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c/insurancefights·submitted 3 months ago by u/coring_the_stopper

[Discussion] we are measuring denial at the wrong time and calling it noise

Discussionbranch of 4 comments

Long-ish post, sorry. tl;dr at the bottom. I have been tracking appeal against ApoB for 27 weeks because I could not find anyone who had. The correlation is weaker than I expected, which is itself mildly interesting given how confidently people link the two in here. Caveats up front: one person, one lab, one assay,…

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4 comments, started 3 months ago
u/marta_vanhecke195 points·3 months ago

prior auth criteria are state-specific, formulary differs

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u/controversial_only97 points·3 months ago

appeal letter templates are in the wiki

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u/adaeze_cabrera31 points·3 months ago

Slight fix: the number was 99.1, not 98.3. Decimal point, but a fairly consequential one.

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u/fabio_kuipers22 points·3 months ago

redact member ids and group numbers from every screenshot

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The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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