These denials pose a particular challenge in pediatric medicine because many of the medications used to treat the same illnesses in adults are not yet FDA-approved for use in children and are prescribed"off-label."
"Two immediate problems emerge here," explains Bousvaros."The first is that your patient won't get the medication they need to treat their illness. The second is that there is now a lot more paperwork for the provider, which means less time is being spent with patients."While theseshow no signs of going away, Bousvaros recommends three ways that pediatric specialists can help patients access the medications they need.
Draw on resources. If you work within a larger hospital or health system, you may have access to resources for insurance denials. For example, Boston Children's has a dedicated team that assists with prior authorizations for physicians, limiting the amount of time spent away from patient care. Perfect your letter writing. In another paper by Bousvaros and Kahn, they share specifics of how to write a letter of medical necessity. The goal of a letter of medical necessity is to make the case for why a patient will benefit from the drug being prescribed."It can be really emotionally taxing to write these letters, but they are absolutely crucial to get right when you're fighting for your patient," says Bousvaros.
Take a stand. Bousvaros encourages physicians to advocate for their patients. At Boston Children's, for example, there has been great success in advocating for patients to gain access to rare services by treating payors as partners."We also encourage specialists to collaborate with professional and patient organizations to initiate additional advocacy efforts so that our patients get the treatments they need," he says.
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