medical policies to see if specific treatments are covered. He also recommends migraine and headache sufferers enroll in reputable, well-constructed clinical trials to evaluate newer treatments and advance the clinical evidence upon which providers base their decisions.
“ If there’ s good clinical evidence supporting a medical treatment, usually the benefits will follow,” he says.
Migraine and headache patients also have ways to appeal services that are denied coverage. Most major health insurance plans allow for both an internal review and an independent external review if a patient and his or her physician think a denied treatment is medically necessary. In addition, federal legislation passed last year, the Patient Protection and Affordable Care Act, entitles patients whose benefit plans are covered under the act to an independent review process.
However, be forewarned: There are limitations to what a patient can procure through the appeals process. For example, if a benefit plan explicitly states a provider will cover only a certain amount of a drug, that determination may not be subject to an independent external appeal, Dr. Rosenberg says.
“ If a person starts by reading what’ s in his or her specific benefit plan and if the treating physician submits the relevant clinical information, the appeals process is much more likely to be effective,” he says.
4. Don’ t go it alone
Like other people with chronic pain, migraine and headache sufferers can be at a disadvantage when charting their course of care. In addition to pain, patients often struggle with work issues related to their condition, a lack of time and money, and other health ailments— all of which make it difficult to spend time skimming coverage packets and questioning claims representatives.
“ Patients often say,‘ I’ m too sick to take action,’” Patrick-Lake says.“ But we have friends and family that can take action on our behalf. If we don’ t, we will continue to be denied therapies.”
Strong patient advocates can help research health care plans, compare pharmaceutical prices, and speak with doctors and insurance companies on your behalf. It also pays to think slightly outside the box when choosing a resource. Patrick-Lake says people looking to switch health care plans or providers should talk to their doctor’ s front-office staff to see which companies respond promptly to requests for approval.
“ I want to know the staff’ s impressions on various insurance carriers because those are the folks processing claims on my behalf,” Patrick-Lake says.
Navigating the United States’ convoluted health care system is a stressful process, but don’ t become discouraged by missteps, bad news or what appears to be an endless uphill climb.
“ I’ m a highly educated advocate, and I still got a surprise last year of close to $ 2,000 in out-of-pocket expenses that I wasn’ t expecting to pay,” Patrick-Lake says.
What’ s most important for migraine and headache sufferers is to keep lobbying for the benefits they need— whether that’ s alternative therapies or specialist referrals— and not to take no for an answer, Dr. Diamond says.
“ Patients need to be persistent,” she says.“ Not just for themselves but for the care they need.” HW
Most major health insurance plans base their policy decisions on credible scientific evidence published in peerreviewed medical literature.
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