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 .
www . headwisemag . org | National Headache Foundation 39