Home - About Us -  Member Areas - Local Support Groups
     Support  | Services  |  library |  Products  |  Sponsors   
" With Friends with MS online you're never alone!"  
All of our links
What is MS?
MS Symptoms

Denied Care

Denied care? Go over your insurer's head
In most states, review boards can -- and often do -- overturn a health insurer's decision to refuse to pay for treatment you need. Here's how to build an appeal.
By Christy Fisher

Debra Cordell wasn't about to take no for an answer -- especially from her health insurer. deniedcare

The 42-year-old married mother of three from Orangevale, Calif., has multiple sclerosis and was suffering from debilitating back pain because of excess weight that compressed her spine. After multiple weight-loss programs failed, Cordell, 42, and her doctor determined that she was an excellent candidate for gastric bypass surgery, which modifies the gastrointestinal tract to reduce food intake. But her health insurer refused to pay for the procedure, which costs between $20,000 and $30,000, on the grounds that it wasn't medically necessary.

Cordell appealed her insurer's two denials to the California Department of Managed Health Care, which authorized an independent panel of doctors to conduct a medical review. In September, the panel ruled in her favor.

Cordell had her surgery in late October. Since then, she's dropped 101 pounds and now weighs 185. She walks with the assistance of a cane instead of having to use an electric wheelchair. Cordell also has much more energy. She exercises four times a week doing water aerobics, weight training and walking on a treadmill. She can now do the family's grocery shopping and regularly takes care of a rambunctious 2-year-old granddaughter.

"I feel so much better. My back pain is almost completely gone," Cordell says. "The surgery has increased the value of my life dramatically. It has really made a huge difference in what I can do."

Taking on the insurers
Dealing with a complicated medical condition in your family is stressful enough. It's fraught with tension about the medical outcome, as well as what it might do to your family's financial health. But what happens if your health insurer won't cover your crisis and you believe the insurer's decision is just wrong? You do what Debra Cordell did.

Cordell is one of a growing number of disgruntled health-care consumers who have challenged their insurers' denials and won by taking their cases to a state review process. Each state's external review process is different. But in general, they allow for independent medical review of disputes over the medical necessity of care between certain types of health plans and consumers.

Independent review organizations, on average, reversed health-plan decisions about as often as they upheld them in 2000, according to research done by Georgetown University's Institute for Health Care Research and Policy for The Henry J. Kaiser Family Foundation. Denials were fully overturned in 45% of patient appeals and fully upheld 49% of the time. Decisions were partially overturned, which is permitted in about half the states, 6% of the time.

The District of Columbia and 42 states now have external review programs to resolve disputes between some managed care health plans and consumers -- up from just 14 states in 1998, the Kaiser report says. (The states that don't have them: Alabama, Arkansas, Idaho, Nebraska, Nevada, North Dakota, South Dakota and Wyoming.)

In all, about 4,000 documented appeals were filed in 2001. Many health-care advocates believe that patients and their families could make much more use of review programs than they do.

"Consumers in almost every state should know that they have a place to turn if they feel they are inappropriately denied treatment," says Karen Pollitz, lead author of the study and project director at the Institute for Health Care Research and Policy. And they should know that an external review is worth pursuing because there's a good chance of winning.

In most states, these outside reviews are binding on health plans. In June, the U.S. Supreme Court upheld state laws offering independent review of medical decisions. The court turned away an argument that the federal Employee Retirement Income Security Act (ERISA), which provides national uniformity in employee benefits except for insurance, preempts state laws.

External review isn't available to all
External-review procedures aren't available to everyone, however. In addition to the states that don't have external-review laws, almost half (47%) of covered workers enrolled in employer-sponsored health plans can't use state external review programs because their plans are self-insured. That means the employer finances the plan directly instead of buying a plan from an insurance company. These plans are regulated under ERISA and are exempt from state review programs.

The only recourse for consumers in states without external-review laws, or for workers who are covered by self-insured plans, is to file a grievance with their plan or sue.

Congress has been considering patients' rights legislation that will establish federal standards and extend external review protections to all private health plans, but, so far, legislation to attack this issue isn't going anywhere. (Medicare and Medicaid enrollees have different mechanisms for external appeals, as do federal and congressional employees.)

The evidence so far indicates some states are more sympathetic to a patient's cause. You're most likely to win a review in Connecticut, where the independent review organization sided with consumers 72% of the time last year, the Kaiser report found. Decisions went the consumer's way only 21% of the time in Arizona and Minnesota. (For your state's scorecard, see the chart below.)

