One of the most basic needs in determining a person’s quality of life is reliable, affordable access to health care. Having adequate health insurance is one of the necessary concomitants of obtaining health care. Yet, many people who have health insurance have experienced having their claims for payment by the insurance company denied. Stop Health Insurance Denial is among the members of the legal profession dedicated to fighting for the rights of public employees as health care consumers when they find themselves battling large insurance carriers. Since this is a nationwide problem, Stop Health Insurance Denial works across the United States to help consumers with these issues.

Public employees are in a unique position when it comes to working against the insurers who often seek to deny payment of claims as an ordinary course of business. While consumers who obtain private health insurance, or who are covered by plans provided by private sector employers have a number of important protections as described in this article, public employees have an additional benefit that private sector employees do not: the ability to sue for damages over and above the medical costs incurred when a health care claim is denied. These additional damages might include emotional distress, punitive damages, and even loss of income.

The difference in the situations of public employees as compared to private employees and consumers is due to their differing treatment under a federal law known as ERISA.

According to the Employee Retirement Income Security Act of 1974 (ERISA), insurance consumers are guaranteed the right to appeal any denial of health insurance claims by an insurance carrier. As a public employee, you also have this right. Broadly speaking, there are three basic steps to this first level of appeal.

  1. You have filed a normal claim, also known as a request for coverage
  2. The insurance carrier has denied your claim. This denial by the health insurance company must be explained in writing within designated time frames:
    • A 15-day limit if you are seeking a treatment that requires prior authorization
    • A 30-day limit if you have already received medical treatment
    • A 72-hour limit if you require urgent care
  1. You can now request an internal review with the company, though you must request the review within 180 days from the date your claim was denied.

The insurer will most likely have a number of forms that you will be required to fill out, and you can submit any additional information that you feel is important to your request (for example, a doctor’s letter of explanation.) Some states provide consumer protection departments that might be able to assist you; this burden of filing is also a reason that many people consider obtaining the assistance of a qualified health insurance claims attorney.

As a public employee, it is important for you to understand the process of initiating an appeal if and when your health insurance claim is denied.

Completing an Internal Review When Health Insurance Claims Have Been Denied

Some people wonder what types of denials can be appealed through this process.

If you believe that your health insurance plan offers coverage (either in part or in whole) for a particular service or procedure, you have the right to appeal if your health plan doesn’t pay. They may claim denial for other additional reasons, such as:

  • Your claim is not a benefit covered under your specific plan
  • The medical problem for which you are seeking coverage began before you enrolled in the plan
  • The health services you received were administered by a health care provider (or a facility) that was not in the approved network for your plan
  • You are no longer eligible for benefits under your plan
  • The plan decides to revoke or cancel your coverage retroactively (back to the beginning date of the plan) because they believe you gave incomplete or false information on your application for the plan

There are several things you will need to do in order to complete and support your request for an internal appeal if your health insurance claim has been denied. The following is helpful information from the Federal Healthcare Marketplace, also known as Healthcare.gov:

You should keep copies of all the facts related to your denial and your claim. You should especially keep track of all correspondence from your insurance company, including the following:

  • The form known as an Explanation of Benefits (EOB) shows exactly what services or payments have been denied
  • Be sure to keep a copy of the request you sent to the insurance company for an internal review
  • Copies of any forms or documents that contain additional information you have submitted for your case (doctor’s letter, billing statements, etc.)
  • A copy of any letter or form you’re required to sign if you choose to have your doctor or anyone else file an appeal for you.
  • Dates of any phone calls you made or received from your doctor or the insurance company, along with notes you took during the call. This can include information such as the name and title of the person you spoke with, as well as the date and time of the conversation.
  • Be sure that you keep your own originals and only submit copies to your insurance company. Your request for a review will need to be an original document, but everything else can be a copy. Be sure to keep a copy of the request for review for your own file.

How Long Does It Take for an Internal Review to Be Completed?

  • Internal appeals must be completed in thirty days or less if you are still waiting for treatment or services (in other words, you have not received treatment yet.)
  • The internal appeal deadline for services that you have already received is sixty days.

When the internal appeals process has been completed, the insurer is required to provide you with a written copy of their decision. If, after the internal review, they are still denying your claim for payment or for service, you can now ask for an external review. As part of the insurance company’s notice to you, they must inform you of the procedure for asking for an external review.

Requesting an External Review of Your Health Insurance Claim

The external review process consists of two steps:

  1. Filing for an external review: You are required to file a written request for an external review of your health insurance claim within 60 days of the date you were informed by your insurer of their decision. Your plan may have specific language giving you more than 60 days to file for the external review, but it cannot be less. The notice you received from the insurer denying your claim after internal review must specify both the procedure and the time frame for filing a request for an external review.
  2. A qualified external reviewer will issue a final decision: There will be an external reviewer that will either agree with the insurance company’s decision to deny your claim or will find in your favor and grant your claim. Your insurance company is required by law to abide by the decision of the external reviewer. 

The most common types of denials that go to the stage of an external review include:

  • Denials based on medical judgment when your provider disagrees with you or the provider of health services as to the necessity of the treatment or services
  • Denials based on a claim that the treatment or service was investigative or experimental
  • Any time your coverage is canceled due to the insurer’s claim that you either gave incomplete or false information during the application process for your coverage

Your Rights in an External Review of Denied Health Insurance Claims

All insurance companies authorized to do business in the United States must agree to participate in external review processes that meet the consumer protection standards for health care law in each state where they are authorized.

