Continuity of Care, Without Compromise
The Challenge
After moving to an ICHRA, a long-time infusion patient was placed on an Carrier A plan recommended by Provider A that would not cover her necessary therapy. Over the next year, our Client, JA, Provider A, and Carrier A logged 25+ calls seeking a path to approval.
Repeated denials jeopardized timely treatment and complicated cross-state continuity of care between Indiana and Kentucky. The ongoing back-and-forth created mounting administrative strain for the employer and anxiety for the employee.
The IMPACT
By realigning coverage and care pathways, the employee kept her trusted Louisville specialist while gaining a clear, policy-compliant approval path. Therapy no longer required a hospital infusion setting, enabling a safer, more convenient home-administered regimen and the removal of her port.
Operationally, the resolution ended the cycle of denials and multi-party escalations, returning valuable time to HR and leaders and reducing exposure to unpredictable facility costs. As the client shared, “JA never gave up—after months of denials, they found a way for our employee to keep her specialist and safely receive treatment at home.”
The Strategy
JA stepped in as the clinical and policy integrator—engaging directly with the physicians before and after visits to align medical documentation with plan requirements. We coordinated a move to Carrier B Network and structured a two-physician model: an Indianapolis prescriber paired with the employee’s Louisville specialist to comply with rules that prohibit prescriptions crossing state lines.
Our team partnered closely with Provider A and Carrier B’s medical management, mapped prior authorization pathways, and built a documented playbook to prevent future ICHRA edge-case escalations. The approach combined advocacy, network optimization, and hands-on care coordination.
THE OUtcome
Coverage approvals resumed under the Carrier B plan: 0 cross-state prescription denials following the reconfiguration (current plan year to date).
Continuity of care preserved via a two-physician model (1 Indianapolis prescriber + 1 Louisville specialist), meeting policy rules while maintaining the specialist relationship.
Therapy shifted from facility infusions to a home-administered regimen, eliminating hospital visits and enabling port removal—improving safety, convenience, and day-to-day quality of life.
Operational lift reduced: more than 25 prior multi-party calls replaced by a single, documented process and a repeatable playbook for future ICHRA scenarios.
Things Employers Should Consider
If you offer an ICHRA, do you have a defined process for complex, cross-state or specialty-care cases—including physician engagement and prior-authorization mapping? Are your vendors and carrier aligned on who leads when coverage decisions stall?
Consider auditing edge-case workflows, documenting plan-specific rules (e.g., prescribing across state lines), and designating an escalation team that includes clinical coordination—not just administrative follow-up.