<\/p>\n
A pile of medical bills with an open wallet by volgariver via Adobe Stock <\/p>\n
When a health insurance company refuses to pay for your treatment, most people do exactly what the company is counting on: they give up. They don\u2019t trust the insurer to reverse its own decision, so they swallow the bill or go without the care. But there is a little-known process that can take the decision out of the insurer\u2019s hands entirely\u2026\u00a0 and force the company to pay for what can be lifesaving treatment.<\/p>\n
A North Carolina woman named Teressa Sutton-Schulman found it the hard way. Her husband was in a severe mental health crisis and needed intensive psychiatric care, and their insurer, Highmark Blue Cross Blue Shield, kept denying the claims\u2026\u00a0 even after he attempted suicide twice in the span of 11 days, according to\u00a0ProPublica<\/a>, which followed the couple\u2019s fight. The instructions for the tool that would finally win their case were buried on page seven of one of those denial letters.<\/p>\n \u201cAppeal, appeal, appeal, appeal,\u201d Kaye Pestaina, a vice president at the health policy nonprofit KFF who has studied the process, told\u00a0ProPublica. \u201cThat\u2019s all you have.\u201d<\/p>\n The \u2018Best-Kept Secret\u2019 That Can Overturn a Denial<\/p>\n The tool is called an external review. When an insurer says no, you can (in many cases) demand that the denial be re-examined by a medical provider who has no connection to your health plan. If that independent reviewer sides with you, the decision is binding: your insurer is required by law to accept it and pay.<\/p>\n ProPublica described external reviews as \u201cone of the industry\u2019s best-kept secrets,\u201d noting that only a tiny fraction of the people eligible to use them actually do. That gap is the whole story. The protection exists. Most patients never hear about it.<\/p>\n Sutton-Schulman almost didn\u2019t either. She had been fighting the denials and recording every phone call with the company when she came across the language on page seven. \u201cYou can now request that your case be reviewed by a health care provider who is totally independent of your health plan or insurance carrier,\u201d read the letter, sent by the state insurance department in Texas, where her husband\u2019s treatment had taken place.<\/p>\n Skeptical but hopeful, she filed the request. The case landed with Dr. Neal Goldenberg, an Ohio physician who reviews disputed claims for a third-party company as a side job. After reading the couple\u2019s appeal, he overturned Highmark\u2019s denial\u2026\u00a0 covering treatment that had cost the family more than $70,000<\/a>.<\/p>\n Highmark has said it is \u201cpassionate about providing appropriate and timely care\u201d to its members, and acknowledged that \u201csmall errors made by physicians and\/or members can lead to delays and initial denials,\u201d but said those are corrected on appeal.<\/p>\n Why Insurers Don\u2019t Advertise External Reviews<\/p>\n The reason so few people use external reviews isn\u2019t an accident, according to the advocates and those familiar with the matter. It\u2019s partly that the denial letters themselves are confusing, and partly that insurers benefit when patients walk away.<\/p>\n \u201cThe numbers are low because some people just give up. They\u2019re frustrated. They\u2019re tired. They\u2019re battling cancer,\u201d said Kimberly Cammarata, who directs Maryland\u2019s consumer assistance program. \u201cAnd sometimes the information about why the claim was denied or about how to appeal is terribly unclear. A lot of these outcome letters will say you have a right to an external appeal, but they don’t exactly tell you where to go.\u201d<\/p>\n Kathleen Holt, Connecticut\u2019s state health care advocate, put the incentive more bluntly. \u201cThe insurance companies know that people don\u2019t appeal, and in some ways I think they can be more aggressive with their denials,\u201d she said. \u201cThey don\u2019t expect people to come back, and when they do that very small percentage of the time, it\u2019s the cost of doing business for them.\u201d<\/p>\n The numbers back her up. After Connecticut began printing appeal information in a box on the front page of denial letters in 2023, more than 40% of the referrals to her office over the next two years came from people who\u2019d received the new language. And when patients do push back, they win a lot: Connecticut\u2019s healthcare advocate office has been able to resolve or overturn denials in the patient\u2019s favor about 80% of the time, Holt said.<\/p>\n External appeals have existed at the state level for decades, and the Affordable Care Act expanded them in 2010<\/a> to most people who get insurance through work. But Karen Pollitz, who helped draft the federal rules under former President Barack Obama, said heavy lobbying by insurers and employers weakened the protections \u2014 so today only a fraction of denials qualify, and the health plan itself gets to hire the reviewers. \u201cThere are all kinds of ways they could strengthen the laws and the regulations to hold health plans more accountable,\u201d she said.<\/p>\n What to Do Before You Pay a Denied Bill<\/p>\n You don\u2019t have to navigate it alone, and you shouldn\u2019t pay a denied bill before checking your options. Some general information that might be relevant includes:\u00a0<\/p>\n Save everything: Keep every denial notice, explanation of benefits, plan document and letter. You can also request your full claim file, which most people have a right to under federal regulations. Check for a free consumer assistance program in your state: Many states have them, and their job is to explain your denial and help you appeal (usually for free). Sometimes the problem is as simple as a missing or incorrect billing code. Find out exactly why you were denied and your deadline: Was it ruled \u201cnot medically necessary,\u201d or simply not covered? That distinction shapes how you appeal. Most plans give you about 180 days to file an internal appeal, but don\u2019t wait. Ask your doctor for help: Some providers will file the appeal for you or write a letter of support. File the internal appeal first: You usually have to try to resolve it directly with the insurer before you can go external. Then request the external review: Once internal appeals are exhausted, ask your insurer to send your case to an independent reviewer. For a standard federal external review, the plan generally has five days to confirm eligibility, and reviewers typically have 45 to 60 days to decide. If your situation is urgent, you can request an expedited review, which is supposed to be resolved as fast as your condition requires and no later than 72 hours.<\/p>\n Not every denial qualifies. External reviews generally apply to disputes over medical judgment, surprise bills, experimental-treatment rulings or retroactively canceled coverage, not denials based on plan terms or out-of-network care. But for the cases that do qualify, advocates say it is often a patient\u2019s most powerful remaining card.<\/p>\n \u201cEvery state needs one of these programs,\u201d said Cheryl Fish-Parcham of the consumer group Families USA. \u201cHealth care is so complicated, and people really need experts to turn to.\u201d<\/p>\n \u00a0Or, as Pestaina put it: appeal, appeal, appeal, appeal.<\/p>\n On the date of publication, Caleb Naysmith<\/a> did not have (either directly or indirectly) positions in any of the securities mentioned in this article. All information and data in this article is solely for informational purposes. For more information please view the Barchart Disclosure Policy here<\/a>. <\/p>\n","protected":false},"excerpt":{"rendered":"A pile of medical bills with an open wallet by volgariver via Adobe Stock When a health insurance…\n","protected":false},"author":2,"featured_media":679614,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[97,252,253,26044],"class_list":["post-679613","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-health","tag-health-care","tag-healthcare","tag-n-a"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/679613","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=679613"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/679613\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/679614"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=679613"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=679613"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=679613"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}