Denied Prior Approval? 7 Aussie Ways to Fight Back Against Your Health Insurer
Dealing with a health insurance company that's knocked back a prior authorisation request can be incredibly frustrating, especially when it impacts your access to necessary medical treatment. Many Australians aren't aware of their rights or the steps they can take to challenge these decisions. Don't just accept the 'no' – you have options! This guide outlines 7 practical strategies to fight back and get the cover you deserve.
Understanding Prior Authorisation
Before we dive into the fight, let's quickly clarify what prior authorisation is. It's when your health insurer requires your doctor to get their approval *before* you can receive certain treatments, procedures, or medications. Insurers do this to manage costs, but it can often create unnecessary barriers for patients needing care.
7 Ways to Challenge a Denial
Here's a breakdown of how you can push back against a denied prior authorisation:
- Review the Denial Letter Carefully: The letter should state the reason for the denial. Understand *exactly* why they said no. Is it a lack of medical necessity, insufficient documentation, or something else?
- Talk to Your Doctor: Your doctor is your biggest ally. Discuss the denial with them and ask them to provide additional information or a stronger justification for the treatment. They can also write a letter outlining the medical necessity.
- Appeal Internally: Most health insurers have an internal appeals process. Follow the instructions in the denial letter to lodge an appeal. Be clear, concise, and provide all relevant documentation.
- Gather Supporting Evidence: Don't just rely on your doctor's word. Collect any supporting evidence like specialist reports, test results, and relevant medical literature that demonstrates the need for the treatment.
- Consider an External Review: If the internal appeal is unsuccessful, you may be able to request an external review by an independent medical professional. Check your insurance policy for details on this process.
- Contact the Australian Financial Complaints Authority (AFCA): AFCA is an independent body that resolves disputes between consumers and financial firms, including health insurers. You can lodge a complaint with AFCA if you believe your insurer has acted unfairly. https://www.afca.com.au/
- Seek Legal Advice: In complex cases, or if you're facing significant financial hardship due to the denial, consider seeking legal advice from a lawyer specialising in health insurance disputes.
Important Tips for Success
* **Keep Detailed Records:** Document everything – letters, phone calls, emails, and medical records.
* **Be Persistent:** Don't give up easily. Appealing a denial can take time and effort. * **Understand Your Policy:** Familiarise yourself with the terms and conditions of your health insurance policy.Fighting a health insurance denial can feel overwhelming, but remember you have rights. By understanding the process and taking proactive steps, you can increase your chances of getting the medical treatment you need. Don't let a 'no' from your insurer stand in the way of your health and wellbeing!
