Your dermatologist and you… and your health plan?

Your dermatologist and you… and your health plan?

You may feel that your healthcare decisions are between you and your healthcare professional (HCP). But your health insurer may have a lot to say about what treatments you can get.

When your dermatologist prescribes treatment for a skin condition, for example, there’s a chance your insurance plan won’t pay for it. Arm yourself with information to increase your chances of getting the treatments you need.

What skin treatments can be covered by the insurance?

Medically necessary care to diagnose, treat, and prevent skin disorders is more likely to be covered by insurance. Examples include screening, diagnosis and treatment for:

  • Skin cancer
  • Eczema
  • Psoriasis
  • Skin infections

Which skin treatments are unlikely to be covered by insurance?

Cosmetic dermatology to improve the appearance of the skin is unlikely to be covered by insurance. Examples include services to address the effects of:

  • Aging
  • Sun damage
  • Scars

What is medical necessity?

When deciding which treatments to cover, insurers look for evidence that the service, treatment, or drug is medically necessary.

Medical necessity refers to services or treatments that are:

  • Necessary to diagnose, treat, cure, or alleviate a health condition, disease, injury, or illness
  • Consistent with medical standards or guidelines
  • Not considered experimental or experimental (or unproven or standard)
  • Not for cosmetic purposes or for patient convenience only

Common reasons for insurance denials

Insurers can still deny doctor-prescribed treatments on medical grounds. Common reasons for rejection include:

  • The statement contains errors.
    • Coding errors: Insurers may reject claims if they are not coded correctly.
    • Missing information: Insurers may decline claims if certain information is not included, such as dates or other details about services, the health care provider, or the patient.
    • Late Filing: Insurers set limits on the time healthcare professionals have to file claims. If the health care provider makes the claim late, the insurer can refuse it.
    • Duplication – Sometimes HCP offices will incorrectly bill more than once for the same service.

What can you do?

Often, your healthcare provider can correct these types of errors (unless the filing window has been closed). Ask your healthcare professional to correct the errors and resubmit the request.

  • The service, treatment, or HCP is not covered by your health insurance plan.
    • If your health care provider prescribes a drug that isn’t on your plan’s list of approved drugs (called a formulary), the insurer may deny the request or require approval.
    • If the service itself isn’t covered, such as a cosmetic procedure, the insurer will likely decline your claim or request for approval.
    • If your health care provider is not in your health plan’s network, the plan is likely to deny you coverage even if the service or treatment itself is covered.

What can you do?

You may be able to request an exception to these rules. If you can show that a specific treatment or HCP is the only way to treat your condition, the insurance company can make an exception to cover the service or treatment.

  • The health plan requires that you get authorization before it will cover a treatment or service.
    • Insurers require that you get permission, called prior authorization, before paying for some services or drugs. If you don’t get that approval, the insurer will likely decline your claim.
    • In a prior authorization request, you will need to explain why you need this treatment.
    • Even if you ask for pre-approval, the insurer can still deny your request.

What can you do?

You have rights in the pre-authorisation process, including different levels of appeal. Your healthcare professional may be able to help you. While it is the patient’s responsibility to obtain prior approval, healthcare professionals can prepare documentation to support your request.

  • The insurer requires you to try other treatments first.
    • Sometimes, insurers want you to try a cheaper treatment before paying for a more expensive one. This process is called step therapy.
    • If you haven’t tried the cheaper options first, the insurer may deny your claim until you’ve tried them and proven they don’t work for you.

What can you do?

You may need to take the steps required by your insurer, but your healthcare professional can try to argue that the specific treatment they are prescribing is medically necessary and that alternatives would pose a risk to your health. For example, if you’ve had a bad reaction to a drug in the past that the insurer wants you to try first, your doctor can document that experience. Or, the healthcare professional may be able to demonstrate that delaying your access to treatment by trying others first could be dangerous.

How to avoid an insurance refusal

You may not be able to avoid being denied for skin treatments, but these steps may give you a better chance of getting coverage:

  • Read your health plan documents. No one wants to flip through the membership handbook or the coverage policies your health plan publishes, but these materials explain the rules you need to follow to get coverage for your care. Understanding the rules can help you avoid preventable mistakes.
  • Get prior permission if needed. It’s technically your responsibility to get prior approval for specific treatments, but most healthcare professionals will help you submit prior authorization requests. Your health care provider can include the medical reason for your requested treatment and speak directly with a fellow physician who works for the health plan.
  • Consult with the health care providers who participate in your network of health plans. See a healthcare professional who works with your health insurance. If you can’t find one, ask for approval to see a healthcare provider who isn’t participating, called out of network. You’ll need to prove that the plan doesn’t have anyone in your area with the right experience.
  • Focus on medical necessity. The stronger the proof of medical necessity, the more likely the insurer will cover it.
  • Insist. Just because your insurer denies your claim for coverage doesn’t mean you won’t be able to make them pay for it eventually. Follow the rules for filing appeals and don’t give up. Patients who appeal denials win as much as 4 times out of 10.

If you can’t get your insurer to approve a treatment, you may still have options.

  • Request a cash discount for treatment from your healthcare professional.
  • Use a pharmacy discount card, which sometimes even makes drugs cost less than if you use insurance.
  • Check with the drug manufacturer for a coupon or financial assistance.

This resource was created with support from Eli Lilly.