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. 
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.
