Putting the power into patients' hands: Challenging denied claims
New regulations from the Department of Health and Human Services (HHS) will allow patients to appeal health insurance claims that have been denied by their insurer—putting power back into the patients' hands, where many people believe it belongs.
Nationwide right to external appeal
According to the article HHS rule bolsters appeal rights when insurers say no, "The regulations, which take effect for all plan years beginning on or after Sept. 23, 2010, guarantee a nationwide right to external appeal."
Although some form of external appeal is in place in almost all states, "the laws often leave many consumers uncovered, according to HHS, which is encouraging states to adopt standards for external review that were established by the National Association of Insurance Commissioners," the article continues.
The right to challenge insurers first
The article Hospital bill not covered? Now you can appeal denied claims states that the new regulations give patients the right to challenge denials to their insurers first "and then, if necessary, to external review boards."
White House creates standards
The article quotes a White House fact sheet that promises that the new changes in the regulations will end "the patchwork of protections that apply to only some plans in some states." It says that the system for appeals will be much easier for consumers to navigate than past methods of appeals.
According to the article, the major health insurance lobby, America's Health Insurance Plans (AHIP), gives its support to the new change in appeals and believes the regulations will "engender uniformity or consistency" in the appeals process. AHIP's spokesman Robert Zirkelbach is quoted as saying, "We have encouraged every state to have a third-party review system."
Denial algorithms
The article What to do if your health insurance claim is denied reports that most claims are "electronically adjudicated," which means they are electronically processed without "manual [human] intervention." Instead claims are rejected by "denial algorithms" that are specifically created to locate ways to deny patients coverage.
Pended claims
According to the article, almost 14 percent of claims are "pended," meaning they are "flagged for more information or investigation." Reasons for being flagged can be simple clerical errors. For example, missing information or duplicate information can flag your claim for more review.
"Reasons that are more complicated include services not covered, ineligible providers, experimental treatments and pre-existing health conditions," states the article. If no simple resolution can be found, the claims are often denied.
New rights
The USA Today article Rules to ease consumer appeals in health coverage reports that states have a year to overhaul their external appeals laws to meet the new federal standards that include:
- Informing consumers of their right to internal and external appeals
- Allowing for expedited external reviews in emergency situations
- Providing an independent review body assigned by the state
The article continues that the majority of states don't meet all of these protections. "Several [states] have laws that allow for external review of decisions only by HMOs," according to Phyllis Borzi, an assistant secretary in the Department of Labor.
The six states without any external appeals are Alabama, Mississippi, Nebraska, North Dakota, South Dakota and Wyoming.
