The fact that there is little or no transparency in our health care system is frustrating at best. The fact that you are paying for insurance and are denied coverage for a service or treatment can add insult to injury.
I have clients who are veritable pit bulls with their insurance company and more often than not, they do get positive results. At the California Dept. of Managed Health Care website, you can see the results of appeals requests that may encourage you if you face a denial of coverage.
The website dashboard was funded by an ACA (Affordable Care Act aka Obamacare) grant. It allows consumers to filter through date sets about the plans- including enrollment numbers, rate histories, complaints, quality surveys and financial data. The site covers insured medical plan, dental, vision and mental health. It can be found at: http://www.dmhc.ca.gov/?referral=healthhelp.ca.gov
The fine print of your insurance Evidence of Coverage (EOC) document should explain the appeal and or grievance procedures. For example, Blue Shield of CA states that you can contact Customer Service Department via phone, submitting a letter or electronically at their website. The request must be resolved in 30 days. I recommend copying the Department of Managed Care on the request.
The request can be expedited if the decision “might seriously jeopardize the life or health of a Member or When the Member is experiencing severe pain”. These requests must be decided within 72 hours following the receipt of the request.
For grievances due to denial of coverage for a Non-Formulary Drug the Member, representative, or the Medical Provider may submit a grievance requesting an external exception request review. Blue Shield will ensure a decision within 72 hours in routine situations and 24 hours in “exigent” circumstances.
Any grievance must be submitted within 180 days of the incident or unsatisfactory action by the insurer.
A report generated from this website by Kaiser Health News in October of 2016 showed that more than half of reviews for denial of care resulted in results favorable to the insured. The denials were upheld on less than 40% of requests for Anthem Blue Cross and Blue Shield of CA, the primary insurers in the North State.
This data had been available before, but was not nearly as easy to access and generate reports. One major feature of the ACA was the intent to make health plans accountable. These features of the law do not get enough press and certainly don’t lend themselves to 30 second sound bites, but they are important nonetheless.
Because there is little competition in our area, we might feel that the insurance company holds all the cards. But it’s important to remember that health plans are highly regulated and are subject to regulatory review and action. Also, there are humans behind the screen. They make mistakes. Language is subject to interpretation.
Don’t be intimidated by the process if you decide to file an appeal. However, take the time to organize your request and documents, perhaps with a simple chronology if it is very complicated. Leave out the opinions and/or hyperbole about how much you hate insurance companies and they are a bunch of greedy rip off artists. Keep to the Dragnet Joe Friday mantra, “Just the facts, ma’am!”
Keep copies of everything you send and follow up if you don’t have a reply. Persistence will likely pay off. However, if it is not an expedited issue, expect that they will use every day of their 30 days allowance. Also if additional information is requested, it can start a new 30 day clock, so again try to be thorough.
One important note. Coding errors are not uncommon. Claim denials could be due to something as simple as a wrong code. This situation might be resolved by a phone call to the insurer. For example, you may find that your annual physical was miscoded, that’s why you are not receiving 100% coverage. Or the lab work that was done in conjunction with the physical was not tied to that exam.
My advice is to be an attentive consumer to get the most value from your plan.