During the beginning of the COVID-19 pandemic, there was not a lot of information on the coronavirus or how to treat it. With so little information out there on how to treat an unknown illness, doctors and patients may be more receptive to experimental treatments and medications. This is a difficult position for any patient with a serious illness and few treatment options, it becomes overwhelming. The situation becomes even trickier when insurance gets involved in paying for these treatments. That’s why FBMC is here to offer tips on navigating healthcare in order to help you become a more well-informed consumer.
Some insurance companies do cover experimental treatments and medications, but there are usually some criteria that must be met beforehand. For example, one of the larger national insurance companies writes that a patient must be in a critical health situation and the clinical trial available must be under current review by the FDA. These strict standards were written by insurance companies to ensure that the treatment benefit outweighs any loss or harm. Insurance companies reserve the right to deny the claim for coverage if they feel the treatment falls outside of the set criteria or does not benefit the patient. This is where patients can then appeal a denial for treatment, but an approval is not a guarantee.
When dealing with a denied claim for a treatment that is considered experimental or in clinical trials, it is important to not lose hope. Appeal the decision and keep an open dialogue with your insurance company to understand the reason for a denial. This includes understanding the insurance lingo first in order to be able to respond. Then make sure you’ve submitted all the information they need in order to make a decision. This can mean showing your insurance that you’ve already tried the treatment out-of-pocket, and it’s benefitted your health. Ultimately you are your best health advocate. It helps to be informed about your healthcare and the options available to you. The more you know and are familiar with how your insurance works the more you can advocate for the treatments and healthcare you need. Always do your research and get familiar with your health plan.
