Lessons From Denials-What We Learn from Insurance Pushback
Jun 2, 2025
Lessons from Denials: What We Learn from Insurance Pushback
By Brianna Pepin
No matter how well a prior authorization (PA) is prepared, denials are an inevitable part of the process—especially when working with biologic and specialty medications. While these roadblocks can be frustrating, they also offer valuable insight into insurance patterns, documentation gaps, and strategies to improve future success.
As biologic coordinators, we have a unique opportunity to turn setbacks into growth. Denials help us become stronger advocates, more strategic communicators, and better equipped to navigate the complexities of the healthcare system.
In this blog, we’ll explore key lessons that insurance denials teach us—and how to apply them to build smarter workflows and stronger appeals.
1. Denials Reveal Insurance Trends
Insurance companies are notorious for inconsistencies, but with enough data, patterns start to emerge.
By tracking denials over time, we can identify insurer-specific preferences and red flags. For example:
Step therapy requirements often demand documentation—even if the provider verbally confirmed the treatment history.
Diagnosis mismatches between provider notes and the ICD-10 code used can trigger automatic rejections.
Additional testing such as labs or imaging may be required by certain payers, even when clinical guidelines don’t support it.
Recognizing these trends allows us to proactively tailor our submissions, reduce unnecessary back-and-forth, and anticipate potential pushback.
2. Denials Teach the Art of Medical Necessity Justifications
Crafting a strong medical necessity appeal is an essential skill—and one we hone with every denial.
A compelling appeal goes beyond stating the need for a drug. It builds an airtight, evidence-based argument that insurance reviewers can’t ignore. Strong justifications often include:
Documentation of failed therapies, with specific dates and outcomes.
Detailed explanations of why alternative medications are inappropriate.
Clinical guidelines or supporting literature that reinforce the choice of therapy.
The more denials we handle, the more skilled we become at creating persuasive, approval-worthy submissions.
3. Denials Expose Documentation Gaps
Sometimes it’s not the insurance policy that causes the denial—it’s what’s missing in the documentation.
Common oversights include:
Not documenting contraindications to alternative medications.
Missing lab results or diagnostic imaging required by the insurer.
Incomplete progress notes that fail to reflect symptom severity.
These gaps are often preventable. Reviewing denial reasons helps us refine our PA checklists and submission protocols to ensure every box is checked before sending it in.
4. Denials Help Educate Providers
Many prescribers are unaware of the specific documentation required for biologic approvals. Denials create a natural opening for collaboration and education.
For instance, if a rejection stems from lack of treatment history, we can work with providers to standardize documentation of prior therapies directly in their notes. Small changes like this lead to significant improvements in approval rates and fewer delays.
5. Denials Strengthen Patient Advocacy
Beyond workflow improvements, denials deeply affect patients. Delays in access can cause anxiety, frustration, and fear—especially for those dealing with chronic conditions.
Biologic coordinators play a key role in setting expectations, explaining the appeals process, and reassuring patients that we are advocating on their behalf. Every successful challenge not only gets the medication approved but reinforces the patient’s trust in their care team.
Final Thoughts
Insurance denials are never easy—but they are not failures.
They are moments of insight.
Every denial we receive offers:
A chance to understand insurance trends.
An opportunity to sharpen medical necessity justifications.
A reminder to close documentation gaps.
A platform to educate providers.
A powerful reason to advocate for our patients.
When we treat denials as stepping stones rather than setbacks, we transform the process into one of continuous learning, improvement, and impact.
Let’s keep learning from every denial—and fighting for every approval.
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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.