Why Denial of Service Happens With IBD Drugs and What to Do About It

Persistence may be necessary in order to appeal and overturn a denial of service

In This Article

It’s a common problem for people who live with inflammatory bowel disease (IBD)—a gastroenterologist prescribes a drug, but the insurance company refuses to cover it. This is often called a denial of service. A denial of service can be appealed but it requires that the patient and/or their physician take action to do so. This article will explain why denials may occur and what physicians and patients can do to appeal the decision. 

Why It Happens

In certain instances, an insurance company may refuse to cover the cost of a particular medication that is prescribed to a patient in order to treat Crohn’s disease or ulcerative colitis.

Biologics are the latest class of medication to be approved to treat IBD. Biologics are drugs that are made from living organisms and they tend to be more expensive than other classes of medications. Some drugs that are approved for the treatment of IBD may still be covered under a patent, which means that there is only one version (the originator) of the drug available. As the patents for some biologic medications expire, other versions, called biosimilars, are becoming available. However, biosimilars are still new to the market and there may or may not be cost savings associated with them.

Insurance companies (often called payers) may refuse to cover the cost of a medication even when it is prescribed by a physician. The insurance company may come back to the physician with a recommendation to start either a different drug or biologic medication. However, medications for IBD are not always interchangeable. They have different mechanisms of action and are given in different ways. Because there are now several types of biologics available, patients and physicians have a choice available to them in terms of these medications. Often the patient and physician work together to find the right biologic that fits a patient’s needs not only for their disease, but also for their lifestyle and their ability to actually receive the medication (such as by infusion or by injection).

If one type of medication is denied coverage by the insurance company, another type of drug might be recommended in its place. Often, what is recommended is a therapy that is less expensive. The practice of insurance companies recommending a less expensive option before trying a more expensive one is called “fail first” or “step therapy.”

Step Therapy

Step therapy is a practice where an insurance company recommends a particular medication be tried before a different (and usually more expensive) medication can be used. In the IBD space, this might mean trying to manage symptoms with a small molecule medication before a biologic can be used. A patient would first need to “try” the small molecule and then not feel better before the other drug would be approved and covered by the insurance company.

Patient advocacy groups are not in favor of step therapy in the IBD space because it is not considered to be a patient-friendly practice. In some cases, patients may worsen on the insurance-company recommended medication before their first choice is covered. This could mean not only an uptick in symptoms but also in potential complications and, therefore, costs. A 2017 study published in the journal Inflammatory Bowel Diseases showed that almost all insurance companies do not follow the IBD management guidelines set forth by the American Gastroenterological Association when creating their policies on medication approvals.

When a physician does not agree with step therapy for their patient, they may appeal to the insurance company. Several states have enacted legislation that helps patients and physicians in the appeal process. In most cases, what this means is that insurance companies are being required to address appeals in a shorter time period: usually 48 or 72 hours. This legislation does not require that payers comply with any medical guidelines or set any rules around overturning a denial of service.

What Physicians Can Do

Physicians report spending a significant portion of their time on paperwork. For gastroenterologists who see patients with IBD, the appeal process for medications may be included in the time spent on paperwork.

To appeal with an insurance company, a physician may not only be required to file a written request but also may need to get on a phone call. This is often called a “peer-to-peer” review. What it means is that the gastroenterologist discusses the need for the medication that was prescribed with a physician at the insurance company, usually a medical director. The medical director may have a background in any specialty, not necessarily from gastroenterology.

Discussing the patient’s need for a particular therapy with the medical director, plus filing any paperwork that’s needed, may help get the denial of service overturned. Unfortunately this can be time-consuming and physicians often carry the burden of lost productivity this process.

What Patients Can Do

Patients may also appeal the decisions made by insurance companies. In most cases, having the medical team work on the appeal will make the most sense and result in the quickest response. Patients can, however, file a written appeal. This may mean filling out the paperwork that is determined by the insurance company.

A denial of service is often described in a written letter that is sent to the patient. That letter will also describe the appeal process and what paperwork needs to be filed. Patients can also call the number on the back of their insurance card and ask about the process for an appeal. 

This is where keeping notes from every doctor’s visit and call to the insurance company is important. These notes will be extremely useful when communicating with payers about why a medication should be approved. Some of the things that will be helpful include the names and dates of when previous medications were tried and why a gastroenterologist prescribed the new medication.

In some cases the insurance company has 30 days (although this time may be shorter in some states) to either approve or deny the appeal.

If this appeal, which is called an “internal appeal” fails, an external appeal can also be filed. An external review means contacting the state Insurance Commission or the federal government’s Department of Health and Human Services and requesting a review. Patients can ask for an external review or one can also be filed by a physician or other member of the healthcare team. In some cases there may be a fee (not more than $25) for an external review. 

A Word From Verywell 

A denial from a payer is often a frustrating experience for both physicians and for patients. There are appeal processes in place but these often require time, energy, and sometimes money in order to complete them. This requires persistence on the part of the health care team in order to see an appeal process through to completion, and hopefully, get the approvals that are necessary. When deciding to appeal a denial of service, many things must be considered, including if there is a chance that the IBD may worsen in the time it takes to “fail” another drug or to complete the appeal process. Keeping good notes about every step of the process can help patients when talking to the insurance company. In addition, making sure the lines of communication with the healthcare team and the insurance company are also important throughout the appeal process. It’s not uncommon to need to file paperwork or spend time on the phone in order to get the denial of service overturned. However, it may pay off in the long run in order to get them started on the right therapy as soon as possible.

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Article Sources

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  1. Yadav A, Foromera J, Feuerstein I, Falchuk KR, Feuerstein JD. Variations in health insurance policies regarding biologic therapy use in inflammatory bowel disease. Inflam Bowel Dis. 2017;23:853–857. doi:10.1097/MIB.0000000000001153 

  2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialtiesAnn Intern Med. 2016;165:753-760. doi:10.7326/M16-0961

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