Consumers should understand healthcare denial appeal process

Aug 25 2009

Newspapers report daily that our healthcare system is broken, express concern about healthcare denials and mention that the system shifts costs to consumers. Commonly denied treatments include cosmetic surgeries, experimental/investigational drug therapies, pain management and chiropractic treatments according to NAIRO (www.nairo.org), a trade organization of independent review organizations (IROs). Health plans claim they deny such cases based on whether the treatment is medically necessary, in network, covered by the medical policy or experimental/investigational.

"State laws give patients denied payment of treatment or services recourse for appeal," said Seana Ferris, President of NAIRO. "Unfortunately many healthcare consumers don't understand the process, don't know their right to appeal or quit too soon." Presently 44 states and the District of Columbia have external review legislation. NAIRO provides frequently asked questions about patients' rights on its Website at www.nairo.org/patients-faq.php.

Steps for Patient Appeal

By learning the steps in their health plan's and state's appeal processes, patients can escalate their appeal to appropriate agencies when necessary. "Patients denied payment of treatment must first exhaust the internal appeal process offered through their health plan," Ferris said. "Following the denial of an internal appeal, they can request an external review using a qualified and unbiased third-party, like a URAC-accredited IRO." Generally, the health plan, not the patient, bears the cost of an external review.

Ask Questions

To start the process, patients need to ask questions, like these:

• What is the reason for the denial?
• Did the health plan seek an independent medical review determination from an IRO before denying coverage?
• What are the timeframes to make an appeal and what information is required?

States Decide the Process

IROs assist many leading health plans in making medical necessity determinations as a part of the plan's internal appeal process. Typically, this is a best practice among health insurers. However not all health plans conduct these arm's length reviews. When a health plan denies a benefit, consumers should inquire whether the plan conducted an objective review using an unbiased third party, like an IRO.

Once patients exhaust the internal review process outlined by their health plan, their rights hang on the type of claim denied and the state they live in. Their next step is to request an external review appeal following the process established by their state insurance commissioner.

Role of the IRO

IROs employ independent, credentialed and licensed healthcare practitioners with specialist credentials needed to perform an evidence-based review a case based on its medical necessity. The expert is board-certified, in active practice and has the knowledge and experience to perform an unbiased and thorough medical review of the case.

"Consumers today have many rights when it comes to healthcare denials," Ferris said. "They just need to learn the ins and outs of the appeal process and then see the process through to the end."