External reviews often deal with disagreements about medical necessity of a treatment or whether a treatment is considered to be necessary and appropriate and not in conflict with generally accepted medical standards. These disagreements also deal with requests for experimental or investigational treatments, prescription drugs that aren't on the health plan's preferred list, services in excess of plan limits or services specifically excluded by contract, according to the American Association of Health Plans in Washington, D.C. Requests for newly popularized treatment options, cosmetic surgery, use of out-of-network specialists and surgeries when less invasive alternatives haven't been tried also make up a good number of complaints.

Cases dealing with experimental treatment, which is often defined by the insurer and excluded under contract, are often among the toughest denials to get overturned, says Nancy Davenport-Ennis, founding executive director of The Patient Advocate Foundation in Newport News, Va. The foundation helps patients with chronic, debilitating or life-threatening illnesses when their health plans deny services. It handled 56,067 requests for information in 2001; nearly 7,000 cases were assigned to a case manager or attorney for resolution.

Despite the high success rate in getting health decisions overturned, consumers seem to use these review programs infrequently. A Kaiser study of seven states found that medical necessity appeals initially numbered in the tens of thousands, but only dozens to hundreds of these cases ever made it to external review. In Pennsylvania, for example, some 8,200 appeals were filed with health plans in 1999 and 2000. But only 162 patients ultimately sought external review.

The internal appeals process, which is usually at least a two-step process, could be too lengthy and difficult for most consumers to complete.

"These are sick people dealing with a process that can be frustrating and confusing," says Karen Pollitz. "It's entirely possible that they just get worn out and discouraged."

However, Mohit Ghose, deputy director of public affairs for the American Association of Health Plans, which represents more than 1,000 plans that provide health care coverage to more than 140 million Americans, says that external reviews often deal with extreme cases. Many health-plan disputes begin with denials based on simple paperwork errors or because the treating physician didn't offer enough information. These issues may be resolved quickly. Still, health plans in almost all cases are required by law to inform consumers of their appeal rights.

"External reviews that use an evidence-based medicine standard are a good thing and can help health plans and physicians to uphold quality of care," says Ghose. The one problem: the current system is a patchwork of 42 state laws. The association would prefer a uniform national system.

How to build your appeal
Check your state's rules. Each state's external-review program is different. Most only review denials based on medical necessity, while some won't consider experimental treatment denials at all. Most states require you to complete all steps in your health plan's internal grievance procedure before your denial can be considered for external review. (An expedited review can occur if a delay in receiving services can cause serious harm.) Plus, most states have time limits for when you can file for an external review. Some states have fees ($25 to $50 in many cases) and minimum claim thresholds. Contact your state insurance agency for details.

Know your coverage. Get familiar with your health insurance policy. Get very familiar with it. Remember, for example, that if you're in a self-insured plan, you can't use a state external review process. Ask your employee benefits office for a copy of its Evidence of Coverage document. This document is much more detailed than the summary plan description that you get in your employee benefits package. It will tell you what your health plan covers and what it doesn't.

If you need help learning to read the documents, there's help from Consumers Union, publishers of Consumer Reports magazine, and The Henry J. Kaiser Family Foundation. Their "Consumer Guide to Handling Disputes with Your Private or Employer Health Plan" includes easy-to-use checklists to help you understand your coverage and plan rules and tells you how to appeal denials. A state-by-state summary of external-review programs with contact information also is available. (For more information, click on the link at left under Related Web sites.)

Organize a strong appeal packet. An appeal packet should include the health plan's denial letters, as well as your doctor's or specialist's plan of care. Also, the reviewer must have access to all pertinent medical records. Articles from professional clinical journals that support your case and illustrate medical efficacy also are key. Debra Cordell, for example, showed that she qualified for her surgery by including the National Institute of Health guidelines for the procedure. The Patient Advocate Foundation offers samples of effective appeal letters on its Web site (See link at left under Related Web sites.) Keep copies of all information, and send the packet registered mail return receipt requested.

Get expert help. If the disease is aggressive and your life or a loved one's is threatened, look at hiring a lawyer immediately. Contact your state bar association for names of lawyers specializing in health care law. A number of patient advocacy groups can help, such as The Patient Advocate Foundation (800-532-5274), or Health Rights Hotline (See link at left or call 888-354-4474), which serves four counties in California. Some states, including California, also have ombudsman programs to help you resolve disputes with your insurer.


SOURCE OF STORY: http://moneycentral.msn.com/articles/insure/basics/10290.asp?special=life

Disclaimer  |   Contact  |   Search
Copyright 2010 Friends with MS - Serving the MS community since 1998