The Affordable Care Act (ACA) ensures a patient's right to appeal
health insurance plan decisions. Appeals are important because figures show that
patients are successful 39%–59% of the time when they appeal claims decisions.
Under the ACA, patients can ask a health plan to reconsider its decision to deny
payment for a service or treatment. New rules spell out how plans must handle
internal appeals, but the rules also allow for an independent review
organization to decide whether to uphold or overturn the plan's decision.
Under the ACA, consumers have the right to appeal
decisions made by health plans created after March 23, 2010. The law governs how
insurance companies handle initial appeals and how consumers can request
reconsideration of decisions to deny payment. Under the law, if an insurance
company upholds its decision to deny payment, the consumer has the right to
appeal the decision to an outside, independent decision maker, regardless of the
type of insurance or state an individual lives in. This final check is often
referred to as an "external review."
Regulations issued by the Departments
of Health and Human Services (HHS), Labor, and Treasury standardize
both internal and external processes that patients can use to appeal decisions
made by their health plans. Under new ACA rules, plans and issuers must comply
with the state's external review process or the federal external review
Until a few years ago, the rules regarding such appeals varied by
state and employer. These new rules will more closely align the appeals process
across all types of plans.
Note: The parts of the ACA
that concern internal appeals and external reviews only apply to health plans or
policies that were created or purchased after March 23, 2010. Plans created on
or before March 23, 2010, may be "grandfathered health plans." The ACA imposed
appeals and review rights do not apply to them.
Appeals are worthwhile. A
recent Kaiser Health News article (Pauline Bartolone, Capital Public
Radio, April 14, 2014) reported that data review from California found that
about half of the time a patient appeals a denied health claim to the state's
regulators, the patient wins.
For more information, please e-mail [email protected]. For questions
about appeals, contact Janet McCarty at [email protected] or Laurie Alban Havens at