Common Insurance Roadblocks for Eczema Patients 

Asian woman sitting at a desk talking to another woman.

Health insurance companies put in place policies intended to help control their costs. These policies sometimes are in direct conflict with what doctors and patients agree would best address the patient’s medical needs. The following are some common ways health insurers deny eczema patients access to treatments and care and what you can do about it.

2 common ways eczema patients are denied treatment

1. Prior authorization

Prior authorization requires your doctor’s office to submit a form detailing your medical history, current health issues, medications, and other relevant clinical information, for review by your insurer before submitting a prescription. 

Based on the information provided in the prior authorization form, your insurer will do one of the following options:

  1. Approve the treatment 
  2. Deny the treatment
  3. Request more information

Insurance companies are increasingly relying on prior authorization to control prescription drug costs, especially if it is a brand-name or “specialty” medication where there is no generic alternative. This tactic is often a common roadblock eczema patients face with medications.

For both patients and healthcare providers, prior authorization is a time-consuming, costly and resource-intensive process that can delay treatment. Treatment may be further delayed if the insurer denies the medication or requests more information before making a decision.

2. Step therapy

Also known as “fail first,” step therapy requires a patient to try and fail another (usually less expensive) drug before the insurer will cover the medication originally prescribed by the doctor.

Step therapy can be bad for patient health if the “step” drug the insurer requires:

  • Is contraindicated (should not be used) because of the patient’s medical history or current health status
  • Delays appropriate treatment so the patient’s symptoms worsen or health deteriorates
  • Is expected to cause significant side effects due to the patient’s gender, biology and severity of disease

You may first realize that step therapy is impacting you when your prescription is denied by your insurance company. When some patients are in this situation, they decide to pay for their medications out of pocket, while others may give up on getting their intended medication altogether. 

Ways To Fight Back On Insurance Issues

Managing step therapy issues 

What do you do if you get stuck in step therapy as an eczema patient? If you and your healthcare provider decide that it’s better to avoid step therapy and go straight to the treatment prescribed, you will need to get prior authorization from your insurance company before they will cover the cost. You need to talk to your provider about requesting prior authorization on your behalf. 

Managing prior authorization issues

If your prior authorization request is denied by your insurance company, you have a right to appeal your claim. You don’t have to accept your insurer’s decision. This applies to prescription denials, and any other treatment denials you may encounter.

There are two ways to file a health insurance appeal: 

  1. An internal appeal directly to the insurance company 
  2. An external appeal to your state’s insurance regulatory agency or the Department of Health and Human Services at the federal level

You should always file an internal appeal first with your insurance company. If the internal appeal is denied, then you can submit an external appeal.

How internal appeals work

An internal appeal asks the insurance company to conduct a full and fair review of its decision. You submit it directly to your insurance company. 

You must file your internal appeal within six months of receiving notice that your claim was denied. 

The Patient Advocate Foundation offers templates for writing effective appeal letters.

While it depends on your state, your health insurer is required to respond to your appeal. The typical timeframe is:

  • Within 15 days if you are seeking prior authorization for a treatment
  • Within 30 days if you are appealing a denial of coverage for a medical procedure you have already received
  • Within 72 hours for urgent care cases

We understand how frustrating it can be waiting for your appeal to be addressed — and there might be times that it’s either delayed or the internal appeal is denied. Don’t give up — you can still file for an external review. Please be sure to provide your healthcare provider with updates as they might be able to work with the health insurer on your behalf. 

How external appeals work

If the internal appeal is denied, you can file for an external review. This calls upon an independent third party to review the insurer’s decision. External appeals typically go to your state’s insurance regulatory agency. A directory of all state insurance regulatory agencies is available on the National Association of Insurance Commissioners website.

In urgent situations, you can request an external review even if you haven’t completed all of the insurer’s internal appeals processes.

Get the latest eczema news delivered to your inbox.