Medical treatment

How to respond if you are denied prescribed medical treatment

Has your insurance company ever refused a treatment or medication prescribed by your doctor?

But does this happen very often? According to a recent survey of Californians conducted in late August by the Healthcare Consumer Rights Foundation, insurance companies have denied access to a drug or treatment deemed necessary by their doctor to 30% of Californians. That equates to about 11.8 million Californians not receiving the health care they were prescribed, a number larger than the total population of 44 states.

When your life and health are at stake, you really shouldn’t take “no” for an answer. There is a way to defend yourself.

California has an appeal process called an Independent Medical Examination (IMR). It is available to most patients deprived of treatment prescribed by a doctor. The Department of Managed Care and the Department of Insurance use the IMR process. The type of health coverage you have and the type of medical examination required determines which service will accept the consumer’s appeal.

This is how an IMR works. The California Department of Insurance explains that anyone covered by a health insurer can file an IMR if they believe their health services (which were prescribed by their doctor) were denied or delayed because they were “not medically necessary or deemed to be experimental or experimental.

According to the Department of Managed Care, about 68% of those who applied for an IMR in 2020 ended up receiving the treatment initially denied by their health insurance company.

This includes appeals approved by the independent medical review board and cases where health insurers changed their minds once they were notified that an IMR had been filed. This is great news for those whose appeals have been approved, but the fact is that it only helped 2,600 people.

How can this be when our survey estimates that health insurance companies have withheld doctor-prescribed treatment or medication from 11.8 million Californians? Well, according to our survey of over 850 Californians, less than 2% have used California’s independent medical review process, and only 11.8% were even aware of its existence.

With the billions of dollars California currently spends on health care, we should be spending some of those funds to make sure people get the drugs or treatments their doctor prescribes when their health insurer says no. By using digital and social media, television, radio, and print advertising, the State of California could dramatically increase awareness and use of IMR.

As part of this awareness and publicity plan, we can also equip and educate front-line people — doctors, nurses and pharmacists — about this resource and help them make it accessible to their patients. IMR’s most ardent evangelists should be these medical professionals, because they know what is at stake for their patients if prescribed care is denied. Providing them with step-by-step resources to help guide patients through this process will help expand the use of IMR and improve overall patient outcomes. Increased use of the IMR system will help reduce healthcare costs, as physicians will be able to continue their treatment, potentially avoiding the worsening of symptoms and complications that often result in more doctor visits and prescriptions, and in some cases, a trip to the emergency room. room.

We can take the simple step of spreading awareness about this great resource and helping California healthcare consumers get the care they deserve. Ultimately, the California Legislature and others in elected positions of power must direct these agencies to allocate more resources to expanding the awareness and use of IMR.

Steve Poizner is executive director of the Healthcare Consumer Rights Foundation.