Wall Street Journal Looks at Denial of Care Appeals Options
The Wall Street Journal today looks at "[n]ew channels of appeal both within health plans and outside [that] are making it easier for patients to press their case" with insurance companies. A "backlash against health insurers" has led the companies to draw back from "aggressive strategies" to refuse claims or treatments, the Journal reports, adding that insurers have also cut back on denying claims or treatments "because the savings simply [are not] significant enough." A Kaiser Family Foundation study of 1999 and 2000 data from Arizona, New Jersey, Pennsylvania and Rhode Island found that patients had a 52% chance of winning their first appeal to the insurance company. Should appeals to the insurance company not work, 42 states have independent review boards -- made up of doctors who are specialists in the area of medicine in question -- that have the power to overrule the insurance company's denial. The judgment from the independent review board is "usually fairly swift," coming in 60 days or less, and according to the Kaiser study, the patient has a 45% chance of winning. In addition, new federal rules that take effect this year require insurance companies' in-house appeals boards to give judgments within 60 or 30 days, depending on whether the patient filed the appeal before or after the medical procedure. However, the Journal reports that no more than a "handful of people" use their appeal rights because most people do not have the "time and energy" to pursue complaints about denials. "A certain percentage of appeals drop off because people are tired, they're confused, and they may be dealing with a family health crisis that doesn't give them the wherewithal to figure this out," Gerry Martens, a Connecticut state official who helps represent consumers in insurance disputes, said (Landers/Dockser Marcus, Wall Street Journal, 9/17).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.