to determine what is actually covered (and what’s not) with your policy.

Potential Solution Number Three — Exhausting Other Options

What if, despite all efforts, the insurance company refused to pay for the treatment? A patient advocate can help you determine your other options. Would the same procedure be covered by a different provider? Or perhaps covered in a different setting or location? Or perhaps an initial treatment must be tried first, and then your health insurance will approve the treatment? Can we go directly to the manufacturer to try to get treatment covered? What similar treatments are available that may be covered?...the list goes on.

As you can see, this process is time-consuming and may seem pretty cumbersome. A private patient advocate can take away this worry because he or she is experienced to manage your issue in a time-sensitive manner.


Call Pathway Patient Advocates to learn how we can help you get the medical treatment you need to be covered. (947) 517-8395