On the state level, your state of residence may have stricter standards for an external review than other states or the federal government. If this is the case, you are entitled to the stricter standards of your state in an external review process. Your state will outline the specific protections that you are entitled to.

If for any reason, your state’s external review process does not meet the minimum standards for protecting consumers as outlined by the federal Department of Health and Human Services (HHS), then the federal government’s standards will apply, and the Department of HHS will oversee the external review process.

The following situations may apply to you, depending on where you live and the type of plan that you have:

  • Your insurance company may choose to join in an HHS-administered review process or may contract with an accepted independent review agency if your state does not provide an adequate external review process.
  • If your health insurance plan is employer-sponsored, you may not qualify for an external review process overseen by your state or by the HHS.
  • If this is the case and your plan is not covered by the state or federal review process, then your health insurer must contract with a review organization that is both approved and independent.

Where to Obtain Information About an External Review Process in My State

  • The best places to begin your external review request include the Explanation of Benefits (EOB) page from your insurance company, as well as the final denial document you received from your health plan provider. That document must include contact information for the group that will handle the process of your external review.
  • There is an excellent website maintained by the Department of Health and Human Services that lists information for each state regarding the external review process.

How Long Does It Take for an External Review to Be Completed?

While most standard external reviews are accomplished as quickly as possible, the guidelines state that they should be completed within 60 days after the initial request was received.

What About Urgent Decisions?

When a situation is urgent, you can make a request for an external review even if you have not completed the internal review process designated by your health insurance plan. If the normal timeline for filing appeals will jeopardize your health, your life, or your ability to regain satisfactory function in your daily life, you can file an expedited appeal. It is also possible to file an internal appeal and a request for external review at the same time.

When requesting an urgent decision, your appeal must receive an answer as quickly as your medical condition dictates – but in no instance can take more than 4 business days after receiving your request. An urgent appeal can receive a verbal response (when needed for speed) but must include a follow-up written notice within 48 hours after the decision is rendered.

Is There Help Available for Filing Requests?

Each state has some type of office of Consumer Assistance that may be able to help you get information about filing an internal appeal or external review. Additionally, every state has some form of a Department of Insurance that may be able to offer assistance. The federal Healthcare Marketplace also offers information on their website at HealthCare.gov.

Many consumers find the process daunting and confusing and seek help from a qualified attorney.

What Are My Extra Rights as a Public Employee?

One distinct advantage of working as a public employee is the fact that an external review is not your final option in the event your health insurance claim is denied. You also have the option of filing a lawsuit against your insurance provider. A lawsuit may produce leverage against your insurance provider that could encourage them to settle your claim. Often, a notice from an attorney regarding a lawsuit will garner you more attention than the internal or external review.

Additionally, a lawsuit can result in a settlement that completely covers the cost for a disputed medical treatment – not to mention the possibility of further monetary awards such as pain and suffering, loss of income, and punitive damages against the company due to their bad faith efforts in denying your claim.

Is Appealing My Health Insurance Denial Worth the Trouble?

A recent decision after a lengthy appeals process in a health insurance denial case in New Jersey illustrates both the tremendous effort required in doing battle with insurance companies and the enormous reward that come from persistence and determination.

A couple who had suffered four miscarriages and who had been denied for health care coverage for fertility treatments by the Horizon Blue Cross/Blue Shield organization in New Jersey had grown weary of the appeals process.

But they decided to read one more letter that came to them from a doctor involved in an external appeals process with the carrier, and they were shocked to learn that the doctor agreed with them about their right to coverage. In the doctor’s opinion, the service the couple sought should have been covered by their health plan and the decision of the insurance company was overturned. The couple received payment for the treatment.

The husband admitted that, after receiving so many letters stating denial after denial, he was shocked to finally receive a positive outcome. According to the New Jersey Department of Banking and Insurance, more than half of the denials issued by insurance companies in recent years have been appealed – and have been overturned.

State officials have noted that consumers are becoming more aware of the options they have to appeal and have begun aggressively fighting back when the insurance companies issue denials.

Unfortunately, the process can be emotionally draining and can often force people to take time off from work; pleading your case in front of an insurance company’s board of review is not fun but can definitely be worth the effort. And, as a public employee, you can also be compensated for any time you lose from work pursuing your claim if your case is upheld.

An organization known as The Doctor-Patient Rights Project was founded in 2017 in response to the levels of interference many patients and health care providers were experiencing in the claims-paying process. They have acknowledged and brought to the forefront many issues such as rising premiums, steeper deductibles, and the increasing use of denials by third-party payers that have affected the quality of healthcare in America.

They cite escalating aggressive tactics by the insurance companies that seek to protect the insurer’s bottom lines while causing problems with the promise of patient care to which the insurers have been obligated by their own products.

When the subject turns to legal language and standards, an attorney who understands and is well-qualified in health insurance law can be a real advantage if you are considering filing an internal or external appeal, or a lawsuit with regard to the health insurance denial of your claim.

Stop Health Insurance Denial Near Me

Many people get denied health insurance unjustly and do not have means or the understanding to fight the large insurance carriers that tend to dominate the health care industry. The professionals from Stop Health Insurance Denial are not only qualified to assist consumers and public employees when their health insurance claims are denied but they are also passionate about fighting to protect your rights. You can speak with a professional at Stop Health Insurance Denial by calling 310-695-5241.