Challenging a denial from your health plan for a treatment, therapy or medication may feel like an uphill battle, but here’s the good news: California consumers often succeed.
In the past two years, patients have prevailed in roughly 68 percent of independent medical reviews conducted by the state Department of Managed Health Care, which regulates the majority of coverage.
Even so, the two-part appeals process can be time-consuming or taxing for people who are already dealing with aging, disabilities or serious illness, says Scott Glovsky, a Pasadena attorney who specializes in insurance cases.
“The power inequality is so great that a lot of people get a denial and think, ‘What, I’m going to fight this multibillion-dollar company?’ The truth is, you absolutely can,” Glovsky says. “One of the keys is to be persistent and never accept any denial as final.”
Consumer advocates say consumers need to understand their rights.
“Often patients are unaware of their health plan’s appeals process because health plans are not consumer-friendly, and plan documents are often filled with fine print and legalese, which is intimidating for many people,” said Ashira Vantrees, an attorney at the Washington, DC-based Aimed Alliance, a nonprofit promoting health care rights, in an email.
“For consumers, it is important they act as their own investigators to carefully review their plan documents and coverage requirements when they receive a denial letter.”
Grounds for appeal
Glovsky says expensive care, such as proton beam therapy for cancer, biologic drugs or residential mental health treatment, is denied most often. That’s especially true, he says, if the therapies would require going outside the insurer’s contracted network.
“If the treatment is medically necessary and your plan can’t provide it, they’re required to provide the treatment to you out of network,” he says. “I see all the time treatment that the plan cannot provide, yet they still deny it even though under the plan that’s illegal.”
If a consumer disagrees with a denial, the first step is to appeal internally with the insurer.
“Essentially, an internal appeal is a request for the health plan to conduct a full and fair review of its denial decision,” Vantrees says.
Consumers should do the following:
Carefully review your denial letter. The letter should say why the insurer denied the claim and provide instructions on how to internally appeal the decision. Health plans may refer to the process as filing a grievance. “The denial letter is really going to lay out the battle that you must fight,” Glovsky says. That’s going to say exactly what the basis of the denial is.”
If the letter does not include an explanation of how to appeal the decision, then patients should call the customer service number and ask, Vantrees said. You can also name an authorized representative or attorney to handle the appeal on your behalf.
Glovsky says to communicate with the health plan via email to ensure that all information about the denial is in writing.
If you do have any phone conversations, take notes with the date, time, name and title of who you spoke with and details about the conversation, according to consumer tips from the US Department of Health and Human Services.
Gather additional information. Most often, a health plan’s appeal process will require consumers to submit additional information that demonstrates why the requested medication or treatment is medically necessary, Vantrees said.
She said plan documents will provide information on how the plan defines what is medically necessary. From there, work with your health care provider to demonstrate medical necessity.
Glovsky said that, ideally, your doctor would cite the health plan’s own language surrounding medical necessity to make the case, and describe what will happen to the patient’s health if the treatment is denied. He also suggests having more than one doctor write a letter to bolster the appeal.
“Health care providers can be patients’ biggest advocates as they pursue health insurance appeals,” Vantrees says. “They can explain to the insurer why a treatment or medication is necessary for the patient, and they often have staff members who are familiar with benefit utilization policies and appeals processes.”
Submit the appeal quickly. Many health plans require an appeal within 180 days of a denial. They have 30 days to process the appeal, except for in emergency situations. In most circumstances, consumers must wait that long before pursuing outside, independent review.
Glovsky says internal appeals are often unsuccessful because the insurer is applying the same criteria that led to the initial denial. But, he said, sometimes the insurer initially received incomplete medical information and that can be submitted to reverse the decision.
The health plan must issue a decision in writing and include the avenue for outside review.
If the appeal is denied by the health plan, patients can request free, external review from either a state regulator or federal review program, depending on the insurance plan. (See below for more information on this.)
Before appealing to the DMHC, Glovsky recommends reviewing an online database of past decisions. The information is searchable by keyword, category (medical necessity, experimental/investigational or emergency/urgent care), and whether the consumer or health plan prevailed.
“You can get a good sense of whether your treatment may be approved based on other independent medical reviews,” he says.
The DMHC’s independent medical review form will ask for a description of your medical condition, as well as what treatment, service or medication you are requesting. Medical records and correspondence from the health plan should also be uploaded.
Reviews, which are conducted by doctors, are usually decided within 45 days, or within seven for expedited appeals for urgent situations.
According to the state Department of Insurance, independent doctors review cases by considering peer-reviewed scientific evidence regarding the effectiveness of the service, nationally recognized professional standards, expert opinion and treatments likely to be effective.
Decisions are final, and health plans must promptly provide the service if their denial is overturned.
“There’s a lot of barriers to access the care that you’re often entitled to under your plan,” Glovsky says. “Invariably, the consumers that educate themselves and take the time doing the work that’s necessary to appeal the denials are often successful.”
How to file an appeal with your insurer
You can file by phone, mail or, potentially, online. Health plans are legally required to respond to consumer appeals within 30 days, or within three days for an immediate, serious threat to patient health.
If you disagree with the health plan’s decision, you can file a complaint with the government agency that regulates your plan.
How to request an independent review
If you don’t know which agency regulates your plan, call your insurer to find out.
All HMOs and some PPOs and EPOs are regulated by the Department of Managed Health Care. Consumers can request Independent Medical Review for denials, delays to treatment requests and refusal to cover emergency treatment. Consumers are allowed to bypass the internal health plan appeal process if they were denied on the basis of an experimental/investigational treatment. Detailed information is available online or at 888-466-2219.
For policies regulated by the Department of Insurance, Independent Medical Review is also available. See information online or at 800-927-4357.
Find information on the Medicare appeals process here.
The Health Consumer Alliance, a network of consumer assistance programs, offers free help for insurance denials. 888-804-3536
Aimed Alliance has a guide to the appeal process in California.
Medicare beneficiaries can receive free help through the Health Insurance Counseling and Advocacy Program. Call to find your nearest office: 800-434-0222
Insurance contacts for appeals/grievances:
Anthem Blue Cross: 800-365-0609
Blue Shield: 800-393-6130
Kaiser Permanente: 800-464-4000