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Step therapy: positive insurance reality or a bundle of negatives?

On Behalf of | Jan 23, 2018 | Denied Insurance Claims

So-called step therapy helps “to ensure better outcomes and affordability for everyone,” says an insurance company spokesperson.

Not exactly, counters one patient who was adversely affected by its application. He terms step therapy “a big nasty loop that you have to go through with the insurance company every time.”

That, of course, begs this question: What is step therapy, and what does it entail?

A recent article discussing the topic notes that it is the common insurance industry practice of denying a doctor-recommended treatment or drug in lieu of “less expensive, older treatments.” Proponents –unsurprisingly, insurers and those who they heavily lobby — say that injecting a step-therapy requirement into a patient care process keeps premiums down and discourages MDs from promoting unproven therapies.

Such assertions are largely nonsense, say naysayers. They point to insurers are being the sole beneficiaries of step-therapy calls. They say unregulated step therapy delays necessary treatment, undermines a doctor’s professional judgment, and actually ratchets up costs in most instances.

Well-known organizations that include the American Cancer Society and American Diabetes Association are currently lobbying hard in one state to curb insurers’ absolute discretion in demanding that step-therapy processes be followed. Those groups argue that doctors — not insurance administrators — should logically have the final say on what will work best for patients.

Step therapy-related issues and disputes have cropped up in many states, and legislators across the country have responded by enacting some restrictions. Questions or concerns centered on step therapy can be directed to a proven insurance law attorney who routinely advocates on behalf of patients and their families.