Insurance coverage does not dictate clinical needs or decisions. You must advocate for the care or treatment warranted by your patients' conditions. Be direct with patients and their managed care organizations (MCOs). Become familiar with the MCO’s appeals and grievance process. If necessary, make an appeal, or prompt an appeal by the patient or employer. Move up within the MCO as necessary to reach a key decision maker. Ask to speak to a physician reviewer within the MCO, ideally one trained in the specialty in which treatment is sought.
If treatment is still not approved, dispassionately make your case to the MCO’ medical director in a letter. Do not “cc” state agencies, medical societies, or others as a technique of intimidation. Based on the outcomes of those advocacy efforts, you then need to obtain your patient's informed consent to, or refusal of, treatment. You may need to assist patients with alternative payment options. Include patients (and family members wherever possible and appropriate) in the decision process. Consider reasonable alternatives to a rejected treatment plan.
Additional Resources
Bedside Rationing of Health Care Services [PDF]
Health screening test is not covered by the patient's MCO [PDF]
Appealing an MCO's denial of coverage for recommended treatment [PDF]
An MCO recommends that you observe specific practice guidelines [PDF]