How to fight back if denied a prescribed medical treatment

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

But does this happen very often? According to a recent poll of Californians conducted in late August by the Healthcare Consumer Rights Foundation, insurance companies denied access to a medication or treatment deemed necessary by their doctor to 30% of Californians. That amounts to approximately 11.8 million Californians not receiving the health care treatment they were prescribed — a number higher than the total populations of 44 states.

When your life and health are on the line, you really should not take “no” for an answer. There is a way to fight back.

California has an appeals process called an Independent Medical Review. It is available to most patients denied a doctor prescribed treatment. Both the Department of Managed Care and the Department of Insurance uses the IMR process. The type of health coverage you have and the type of medical review required determines which department will accept the consumer’s appeal.

Here’s how an IMR works. The California Department of Insurance explains that any individual covered by a health insurer may file an IMR if they believe that their health services (that had been prescribed by their medical doctor) were denied or delayed because it was “not medically necessary or deemed to be experimental or investigational.”

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

That includes appeals approved by the Independent Medical Review board and cases where health insurers had a “change of heart” once they received notice that an IMR had been filed. That’s great news for those whose appeals were approved, but the fact is, that only helped 2,600 people.

How can that be when our polling estimates that health insurance companies denied treatment or drugs prescribed by their doctor to 11.8 million Californians? Well, according to our survey of more than 850 Californians, less than 2% have used California’s Independent Medical Review process, and only 11.8% were even aware it existed.

With the billions of dollars California currently spends on health care, we ought to spend a portion of those funds to ensure that people get the medication or treatment prescribed by their doctor when their health insurer says no. Using digital and social media, television, radio and print advertising, the state of California could dramatically increase IMR awareness and usage.

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

We can take the simple step of getting the word out about this great resource and help California health care consumers obtain the care they deserve. Ultimately, the California Legislature and others in elected positions of power must direct these agencies to allocate more resources toward expanding IMR awareness and use.