Practical guidance for navigating complex world of insurance coverage, payer issues


Over the last year and a half, physicians around the world have been focused on managing patients, their teams, and themselves through the COVID pandemic. This has not been an easy time for physicians.

Big picture, what sort of mindset is helpful for a practicing ob-gyn to have when wanting to get more involved in coverage by health plans for ob-gyn services?

Over the last year and a half, physicians around the world have been focused on managing patients, their teams, and themselves through the COVID pandemic. This has not been an easy time for physicians. Right now, many feel like firefighters returning to the firehouse after putting out a big fire, exhausted. For our ob-gyn colleagues, in particular, there may be an overhang of postponed surgeries and office visits to attend to. For many, it’s simply not an easy time to find the energy and focus. Some practicing physicians we know are energized by spending time regularly advocating for coverage policy changes. It’s energizing to them because advocating for these changes is an important way for them to exhibit beneficence for their patients.

An important first step before getting involved in such an endeavor is to think about how it will align with the way you are wired. Here are some questions to answer for yourself before you get started to make sure this is an activity that is likely to align with what brings you energy:

Do you feel that there are coverage issues that are having a negative impact on the quality of care that you can deliver to your patients?

Would you like to be a part of the process that brings about changes to this situation?

Are you comfortable with a certain amount of conflict?

Robert C. McDonald, MD, MBA

McDonald is president and founder of Aledo Consulting in Indianapolis, Indiana.

Robert C. McDonald, MD, MBA

McDonald is president and founder of Aledo Consulting in Indianapolis, Indiana.

Do you mind that these efforts, typically, play out over the long-term rather than the short-term?

Enjoying the process and seeing it as grounded in your professional role of exhibiting beneficence towards your patients are both important aspects to feel positive in the long run about your involvement in the activity and being able to stick to it over the long run yourself.

The old saying goes, “A journey begins with a single step.” Changing coverage policies is an iterative process. It very rarely occurs with the first letter, the first phone call, or the first appeal of a claim. The ultimate reward is that when the change comes, you can look at the effort you spent to change the coverage policy and improve the care of your patients, and you can say, “I am a part of that.” For many physicians, such an experience can be quite energizing.

Karla F. Loken, DO, OBGYN, FACOOG

Loken is a founding member of Diana Consulting, a women’s health medical and clinical affairs agency.

Karla F. Loken, DO, OBGYN, FACOOG

Loken is a founding member of Diana Consulting, a women’s health medical and clinical affairs agency.

How can a practicing ob-gyn meaningfully influence the coverage of ob-gyn services for their patients?

There are 4 important steps to take to have a meaningful influence on the coverage of ob-gyn services for your patients.First, know the payment rules that are a concern to you. Yes, payment rules are complicated, but if you are going to advocate for their change, you must know what they are currently because it helps you to “talk the talk.” Second, when you think a policy is not appropriate, write a letter explaining why it is not appropriate and how it can be made right. Third, if you have the opportunity, call up the accountable health plan Medical Director and tell them the same thing that you would put in a letter. Fourth, and finally, if claims for services are being denied because of a policy that you disagree with, appeal the denial of payment.

In discussions we’ve had over the years with medical directors about their policies, there is 1 common answer that they enjoy giving, “I’m not hearing any complaints about that.” That answer means that there is no reason to change the current policy. The real purpose of all the letters and calls and appeals is so that medical directors cannot fall back on that comment. It’s important to appreciate that 1 letter, 1 phone call, or 1 appeal ordinarily does not cause a change to a coverage policy. It typically takes dozens to hundreds of interactions at each health plan, depending on the size of the health plan. The most common answer you will receive is a polite and non-committal, “Thank you for your communication, we will take it under consideration in our future deliberations on this topic.”But your efforts have put a stake in the ground and established that the physicians are to some degree in conflict with the existing policy.

Also, if you are writing about a specific coverage policy, know the next review date. That’s commonly printed right on the policy. You can send in another updated letter about 100 days prior to the next review date. Let them know that you remain passionate about this issue.Persistence has an important role in how these policies are changed. So, whether you write 1 letter about a policy that concerns you or dozens of letters, you were part of that change. And when the policy is changed, you have changed the type of care that your patients can receive routinely. And that should be an uplifting chain of events for you.

