Barriers To Care In The Part D Appeals Process

Medicare regulations establish an appeals process that, in theory, can be navigated by any person with Medicare who has been denied coverage for a prescription by his or her Part D plan. But problems frequently arise because Medicare Part D plans refuse to abide by the rules and prevent people from getting medically necessary medicines. These are the most common obstacles patients face:   

1. Plans ignore appeals submitted by members and their physicians.
Part D plans routinely fail to respond to requests for drug coverage. Time and again patients or their physicians submit requests for coverage and weeks, if not months, pass before their plan reached a decision—if one was provided at all.

2. Consumer representatives cannot provide information to members about the status of their appeals.
When Part D enrollees do not receive a response to their appeal, it is virtually impossible to get any information about the status of a pending appeal from Plan customer service representatives. When advocates call customer service lines to inquire on behalf of clients, they are told that consumer representatives have no access to the appeals database. Advocates are then referred to another hotline, and forced to leave messages. Guess what? Often, these messages are never returned.

3. Plans do not take into account submitted medical support, but rather “rubber stamp” denials, and customer service representatives cannot advise members what (additional) medical documentation is needed.
Part D plans notoriously fail to read physicians’ supporting statements indicating that alternative medications have been harmful or ineffective. Plans deny medications for failure to meet step therapy or prior authorization requirements even when physicians explicitly indicate that such requirements have been met. Furthermore, when frustrated members call their plan for advice, customer service representatives routinely tell them they must meet plan requirements. They rarely, if ever, provide substantive advice about the appeals process or what additional medical information may be necessary to win an appeal.

4. Customer service representatives often misinform members about their appeals rights.
Medicare private plans must abide by strict timelines in issuing decisions. Plans must return decisions on standard (not expedited) exception requests for coverage within 72 clock hours and appeals decisions within seven calendar days. Clients who call their Part D plans to find out the status of their appeals are repeatedly been told by representatives that these timelines count only business hours, not clock hours. Plan representatives claim that the plans have 30 days to make decisions. This is only true for grievances, not for requests for coverage. 

By making the appeals process as frustrating and protracted as possible, Part D plans are driving many of their enrollees to simply give up and either stop taking needed medications or pay out of their own pockets. 

References/Notes

“In the Part D program, beneficiaries’ access to prescription drugs is a function not only of whether a particular drug is on a plan’s formulary and whether it is subject to utilization management tools, but also how plan sponsors make individualized coverage decisions when requested…Administrative barriers in the appeals process can have implications for beneficiaries’ drug coverage.” (Plan Sponsors' Processing and CMS Monitoring of Drug Coverage Requests Could Be Improved, United States Government Accountability Office, January 2008)

“Of course, the plan you signed up for in 2006 may not cover that drug, in which case you will have to file an appeal for coverage, a process that can take much longer than Part D regulations mandate.”(Time to Take Another Look at Medicare Drug Plans, New York Times, November 7, 2006)

“Every prescription written for pain and a few others have been denied upon presentation although they were accepted for 1 1/2 years after 2 appeals each. I was told that my prescriptions would be covered but EVERY time I go to the pharmacy there is a problem. I have very high blood pressure and without pain medications it sky rockets.” (Story submitted to the Part D Monitoring Project, from Ithaca NY, July 2008)

-From: “Barriers to Care in the Part D Appeals Process”,   Asclepios , Your Weekly Medicare Consumer Advocacy Update, August 14, 2008 • Volume 8, Issue 33.

 

9/08