Does your desk have a stack of denial letters from insurance companies?

w/ millions losing employer-sponsored insurance and transitioning to other plans, you may be redoing prior auths and seeing an influx of denials.

Here’s my #Tweetorial on writing appeal letters. 1/

Quick disclaimer: I primarily write pharmacy (not medical) appeals.

What’s the difference?

Drugs purchased by the clinic or hospital where they are infused are billed to medical benefits. Drugs sent from a pharmacy might be billed to either, depending on the drug / plan.

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I’m also not including tips on the initial prior authorization (PA) process here.

But please let me know if this is something you’d like to see as a future thread!

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1. Get organized

Review due dates in denial letters (ex. response needed in 30 days, 60 days) , timeline to when patient needs drug (ex. already has 2 month supply at home vs urgent new start vs almost out of med), and see if you’re waiting on lab / test results.

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2. Fax Covers

I use a template to save time and to be sure to include necessary + accurate info.

- Institution logo
- Date (auto-populate)
- “To” box
- “From” box w/ my info
- Description: appeal, urgent appeal, or additional info
- Confidentially statement, because HIPAA

Next, start writing it!

3. The Basics

I use another template for the start and end of the letter, to remind me to include:

- Date
- Patient’s name, DOB, other identifiers
- Greeting

And later:

- The words “medically necessary”
- Signature lines

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You can think of these items as the slices of bread on your appeal letter “sandwich”. You need them holding the rest together, but what’s in the middle that’ll make the recipient decide if they’ll buy it.

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4. The Details

Address any criteria, point-by-point.

Cite guidelines / large RCTs, if they exist.

Include additional patient info. (ex. growth charts to demonstrate why an 11 y/o may be fine w/ a 12+ y/o dose.)

Cite the package insert if it’s a newly approved indication.

Don’t have guidelines or large RCTs?

Cite other studies / case series, but in this situation *PRINT THEM AND ATTACH THEM*. The person reviewing your letter may not have access to much more than guidelines and 1-2 drug references.

Details are the sandwich meat in our analogy. 9/

5. The Extras

a. I mention all multidisciplinary team members involved in the decision. (ex. another specialty, PharmD, RD)

b. If you google “how to write an appeal letter”, it’ll tell you not to bother with a “sob story”.

I (partly) disagree.

Why? Two reasons...

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First, these departments at pharmacy benefit managers (PBMs) have incredible amounts of turn-over. Many utilize temps in these roles. It’s a constant revolving door.

You might get a reviewer who is new to the organization, or burnt-out and surprisingly sympathetic.

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Second, writing appeal letters is dreaded, frustrating paperwork. And as mentioned above, I’m using templates.

Including words or sentences that remind me of this specific, individual patient help me stay focused on the person, not just the “criteria”. 12/15

No need for a whole paragraph, but I might say “little boy” instead of “child”. Or I might highlight the physical pain or emotional distress associated w/ that disease.

Again, partly for the reviewer, and partly to keep me feeling connected to my work.

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Check for any errors, a polite but firm tone, and fax it over. Think you’re done now? Almost!

6. STAY organized

Know when to expect a response , and call to confirm status (“under review”) weekly .

Don’t wait 15 or 30 days to find out they never got your fax. 14/15

Do you have tips of your own? ( @ShivaniPharmD @pharmgabbs)

Are there other parts of this process, or other steps between deciding on a treatment plan getting drug into a patient’s hands that you want to hear more about?

Comment below!