Securing Insurance Coverage

When it comes to insurers covering therapy related to MS, the news is neither all good nor all bad, according to the three experts interviewed for this article. They noted:

1. While there is wide variance in what insurers will and will not cover, obtaining approval for an initial assessment typically is relatively easy. Securing approval for ongoing therapy can be more challenging.

2. When deciding whether to approve therapy services for a person with MS, insurers want to know specific needs, goals, and potential benefits – to the patient and to the healthcare system. The more information that a clinician can provide when referring for therapy, the better. Similarly, the more documentation the therapist can provide about how the treatment regimen relates to the patient’s goals and offers benefits, such as reducing the risk of a fall or other problem that could lead to a costly hospitalization, the more likely an insurer may be to continue covering care.

3. Demonstrating progress is vital. Just as you don’t want to spend your time pursuing therapy that isn’t yielding results, insurers don’t want to spend their money paying for such therapy. Conversely, providing objective evidence of progress may prompt approval for continued sessions.

4. Draw on the expertise of the clinic’s staff. Office personnel often are well-versed in the nuances of different payers’ policies and frequently have good rapport with the people who assess claims at the insurance companies. Don’t be shy about asking for help if needed. It’s also important to feel comfortable discussing any financial concerns about co-pays and deductibles with your therapist.

5. Check if your insurer has a chronic care case manager who can be assigned to work with you. Many insurers employ nurses or other healthcare professionals to coordinate the care of people living with ongoing conditions or illnesses. The payers want their plan members to be well, and they don’t want to spend money on expensive healthcare services that perhaps can be avoided with a modest investment upfront. Think, for example, of the difference in cost between a flu shot and an emergency room visit for the flu. While case managers work for the insurer, they generally will be strong in-house advocates for services that promise to benefit both the patient and the insurer.

6. Be an advocate – for yourself and for other people with MS. Persistence often pays off in today’s healthcare system. So, if your request for therapy services is denied, speak with your therapist and medical provider for assistance in resubmitting the request, possibly with stronger evidence.

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