Understand Your Value When Negotiating with Insurance Companies

He launched a multiprong plan of action to get the policy overturned, starting with writing what he called a one-page white paper, complete with references showing that Botox was the most evidence-based treatment for nonflaccid facial paralysis. Every time the insurance company denied coverage, he would send an appeal to the denial with the white paper attached.

He also enlisted the support of the North Carolina Society of Otolaryngology-Head and Neck Surgery, which reached out to the payer expressing its support for Dr. Miller’s cause. Dr. Miller thought the inclusion of both academic and private practice physicians, who comprise that Society, was important when trying to overturn the payer policy.

To ensure his white paper was being seen by people in the payer organization with decision power, he sent what he called an “Executive Inquiry” which, basically, is a letter that goes to executive leadership that mandates a response. Although Dr. Miller is uncertain if all insurance companies have an “Executive Inquiry,” he suspects they all have something along the same line.

The penultimate step he took was to file a complaint with the North Carolina Department of Insurance, which by law must appoint a state investigator to handle complaints and work with filers to negotiate with the insurance company. Finally, he enlisted the University of North Carolina Health System’s managed care leadership and asked them to get involved.

Two months after the policy change, the insurance company reversed its policy.

Saying that people need to pick their battles with insurance companies, Dr. Miller said this is the type of battle to pick, as the data supported his argument. “When there is something evidence-based and insurers are telling patients that they are going to change coverage or drop coverage of that evidence-based treatment, that is the type of battle to fight,” he said.

He urged people to consider pursuing an “Executive Inquiry” in their negotiations to make sure decision makers are involved, and he also cited the good support he received from the state’s Department of Insurance.

“If you can make sure that the people who are actually making the decisions are seeing your argument, and if you have a well-crafted argument with medical references, the insurers will see that you are being rational,” he said.  

Mary Beth Nierengarten is a freelance medical writer based in Minnesota.