Sometimes we hear the phrase, “You should appeal every claim even if you do not win.”What do you think about that?

Appealing claims is an important way to let health plans know that you are a clinician who believes that a certain policy should be changed. Hockey legend Wayne Gretzky once said, “You miss 100% of the shots that you don’t take.” If you have a denied claim, and you don’t take any action to appeal the denial, that’s pretty much the end of it and there is essentially a 100% chance that you won’t get paid for the service. When you file an appeal, your communication should be about the appealed claim and about the policy that the denial was based upon. You need to have measured expectations of the result of any appeal.In hockey, not every shot on goal scores, and in the appeals game, not every appeal results in payment for the service.

When you appeal denials, it is important to know that there are multiple levels of appeal.There are: 1) first-level appeals, 2) reconsideration appeals, and 3) at the highest level, outside appeals when appeals are sent to an independent clinician reviewer outside of the health plan. First-level appeals, for the most part, confirm that the denial followed the existing policy appropriately. Doing a lot of first-level appeals is not going to create pressure for changing a policy. Second-level appeals tend to be where the individual patient factors are taken into consideration. Highest-level, outside appeals, are when claims are sent to a panel of outside reviewers, and they may be as open to look at the coverage policy as well as the actual service provided.Also, outside reviewers are often specialty-matched, so the person or people reviewing your issues is likely to be an ob-gyn, just like you. If they agree with your position, it can put pressure on the health plan to change its coverage policy.

If you were to take 5 claims and submit 5 first-level appeals, that amount of effort is likely to have a much smaller impact than if you took one claim and appealed it multiple times until it went to external review. The focus isn’t really on the policy itself until you have an external appeal. If you appeal a claim, be prepared to receive a “No,” and then be prepared to take your appeal to the next level.

What role does our specialty society, the American College of Obstetricians and Gynecologists (ACOG), have in advocating for changes in insurance coverage?

The role of ACOG in advocating for coverage changes cannot be overstated. As a practicing ob-gyn, you should think about whether to focus your policy change advocacy efforts on working on your own, on working as part of the ACOG process at the state level, on working as part of the ACOG process at the national level, or on working simultaneously in more than 1 of these manners.

Here’s a recent example of the importance of ACOG in changing health plan coverage decisions. On September 23, 2020, ACOG expanded its recommendation for noninvasive prenatal testing (NIPT) from just high-risk pregnancies to all pregnancies.1 One month following this announcement, Centene became the first large national health plan to update its NIPT policy to cover average risk pregnancies.2 Centene was simply the first domino to fall, and, essentially, all the other health plans followed rapidly.A major factor in all these policy changes was that ACOG gave a full-throated endorsement of NIPT as the new standard of care in the management of pregnancies. Getting payer coverage of services can require an endorsement of the type that leaves no question that any health plan that chooses not to cover the technology is not supporting the professionally recognized standard of care.

How might steps differ for an ob-gyn who is part of an integrated system versus in private practice?

If you are an ob-gyn practicing within an integrated system, your system is a stakeholder in your advocacy efforts, whether you want them to be or not. Sometimes that can be an advantage.Take, for instance, when the integrated delivery system contains a health plan subsidiary. Think of the example of Geisinger Health System and Geisinger Health Plan. The health plan may be just across the parking lot from where you practice; the decision-making staff at the health plan may be people whom you know due to a shared experience at the health system; and your health system and the health plan may report to a common senior management team. In such a situation, your advocacy efforts might be amplified, and you could be more effective than, say, if you are in independent practice.

In conclusion, advocating for changes in health plan coverage policies is an important way that ob-gyns can exhibit beneficence toward your patients beyond the typical care-giving roles.Changing these coverage policies requires broad collaborative efforts between physicians and their specialty societies.Each discrete action, no matter how modest its scale -- 1 appealed claim, 1 letter to the health plan about the situation, or 1 phone call to a medical director -- contributes to the overall effort and makes you, ultimately, part of the eventual success.


New ACOG guidelines recommend cfDNA-based NIPT for all pregnancies, not just risky ones. American Society for Clinical Pathology. Accessed July 20, 2021.

ACOG win! Major player updates coverage guidelines to align with NIPT recommendation. The American College of Obstetricians and Gynecologists. Accessed July 20, 2021.

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