Insurance denied Pennsylvania man cancer medication. Here's how he still got it.
When Paul O'Hara's health insurer denied him coverage for his life-saving cancer treatment, he wasn't willing to take no for an answer.
The Bucks County, Pennsylvania, man credits his survival to the prescription medication Sprycel, which he says he's used to treat his chronic myeloid leukemia for the past 12 years.
"Every morning it's the first thing I take," O'Hara said. "It has little to no adverse side effects."
But O'Hara said he was recently informed his insurance would stop covering the medication until he first tried and failed on a cheaper drug. With a history of adverse reactions to the few other leukemia treatments available, O'Hara said he and his oncologist feared switching from a successful treatment posed too much risk.
"If I go off of it for any period of time, it can weaken the response," he said. "So that's why this can be a life or death situation because this could stop working for me."
Appealing denials
Health insurers deny an estimated 450 million claims each year, by health care improvement company Premier Inc., which is about one out of every 10 claims filed.
Rob Field, , said insurers count on the fact that most people don't realize they can appeal a denied claim.
that consumers rarely appeal denied health insurance claims, with fewer than 1% of denied claims appealed.
But when claims are appealed, it's often in the patient's favor. KFF found in 44% of cases, the original decision was overturned.
"Very often that first level of denial is going to be reversed," Field said. "And even if it isn't, there are often further layers of appeal, often to a medical director and then many insurance companies will have an external appeal process."
When appealing, Field recommends asking your doctor to write a letter explaining to your insurer why you need the treatment or service they're denying. He said you should also ask them to provide medical records to help support your claim.
"It's the squeaky wheels who get the most out of health care," Field said.
Other options to get approval
If the appeal process doesn't work for you, Field said consumers can get creative.
One strategy Field said he's seen used is to ask your company's human resources department to contact the insurance company on your behalf.
An insurance advocate, a professional who can help you navigate the complexities of health insurance and claims, might also be able to help, Field said, but know they might charge a fee to do so.
In some cases, you might also be able to request help from your state's insurance commission. For example, in 2024.
In its first year, the state said the program overturned half of the denials it reviewed. But before you request a review, you must go through an internal appeal with your health plan.
Field warns that whatever you do, it's a process that can be time-consuming and stressful.
"So you've got to be prepared for that and decide in advance that it's worth it," he said.
Finding success
O'Hara said the stress of trying to get his medication has started to take a toll.
"This has been an awful month," he said, recalling how sick he was in the first few years before finding successful treatment. "There's a lot of people that are just going through cancer and getting denied these treatments and they don't know where to turn."
After exhausting his appeals, O'Hara said his oncologist went a different route and applied for coverage .
O'Hara was provided a one-year supply of medication from Bristol Myers Squibb at no cost.
where you can apply to get certain medications at a lower cost or no cost.
"You don't have to take no for an answer," he said.
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