DPRP is a nonprofit coalition of physicians, patients, caregivers, firms and advocates aiming to curb patient care denials. For its report, titled “Access Denied: How Utilization Management Protocols Can Block Access to Life-Saving Treatments,” DPRP examined survey results of insured Americans, academic literature and news reports to analyze common coverage denials.
Here are five common coverage denials experienced by patients, ranked by percentage of patients experiencing the denial.
1. Formulary exclusion (insurers list specific treatments they will not cover): 37 percent
2. Medically unnecessary: 24 percent
3. Prior authorization (insurers require physicians obtain approval before the insurer will cover a medication or procedure): 12 percent
4. Step therapy (insurers require patients use a preferred treatment before using a different medication): 9 percent
5. Nonmedical switching (insurers switch patients’ medication to another treatment in the same therapeutic class): 5 percent
For the full report, click here.
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